Category: Insights and Tools

How to Help Learning Stick for Clients

By Tori Rodriguez

It’s usually easy to see when clients are tuned out or turned off, simply not absorbing what you’re trying to get across. What’s puzzling is when things seem to be really clicking in session—when you’re sure clients will return to report their success at having applied the new awareness and skills they’ve just acquired to their lives—and then you find that they haven’t followed through.

A study by David Atkins and colleagues, published in the June 2012 issue of Behaviour Research & Therapy, found that clients in couples therapy are less likely to recall communication skills learned during high levels of emotional arousal. As the authors report, “Greater emotional arousal predicts remembering fewer skills,” and “sustained emotional arousal may impact memory through encoding, retrieval, or both.” Other studies have also established how strongly stress hormones can affect learning and memory. However, in the June 2013 issue of Couple and Family Psychology: Research and Practice, couples therapist Brent Atkinson offers some practical suggestions for addressing this obstacle to therapeutic change. He proposes that combining our emerging understanding of brain science with the power of deliberate practice gives us effective tools for mitigating the power of emotionally charged situations. Keeping emotions in check would then prevent clients from losing access to the insights and skills they’ve presumably acquired in the consulting room.

“Many clients don’t have a basic level of mental fitness required to make changes,” says Atkinson. For these clients, despite their best intentions, being in conflicts with their partner or in other triggering circumstances results in flooding, or becoming overwhelmed by negative emotions. This often triggers diffuse physiological arousal (DPA)—activation of the autonomic nervous system’s alarm response, which initiates changes like increased heart rate, blood pressure, and levels of stress hormones like cortisol, all of which help prepare the body to deal with threats. In spite of the new insights and skills explored in therapy, the chance of new responses being tried out when a client’s nervous system has been hijacked by DPA are radically diminished. So before clients can make changes in their relationship with a partner, before therapy can really begin to have any real impact, the first order of business is to change clients’ relationship with their nervous system.

In Atkinson’s treatment model, the therapist first works with clients to get them motivated to tune up their nervous system, helping them understand why it’s important and introducing them to the concept of mindfulness. The couples then participate in an eight-week mindfulness course, and during concurrent couples therapy sessions, they practice extending the skills they’re learning to their relationships. If clients need help mindfully responding during stressful partner interactions, they listen to their partner’s criticisms via prerecorded voice messages, during which they practice using mindfulness skills to turn down their physiological and emotional arousal. As clients become more skilled at self-soothing, the therapist helps them to identify their typical sequence of conflict and to mentally rehearse how to respond more effectively when conflict arises—much like how athletes or musicians might engage in mental practice to enhance their skills.

Treatment models like Atkinson’s move the field of therapy away from a faith in the magical power of insight, or even the generalized benefits of the therapeutic alliance, toward a closer look at how to concretely make the process of emotional learning more efficient and sustainable. Since therapy outcome studies consistently show a discouraging overall finding—the average results of psychotherapy haven’t improved over the last 50 years—this new research certainly seems to be a step in the right direction.

Talking on the Edge

Assessing the risk of suicide

By Douglas Flemons

Q: I feel unprepared to make a proper suicide assessment with my clients. I’m nervous that I’ll neglect to ask, or the client won’t tell me, something vital to making the right clinical decision. Can you recommend an objective measure for reliably determining suicidality?

A: Suicide assessment is a high-stakes process infused with uncertainty, so your desire to find an assessment instrument to help with your decision-making is understandable. However, even the best scales can be unreliable when they’re completed in the midst of an emotional crisis. Thus, rather than outsourcing your decision-making to an instrument, I recommend that you learn how to conduct a conversational evaluation that builds on your therapeutic skills. While most clinicians already know to ask whether a client has an intent to die, a suicide plan, or access to a means for carrying it out, it’s important to go beyond simply posing these questions to get a fuller picture of the client’s risk of suicide.

Effective suicide assessments are built on a foundation of empathic connection. When clients feel heard, understood, and respected, they’re likelier to let down their guard and explore sensitive topics. In broaching such topics, the best way to protect them from feeling grilled is to intersperse your questions with empathic statements, such as “Sometimes your obligations feel impossible to meet,” or “It sounds exhausting to have to fend off intrusive thoughts of taking your life all the time.”

To help guide your assessment dialogue, my colleague, psychiatrist Len Gralnik, and I have identified four broad categories of inquiry:

Disruptions and demands—such as the loss of a relationship or social and financial status, overwhelming expectations and obligations, legal entanglements, and instances of abuse, bullying, or other traumas.

Suffering—from emotional problems (depression, mania, anxiety, anger, obsessive thinking), psychiatric problems (hallucinations and delusions), social pain (conflicted identity, shame), sleep problems, and physical problems (pain and illness).

Troubling behaviors—those that increase the danger of a client’s situation, such as withdrawing from activities and other people, engaging in substance abuse or disordered eating, acting impulsively or compulsively, and harming oneself or others.

Desperation—which encompasses many of the most urgent indicators for concern, such as hopelessness, an intense desire for relief, an intent to die, a plan for making a suicide attempt, a history of making one or more attempts, or making preparations for a future attempt.

To get a deeper sense of whether clients are in imminent danger of making a suicide attempt, you must obtain a clear view not only of the likelihood that they’ll act on their desperation, but also of their resources for making it through the crisis. To this end, you’ll want to explore intra- and interpersonal sources of resilience, protective beliefs, exceptions to problems, past successes, current skills, and effective strategies for dealing with stressors. For example, I once saw a former college football player whose game-hardened ability to keep moving forward, regardless of injuries and pain, served as a source of resilience when he felt like succumbing to suicidal thoughts. Also, some of my deeply religious clients have been protected by their faith’s prohibitions against suicide. I can almost always find some degree of variation in my clients’ desperation. If there are times when they feel more overwhelmed and depressed, that means there are times when they feel less so.

However, when you make note of your clients’ resources, take care not to appear overly impressed by their resilience or the support that’s available to them. To them, life is hopeless, so straightforward optimism on your part will likely be slapped away as irritating naivety. Instead, it’s helpful to adopt a casual manner when making resource-based inquiries and noting any positive discoveries. For example, you could say to my client who’d played football, “So when you were playing college ball, you didn’t let the pain slow you down? Have you always had that kind of strength and determination, or was it something you learned? How’s that coming into play these days?”

Some clinicians routinely use boilerplate no-harm or no-suicide contracts, hoping to secure a troubled client’s commitment to live and lessen their own legal exposure if the client were to end up completing suicide. Research has shown, however, that signing such contracts doesn’t afford the client any added protection; and when sued, clinicians who use contracts don’t fare any better in the courtroom.

Instead of no-harm or no-suicide contracts, I prefer working with clients to construct a uniquely relevant safety plan, a resource-based to-do list that identifies protective steps the client and his or her significant others are willing and able to undertake.

In developing the safety plan together, first decide how the client and significant others can restrict access to all possible means for attempting suicide. You can also explore reasonable alternatives to troubling behaviors for coping with distress and identify safe havens the client could access for a limited time if necessary. Write down the contact information for anyone who could offer a safe haven or other forms of support.

I once consulted on a case involving a young suicidal woman, Michelle, who had persistent thoughts of jumping off the balcony of her 11th-story apartment. Although her parents weren’t available to help, Michelle said she had a good friend, Vanessa, who lived on the ground floor of the same building. I arranged for Vanessa to come into our session, and the three of us worked out details of a safety plan. We decided that whenever the thoughts of jumping ramped up, Michelle would first go to her walk-in closet, which she considered a safe haven. Once there, she’d meditate and, if necessary, call the numbers of family, friends, and professional resources that we wrote down. If these measures didn’t feel safe enough, she’d take the elevator down to Vanessa’s, and—with the key that Vanessa said she’d give her once they got home—let herself in. Michelle didn’t consider or worry about any other methods of dying, so the measures necessary for keeping her relatively safe were fairly straightforward.

A safety plan is designed as a temporary measure to get suicidal clients through distressing times, so you need to make sure the plan is reasonable and doable. A plan that’s too elaborate or demanding isn’t safe. In addition to significant others, you and the client should consider enlisting his or her work supervisors or school administrators to alter the client’s schedule, reduce his or her workload, or grant a leave of absence. Also, determine whether the client would consider initiating, resuming, or continuing relevant therapy or treatment. In addition to generating a list of personal and professional contacts the client could call if necessary, identify emergency contacts such as crisis lines and nearby hospitals. Once the safety plan is complete, make a copy for your file and give the original to the client.

If the client appears to be at imminent risk of making a suicide attempt and a safety plan doesn’t seem feasible or sufficient to keep him or her safe, then you’ll need to arrange transportation to a psychiatric receiving facility for evaluation and possible involuntary admission. But never make this choice simply to be on the safe side. Sending someone to the hospital who’s depressed but not suicidal, for example, may alleviate your immediate anxiety, but it may cause the client to avoid seeking out mental health treatment in the future.

Arrive at your safety decision by piecing together all the information you gather throughout the assessment: what the client tells you, what you empathically glean, and what you know from the professional literature about risks and resources. Whenever possible, consult with a colleague or supervisor, so you can compare your perspectives.
Once you make a decision, give yourself the opportunity to take a second look at it, along with the data informing it. If, upon considering everything a second time, you come to the same conclusion, then you can proceed with added confidence. If you end up with second thoughts, listen to your doubts and use them to prompt further information gathering.

It isn’t unusual for me during an assessment to change my mind several times about whether a safety plan can be a viable option for keeping a client alive. Much of what Michelle told me—about her depression, thoughts about jumping, absence of family—pointed to hospitalization as the best choice for keeping her safe. But glimmers of hope kept appearing, so I kept asking questions, and together we finally determined that she had the necessary resources to stay safe—and we were right. She told me much later, when the crisis had passed, that she’d pinned up her safety plan inside her walk-in closet and would go in there and read it as a source of reassurance and inspiration.

Ultimately, suicide assessments are inherently anxiety-provoking and emotionally taxing, even when they go well and the client can safely negotiate harrowing desires, thoughts, and circumstances. Following an assessment, it helps to secure time with colleagues to talk through how the client presented, what you were able to discover, what you decided, how the client responded to the process as a whole, and what you were experiencing throughout the process. Taking care of yourself in this way will help you feel better prepared the next time.

Douglas Flemons, PhD, is Professor of Family Therapy and Clinical Professor of Family Medicine at Nova Southeastern University. He’s coauthor of Relational Suicide Assessment, author of Of One Mind, and coeditor of Quickies: The Handbook of Brief Sex Therapy. He offers workshops on suicide assessment, hypnosis, and brief therapy. Contact: douglas@nova.edu.

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Evoking the Inner Artist

How to replace pathology with creativity

By Lisa Mitchell

As both an art therapist and a marriage and family therapist, I believe that vulnerability, doubt, fear, and uncertainty—feelings most people try to avoid—are essential to getting unstuck in life and engaging in creative problem solving. I try to guide clients to find new approaches to old problems by teaching them how to move beyond “artist’s block,” a state of being joylessly trapped in repetitive patterns and rigid expectations, and how to welcome the type of anxiety around the unknown that creativity invites.

I used this approach with Pam, a 30-something associate director of a nonprofit organization, who came to my art studio after hearing from a colleague about a training on creativity I’d facilitated. Frustrated by her previous inability to get out of her head in therapy, she was intrigued by my alternative, more experiential approach. On the phone, she told me she was seeking therapy because she felt her “inner slave driver,” which had once helped her succeed in managing her career and three children under the age of 12, had begun to dominate her life. “There are endless lists that structure my every waking minute,” she said. “I feel like I’m being worked to death, and there’s no joy in it.” She went on to say that her anxiety and feelings of emptiness had become even more intense since her best friend had died, six months before.

To start our first session, I asked Pam where she thought her inner slave driver came from. She described being 7 years old and having to care for the household and her younger brother after her mother abandoned the family and her father had immersed himself in work. She’d learned how to manage her life with great order and precision, dedicated to the belief that no one could do anything for her that she couldn’t do for herself. But recently she’d begun to question this stance and note the problems it was causing for her, particularly after a confrontation at dinner with her 6-year-old daughter, Gena. That night, after a long standoff in which Gena had refused to eat her broccoli, Pam had finally gotten her to take three rule-abiding bites.

“I thought I was doing the right thing by enforcing the rule,” Pam said. “So when Gena threw up her dinner, I thought she was just being impossible, and I marched her off to bed. But during the night, Gena woke up with a stomach flu. I spent the whole night nursing her and feeling guilty.”
Instead of offering parenting strategies, I told Pam that I wanted to spend our time looking at new ways to behave when her inner slave driver was keeping her stuck in old, rigid patterns, blocking her from other creative possibilities for responding.

Identifying a Creativity Goal

Early in therapy, I try to introduce the idea of flow as a reference point for clients, like Pam, who complain of feeling stuck and blocked. Trying something new and a bit risky, like singing karaoke or canoeing under a full moon, might be a flow experience for some; others might feel flow when expressing deep love or being vulnerable with a partner. In other words, flow happens in moments when time feels unimportant, connection to self and others feels meaningful, or life feels vibrant with newness. For Pam, I suspected that caring for her lifelong friend, Sandy, through the late stages of breast cancer had forced her to let go of her usual rigid mode of being, and thus had been a flow experience.

“When we first talked on the phone and you told me about Sandy,” I said. “I noticed softness in your voice that was different from when you talked about your daughter. I wonder if you see that difference, too.”

Pam replied thoughtfully, “Yes, I was totally different with Sandy. With her treatment, I couldn’t predict how the next day or week was going to go. I had to let go and be vulnerable. Sometimes I wasn’t a pretty picture. I cried a lot and couldn’t find the right words to say to Sandy. But instead of finding an escape, I was at her side when she breathed her last breath. I want that feeling of openness and authenticity in other places in my life.”

The Five Stages of Creativity

As part of my work with clients to help them find flow, I usually spend time telling them about the five stages of creativity—incubating, initial idea, diving in, flexible commitment, and flow—and how each requires tolerating unpleasant experiences of doubt, fear, and anxiety. I offer quotes from various artists to introduce each stage, like Degas’ idea: “Only when he no longer knows what he is doing, does the painter do good things.” I play compositions by Keeril Makan, who said, “When fear arises, I’ve reached the threshold between the known and the unknown. If I’m able to continue composing while tolerating the fear, I will be writing music that is new to me.” I talk about writer Anne Lammott’s take on “shitty first drafts” and choreographer Twyla Tharp’s emphasis on “showing up no matter what.”

Pam was able to see the contrast between these artists’ approaches to creativity and her own approach to life. Still, she had doubts about her ability to change. In response, I told her that sitting with doubt was one of the most creative things she could do right now.

Shrugging she said, “I’ll try.”

Don’t Force a Solution. For our subsequent sessions, I asked Pam to bring in current life examples of feeling blocked so we could identify where in the creative process she was getting stuck and practice getting unblocked. She shared that her 12-year-old son had recently thrown a tantrum when she refused to let him visit a friend on a school night. She said, “I know I handled it wrong because I just laid down the law, and I definitely didn’t feel open or connected to my son.”

I asked her to view the situation with her son as if it were a painting, reminding her that to start a painting, an artist must create space and time for the thoughts to come together.

“OK,” she said immediately, “I’ll just stall and won’t give him an answer right away next time.”

“Try it right now,” I suggested. “See what it feels like to sit and generate options. Look at all the perspectives involved. Just sit with my question, sit with your son’s request. Let it incubate and postpone your answer.”

She sighed and sat quietly, then said, “I can see myself being so much more connected to my son when I sit with the feelings he must’ve been having. It feels totally different.”

Embracing Not Knowing. With each real-life example that Pam brought into session, we began to see that she had difficulty not only with incubating, but also with tolerating the discomfort that comes in the second stage of creativity: Pam’s fear of not being good enough and not knowing if she was doing the right thing wouldn’t allow her to experiment with options in the initial idea phase.

I invited Pam to watch some two-minute animated films on YouTube made by artists. When I stopped one of the films after a few moments and asked Pam to predict what was going to appear in the next frames, she realized it was impossible. Then I asked her to imagine writing her own animated film. Closing her eyes, she described herself and her husband at the start of a trailhead where they liked to hike. She then expressed surprise and delight when her imagination changed her and her husband into birds, flying off and landing in a nest of water, where they turned back into people lying hand in hand in a bed. This spur-of-the-moment internal filmmaking gave her an immediate experience of how an artist can create something without being wed to a definitive outcome. Her surprise to see this internal animation unfold so smoothly tickled her. She looked brighter when she said, “I never just let it unfold, do I?”

I said, “Your old pattern dictates that you either know the outcome or just follow the rule. This is a new way of doing things. Is there somewhere in your life you’d like to try out this letting go and unfolding?”

“I think it’d be helpful when I come home from work,” she said. “Maybe I can just back off and try to see our chaotic evenings as a surprising animated film.”

Fear Is Good. When Pam arrived for her next session, she reported that driving home from work, she’d tried to stay committed to the “letting it unfold” idea, but could only imagine bad things happening when she walked in the door. She expressed doubt about the whole “creativity thing.”

“Experiencing doubt is a good sign,” I said. “It means you’re partnering with your creativity.” To illustrate how anxiety is actually part of the creative process, I asked her to make a scribble on a piece of paper. After she made some messy lines, I said, “Good. Now let’s think of things we could turn your scribble into.” We brainstormed options and chatted a bit about the noisy wild roosters outside my studio, then I invited her to get to work.

She froze. “A minute ago, I had an idea, and now I think there’s no way that I can make my scribble look like the idea. I’m not artistic. It’s not going to turn out.” She’d arrived in her familiar place of feeling blocked.

“Just start with a color,” I said, “and see what it wants to do. Don’t worry about what it’ll become, just start.”

Soon her turquoise blended with purples and a peacock’s feather fanned itself from the back of a bird. Pam muttered as she drew, “I don’t know why I came up with a peacock. I have no idea how to draw the beak, but I absolutely love these colors. I’ve never seen a peacock that looks like this. I’m so madly in love with this bird.”

Pam told me afterward, “I get it, I really do. I have to take the plunge and just dive in. When I do, I have to embrace not knowing and just let it unfold, even if it’s scary.”

I related this to her initial expression of fear. “OK, you’re driving home, you’re scared of the chaos that’ll unfold when you get there, you remember that fear is OK. All you need to do is start with something, like the color in your scribble. What do you want to start with?”

“The feeling of love for my family,” she replied. “Yeah, and I can try to let things go from there.”

“Sounds creative—very open and authentic,” I said.

Mistakes Are Opportunities. Since artists are committed to the act of making art no matter what happens, they have to treat mistakes as opportunities to discover something new, and change direction if something leads them down a different path. Although Pam and I had talked often about the importance of allowing flexibility and vulnerability into her life, it was difficult for her to let go of feeling certain in all situations. But one week, she announced, “I told a board member that I had no idea what the right decision was. I felt authentic and honest, and took the risk of looking completely stupid. It turned out great, though, because instead of making a firm decision right away, we decided to elicit more information. So now, the whole organization has been invited to collaborate. It’s like we’re painting a huge mural together.”

Flow: The Artist’s Reward. Over the next few months, Pam loosened up in many ways, even physically. She became noticeably less stiff in her shoulders and made more eye contact when we talked. It was evident that her inner slave driver was letting go. With her 12-year-old son, she signed up for a photography class, and she started having coffee on Sundays with friends. In one of her last sessions, she told me about a memorable Sunday-morning breakfast with her family.

“My youngest was pouring syrup on her pancakes when the dog came up and bumped her elbow,” she said. “The bottle went flying, and syrup poured all over my daughter. I was horrified and told her to get in the bath quickly before more of it dripped on the floor. While I got the sticky-pawed dog outside, she started the bath water. I went to check on her and discovered she’d gotten in the tub with her clothes on. Instead of scolding her, I hugged her and eased myself into the tub, jeans and all. The memory of us giggling uncontrollably has carried me the entire week!”

This experience exemplified Pam’s new ability to partner with her creativity and open herself to being vulnerable and flexible. She said her anxiety was decreasing with each day, and she actually looked forward to being with her family. No longer checking out on her relationship with them, she felt she’d discovered the creative secret of how to keep checking in.

CASE COMMENTARY

By Jay Efran and Jonah Cohen

Lisa Mitchell’s approach to therapy focuses on cultivating creativity rather than fostering insight. Similar to Acceptance and Commitment Therapy, her methods encourage clients to sit with their distressing thoughts instead of avoiding them or rushing prematurely into action. Specifically, in response to Pam’s request for help with her “inner slave driver,” Mitchell developed a series of creativity exercises designed to increase Pam’s flexibility and self-acceptance. Pam found these methods helpful and reports an increase in spontaneity.

It’s important to keep in mind, however, that there are limits to what creativity training can accomplish. If creativity was truly a mental health panacea, we would see fewer artists, writers, and performers in our practices. Moreover, if it really had a lasting impact on either mental stability or generalized problem-solving ability, it’d be included in required courses at colleges and business schools all across the country. In the current case, it’s difficult to parse how much of Pam’s progress is due to her art therapy exercises and how much is a function of therapy’s nonspecific factors, such as a strong therapeutic alliance and receiving positive reinforcement for taking risks.

Incidentally, personality theorist George Kelly wrote that creativity cycles always involve two phases: loosening and tightening. Without the first, there’s no novelty; without the second, there’s no productivity. Thus, the most crucial skill may be learning to shift easily between these two phases—from open-ended brainstorming to useful synthesis. In this context, Pam’s willingness to solicit information from other members of her organization can only be considered a partial success. A full victory would require that she also be able to collate and make effective use of the feedback she receives.

Instead of endorsing Pam’s metaphor about fighting her inner slave driver, we would have encouraged her to fully embrace her obsessive, perfectionistic style. Such characteristics are legitimate and valuable aspects of her personality—friends to be courted, rather than enemies to be vanquished. After all, without her drive and attention to detail, would Pam have had the same degree of success in business and child rearing? The truth is that each of us falls somewhere on the obsessive-impulsive spectrum, and every position on that continuum brings benefits and headaches. Furthermore, as the developmental research shows, our fundamental temperament traits have large genetic loadings and are likely to remain for life, regardless of how many years we spend in therapy or how many improvisation exercises we complete. Therefore, the trick is to appreciate our characterological quirks and learn how to put them to good use. As we tell our clients, it’s usually easier to ride the horse in the direction it’s going. Of course, Pam needs to remind herself to go off duty once in a while. Yet she should also take time to celebrate the gifts provided by her often ambitious, single-minded nature. This is true self-acceptance.

AUTHOR’S RESPONSE

While artists, writers, and performers may know a great deal about being creative in their chosen art form, they are often not aware of how to apply the creative process to other aspects of their lives. They can benefit greatly from learning to see relationships, emotions, and problem solving in the same way that they see their art. Along the way, they can also learn how to tolerate doubt, uncertainty, and other unpleasant emotions in service of an expanded experience of life.

While it’s difficult to say whether Pam’s single-mindedness was due to genetic loading or other factors, it was clearly taking a toll on her relationships. In the process of learning to tolerate the uncertainties that come with delayed decision-making, she was able to soften in her way of being with others and open herself to more creative risk-taking. Eventually, she discovered that she didn’t need to fight her inner slave driver, just understand that this powerful aspect of herself was blocking her access to her own creativity.

Lisa Mitchell, MFT, ATR, writes and trains on the topic of creativity and therapy. She works with clients and therapists to partner with their creative process in her private practice in Sacramento, California, and blogs at Inner Canvas. Contact: lisa@innercanvas.com.

Jay Efran, PhD, professor emeritus of psychology at Temple University, is the coauthor of Language, Structure and Change: Frameworks of Meaning in Psychotherapy and The Tao of Sobriety. Contact: efran@temple.edu. Jonah Cohen, MA, a doctoral candidate at Temple University, is currently researching social anxiety at the department’s Adult Anxiety Clinic.

Tell us what you think about this article by email at letters@psychnetworker.org.

Wearing Your Heart on Your Face

The Polyvagal Circuit in the Consulting Room

By Ryan Howes

As we all learned in school, we have two options in the face of perceived danger: fight or flight. But that was before neuroscientist Stephen Porges, author of The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation, undertook his research into the relationship between human physiology and social engagement.

Porges’s work—which noted researcher Paul Ekman called “a truly revolutionary perspective on human nature”—dramatically broadens our understanding of the sympathetic and parasympathetic systems, and explains how our bodies and brains interact with one another to regulate our physiological states. However, what may be more pertinent to therapists is the extent to which our autonomic nervous systems influence long-term issues with intimacy and trust. In the interview that follows, Porges offers some research-based insights into how therapists can more effectively convey safety to clients and clarifies the evolutionary roots of anxiety, depression, and trauma.

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RH: Can you explain your Polyvagal Theory in simple terms?

Porges: It’s hard to make it simple, but let’s try by starting with what we’ve all learned about the autonomic nervous system. It’s a pair of antagonistic systems: the sympathetic supports mobilization, and the parasympathetic supports immobilization, usually associated with relaxation, growth, and restoration. In the past, we tended to believe that stress responses were, in general, vested within the sympathetic nervous system’s capacity to support fight-or-flight behaviors. But there’s another defense system, unrelated to the sympathetic nervous system and dependent on the parasympathetic nervous system. The mechanisms and adaptive function of this defense system are impossible to understand from the paired antagonism model. The parasympathetic defense response is mediated through a vagal circuit producing a behavioral shutdown such as fainting or, from a clinical perspective, dissociation. This defense system doesn’t fit within the fight-or-flight model. Nor does it fit within the view that the vagus, the major nerve in the parasympathetic nervous system, mediates calmness and induces resilience and health.

RH: Your work suggests that our autonomic systems are better thought of as hierarchical, rather than competing.

Porges: Right. The vertebrate autonomic nervous system has changed through stages of evolution, and the human autonomic nervous system shares several of these autonomic circuits with more ancient vertebrates. Functionally, our autonomic nervous system is composed of three phylogenetically organized subsystems. We utilize our newest systems first, and when they don’t work, we recruit older ones. In terms of evolution, the newest autonomic circuit is a uniquely mammalian vagal circuit, which inhibits the heart rate by placing a tonic inhibition on the heart’s pacemaker. This circuit also inhibits sympathetic activity. The brainstem areas controlling this neural pathway coordinate the nerves controlling the muscles in the face and head. So people are literally showing their heart on their face. That’s because humans are social beings who have to convey to one another that we’re safe to come close to, to hug, and in some cases, to have sex with. To convey this message of safety, we utilize the newest vagal circuit to down-regulate our sympathetic defenses and present cues of safety when it’s appropriate. While the face is a crucial vehicle for this, the voice also plays an important role in conveying a physiological state of calm. If the voice has a higher-pitched frequency, it’s saying, “Don’t come near me.”

The thing to bear in mind is that the vagal circuit is both expressive and receptive. That’s why you feel calmer when I use a soothing, prosodic voice. When the vagal circuit is working, our middle-ear muscles change our capacity to hear predators or low-frequency sounds. Middle-ear muscles, similar to the muscles of the face, are regulated by the brainstem area that controls the mammalian vagal circuit. Typically, when there’s something in the environment that threatens us, we turn off the vagal circuit, because it inhibits our ability to mobilize: it gets in the way of moving to fight or to flee.

RH: That’s because it’s the vagal system that makes us freeze, right?

Porges: Yes, but there are two vagal systems. The root of the Polyvagal Theory is the recognition that in the absence of the ability to fight or flee, the body’s only effective defense is to immobilize and shut down. This can be observed as fainting or nausea, both features of an ancient vagal circuit that reptiles use for defense. However, unlike the uniquely mammalian vagal pathway, these vagal pathways are unmyelinated, and are only effective as a defense system when the newer circuits, including the sympathetic nervous system, are no longer available for interaction and defense. Our reptilian ancestor was similar to a turtle, and the primary defense for a turtle is to immobilize, inhibit breathing, and lower metabolic demands. Although immobilization may be effective for reptiles, it can be life-threatening for mammals, and for humans it can lead to states of dissociation. The Polyvagal Theory provides a way of seeing how the organization of our nervous system can shape our understanding of clinical disorders and issues, enabling us to see symptoms like dissociation not as bad behaviors, but as adaptive reactions to cues in the environment that trigger our physiological responses to perceived dangers.

Think about it this way. When you want to calm a person down, you smile and talk to them in a soothing way. The nervous system detects these cues and down-regulates or inhibits the sympathetic nervous system. But when the sympathetic nervous system is activated as a defense system, it turns off all those social-engagement behaviors. Clinicians are aware of that. But what they often don’t understand is the role of the vagal system in shutting down as a defensive strategy in response to a life threat. When someone is immobilized, held down, or abused, the vagal system is triggered, and they may disassociate or pass out—or perhaps drop dead or defecate. It’s an adaptive response.

I often talk about immobilization with fear and contrast it to immobilization without fear. The mouse in the jaws of a cat is immobilized with fear. The mouse isn’t voluntarily playing dead; it’s fainted. But someone in the embrace of a lover, parent, child, or friend is immobilized without fear.

RH: We might call that stillness, or peace.
Porges: Right, you’re still, but you’re being present. For reptiles and more primitive vertebrates, the primary defense system was to disappear—to immobilize, stop breathing, and look like you’re dead. For mammals, immobilization is a risky business. We have to be selective about whom we can feel still, calm, and comfortable with.
Many clients have difficulty feeling comfortable in the arms of another. They can’t immobilize without fear. If you go through their clinical histories, you’ll find that many were severely abused and had experiences of being forcedly held down. These experiences of forced immobilization trigger fear responses and shutting down. Those who survive these experiences don’t want to be immobilized and find it difficult to be held and calmed, even by people who are trying to be helpful. This response is often expressed as anxiety and a need to keep moving, which is a functional defense to a fear of immobilization. Often individuals with a history of immobilization with fear will adaptively become anxious and go into panic states to avoid this immobilization state. This is a problem many therapists see in their practices.

RH: What are the practical implications of Polyvagal Theory for clinical work?

Porges: It heightens our appreciation of the role of creating safety in therapy. For example, our bodies, physiologically, are extraordinarily sensitive to low-frequency sounds. We, like other mammals, interpret these low-frequency sounds as predatory. If your clinical office is bombarded with sounds from ventilation systems, elevators, or traffic sounds, your client’s physiology is going to be in this more hypervigilant defense mode. Likewise, if you sit some people in the middle of the room away from a wall, they may become hypervigilant and concerned with what’s going on behind them. If we’re not safe, we’re going to assume that neutral faces are angry faces. We’re going to assume the worst because that’s what our nervous system tells us to do. As vertebrates evolved into mammals, they had to interact with other mammals for survival. They needed to detect the social cues and identify when it was safe to be with another mammal. Thus, vocalizations in social contexts are less about syntax and language and more about the intonation conveying emotional state. Again, this is critical in therapy because the intonation of voice conveys more information about the physiology of the client than the syntax.

RH: In other words, how you’re saying something means more than what you’re saying.

Porges: Absolutely. When you were an undergraduate, what were the lectures that put you to sleep? Was it the college professor who was off in space, who basically read from notes and had no prosodic features and no engagement? Social communication has little to do with syntax and a lot to do with intonation, gestures, and a cluster of behaviors we would call biological movement. The face is moving along with the voice and hand gestures. The behavioral features trigger areas of our brain outside the realm of consciousness and change our physiology, enabling us to feel closer and safer with another. Good therapy and good social relations, good parenting, good teaching, it’s all about the same thing—how do you turn off defensiveness? When you turn defense systems off, you have accessibility to different cortical areas for more profound understanding, learning, and skill development.

Ryan Howes, PhD, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs for “In Therapy” at Psychology Today. Contact: rhowes@mindspring.com; website: www.ryanhowes.net.

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The Doctor Is In. . . Your Phone

By Lee Coleman

Currently, there are between 100 and 150 smartphone apps designed to supplement—and occasionally even replace—face-to-face psychotherapy. In fact, the United Kingdom’s National Health Service maintains a library of approved smartphone apps for a variety of physical and mental health concerns. In this country, the United States Department of Defense has assisted in creating several apps designed specifically to help service members track anxiety and depressive symptoms related to military deployment. Given this trend in technology and the high-level support it’s receiving, it’s increasingly important for therapists to understand what mental health-related apps are available in the world and how they might enhance, or in some cases undermine, therapy.

The Optimism app, for example, can help clients become more active participants in their treatment, particularly if some form of self-monitoring is involved. Created by an Australian company, Optimism allows clients to track information related to emotional well-being, such as mood, symptom severity, medication compliance, and hours of sleep. The app generates charts and reports to monitor progress over time, and there’s even a desktop interface that allows clinicians to collect and view their clients’ data. The app started out as a desktop software package six years ago and now averages about 10,000 downloads a month as a smartphone app, according to its developer, James Bishop. Over 80 percent of surveyed Optimism users report using it in conjunction with visits to a mental health professional for a specific mental health issue, usually a mood disorder. For clinicians doing therapy that involves mood charting, supplementary apps like this one can boost compliance by providing a convenient alternative to paper charts.

Numerous apps also offer a form of life coaching and other services traditionally provided through face-to-face psychotherapy. Unstuck, for instance, designed by SYPartners, has had more than half a million downloads since its launch in December 2011. Geared toward people struggling to make difficult life decisions, the app helps users navigate factors that may be interfering with the decision-making process and gives specific advice for developing new perspectives. For example, someone who’s taking on too many tasks alone can indicate that they’re feeling like a “lone leader” and get advice on how to start working more collaboratively.

A related app, MoodKit, was developed by two clinical psychologists to help people use traditional cognitive-behavioral therapy techniques in their daily lives. Among other features, it encourages mood-elevating activities, helps users change self-defeating thought patterns, charts daily moods, and records journal entries to increase a sense of well-being. It can certainly be used to augment professional treatment, but users don’t need to be in therapy to take advantage of what it offers.

These apps and others like them are easy to use and may be promising pathways to increased treatment compliance for that reason alone. However, they’re a long way from being a silver bullet for curing people’s mental woes. As psychiatrist Andrew Gerber of Columbia University notes, “We are built as human beings to figure out our place in the world, to construct a narrative in the context of a relationship that gives meaning to our lives. . . . I would be wary of treatments that don’t allow for that.”

But even as psychiatrists like Gerber contemplate the creation of apps that could undercut the therapeutic relationship, researchers around the world are testing their effectiveness in treating clinical problems. Cognitive bias modification (CBM), for example, involves the use of a game-like app that trains users to respond to distressing stimuli in new ways, which may have applications for people struggling with anxieties and phobias. For example, socially anxious individuals might play a game in which they’re trained to pay more attention to an image of a neutral face than a hostile one. Although the idea is promising, psychology professor Richard McNally of Harvard, whose research team conducted a 2012 study of CBM, notes that people who used the CBM smartphone app became less anxious, but so did the control group whose members played a nontherapeutic game. In other words, the placebo effect might be responsible for at least some of the positive outcome.


So while many jobs these days are being made obsolete by advancing technology, that doesn’t appear to be the case in the therapy field as of now. Rather than fearing these apps as competitors, savvy therapists will want to explore their potential as clinical assistants. After all, as intelligent and intuitive as Apple claims its iPhone personal assistant Siri to be, she’s certainly not ready for licensure.

–Lee Coleman

Resources

Therapy Apps: Benedict Carey. “The Therapist May See You Anytime, Anywhere.” New York Times, 24 December 2012. http://www.nytimes.com/2012/02/14/health/feeling-anxious-soon-there-will-be-an-app-for-that.html?pagewanted=all&_r=1&;

Peter Reuell. “A Therapist at Your Fingertips.” Harvard Gazette, 13 March 2012. http://news.harvard.edu/gazette/story/2012/03/a-therapist-at-your-fingertips/.

Yoga in the Therapy Room

By Amy Weintraub

Centering the uncentered client

Q: I’ve taken yoga classes for several years and know there are many physical, mental, and emotional benefits associated with the practice. How can I use yoga techniques to enhance my work as a therapist?

A:You can offer your clients many yoga-based practices to help them focus, relax, and access their feelings more readily during the session, as well as self-regulate at home. As you may know, the physical postures, known as asanas, are only one aspect of traditional yoga practice. A variety of no-mat yoga practices and rituals can help quiet mental chatter, reduce bodily tension, and promote a heightened awareness of oneself and one’s surroundings. All these techniques are perfectly suited to the consultation room.

The work of therapy can’t begin in earnest if the client’s mind is racing or fogged by depression at the beginning of the session, or if tension is so great that bodily awareness is lost. Offering a simple yoga practice as a portal into the session can enable your client to experience a shift in attentiveness and mood. Having moved into a state of heightened awareness, she or he may then be able to bring newfound clarity of mind to the issues looming throughout the session.

Carol, a woman in her mid-forties with a history of trauma and bulimia, was referred to me for yoga therapy by her psychotherapist. She entered our first session in a highly agitated state. Her shoulders were tight and drawn up toward her ears, and her breathing was rapid and shallow. She was fairly new to yoga and nervous about our work together. After two rounds of a tense-and-release exercise and a brief check-in, I guided Carol in these simple, yoga-based practices: mudra, the use of a hand gesture; pranayama, a simple yoga breath; bhavana, locating an image of sanctuary or peace; mantra, a soothing universal tone; and kriya, a cleansing breath. This series of practices, which took under two minutes, respected Carol’s revved-up state while helping her self-regulate.

Tense and release. To begin, I said to Carol in a calm voice, “Take a moment to tighten as many muscles as you can. Draw the shoulders up to the ears, squinch up your face, make fists with your hands, and sustain your breath. Compress all the getting-here-on-time anxieties and all the judgments you have into a little ball, and place it at the back of your neck. Squeeze the ball, and then let it roll down your back as you let the breath go. Beautiful! Let’s do that again. Inhale and tighten as many muscles as you can. Squeeze whatever is keeping your heart and mind from being completely open. Squeeze, squeeze, squeeze. Now, let it all go . . . beautiful!

Carol was visibly more relaxed after this exercise. Although her breath remained shallow, her face was softer and her eyes more focused.

The use of image. At this point, Carol agreed to try a simple practice we could do in our chairs to bring her current state of mind into balance. I asked her to think of a soothing image. “It could be a place,” I prompted, “real or imagined, where you’re relaxed and at ease. Or maybe,” I said, “a face comes to mind that makes you feel peaceful. It could be a human friend, a precious four-legged friend, or even a deity.”

Carol closed her eyes. After a few moments, I asked her to raise her finger if she’d found an image. When she’d located an image and had opened her eyes, I asked if she’d feel comfortable sharing her image with me. She said she saw her favorite beach in Hawaii. (If your clients can’t find an image, you can ask them to simply think the word peace.)


Notice that as I guided Carol in forming an image, I didn’t use the word safe, as this might have triggered Carol’s mind to think of the opposite, putting her back in a position of fear and anxiety. I also didn’t suggest a specific image, but guided her to create her own. That way, she felt ownership of the image, and her sense of self-efficacy and empowerment was bolstered.

Arm movement, breath, and mudra. Because her breath was shallow and in her upper chest, I didn’t ask Carol to breathe deeply at this stage, since that might have been too difficult. Instead, I chose a breath practice to work with the short breaths she was already taking. I call this practice Stair Step, but it’s actually an ancient technique known in Sanskrit as Anuloma Krama. I demonstrated how to open her arms wide to the sides, raise them up over her head, and then interlace her fingers with her index fingers extended toward the ceiling. This hand position is a mudra.

Mudras engage many nerve endings that activate various regions of the brain. In addition, by asking her to raise her arms over her head, I helped her increase body sensation and body awareness, which is important because many trauma survivors feel unsafe in their bodies. They often say they feel as though they live from the neck up. At the end of the exercise, you’ll see how, through my cuing, I made use of her heightened body awareness to allow her to reoccupy her body safely without ever having to use the word safe.

As we began the practice, I invited Carol to close her eyes or, if that didn’t feel comfortable, to lower her gaze to the floor. I kept my eyes open, so I could see how she was breathing. As a clinician, you want to keep your eyes open while leading a practice, unless your client requests otherwise, so you can monitor the effect of the practice.

As she was lifting her arms, I instructed her to inhale little sips of breath through the nostrils, as though she were climbing a mountain with her breath. When she arrived at the top of the mountain, I cued her to pause and imagine the beautiful scene on the beach in Hawaii she’d chosen as her image—sky, waves, sand, everything. After just a heartbeat or two, I guided her to lower her arms to the side, knowing that from this final position, she’d let her breath out slowly on her own. “Beautiful,” I said.

Adding the mantra. We practiced the Stair Step exercise twice, and then I told Carol that we’d add the mantra so-hum, a soothing sound that I explained means “I am that” in Sanskrit. From my intake form, I already knew that Carol’s religious beliefs wouldn’t be in conflict with a simple, nondeity mantra in Sanskrit. Had this been otherwise, we might have used shalom, amen, or soob-hahn-all-ah to meet her religious beliefs as a Jew, a Christian, or a Muslim, respectively.

We practiced the Stair Step exercise three more times with the mantra. Using the sound helped her slow her breathing even more. Research has shown that mantras are effective because an extended exhalation stimulates the parasympathetic nervous system, relaxing the body. In addition, a soothing sound like so-hum or om deactivates the limbic brain, which is often hyperaroused in individuals with a history of trauma.

Body sensing. As we finished the practice, I invited Carol to sit with her eyes closed and observe the sensations in her arms, palms, and fingertips. “Sense deeply into your palms,” I said. “The mind is a time traveler, but the body is always present. Sensing that feeling in the palms is like having a window into the present moment.”

Notice that I didn’t ask her to feel the sensation in her body in a global way. A client with a history of trauma similar to Carol’s may carry a belief that it isn’t safe to live in her body, or that she’ll be overwhelmed with emotion if she lets herself feel her body. But when we’re specific in our cues to feel sensations in the palms or fingertips, for example—places where there are a lot of nerve endings—we give the client the gift of reoccupying the body in a manner that feels safe.


When we finished these simple exercises, I could see that Carol’s belly was expanding as she inhaled, meaning she was naturally breathing more deeply. Her exhalations came slowly, and her eye contact was steady as well. She said she felt relaxed and a little excited about how easy it had seemed to shift her mood. I told her that the image of the beach in Hawaii was on the altar of her heart, and that she could go back to it any time she felt stressed. She could add the Stair Step breath and the brief pause, for no more than four counts, at the top of the mountain. Since she liked the so-hum mantra, I invited her to use that whenever she felt agitated.

At this point, we rose to move to the yoga mat. However, if Carol were your client, you could begin the work of talk therapy with greater clarity and a deeper sense of connection between the two of you.

Amy Weintraub is the founder of the LifeForce Yoga Healing Institute, which offers trainings in the clinical application of yoga. She’s the author of Yoga Skills for Therapists and Yoga for Depression. Contact: amy@yogafordepression.com.

Tell us what you think about this article by email at letters@psychnetworker.org.

Life After Betrayal

By Steven Stosny

Intimate betrayal strikes at the core of our capacity to trust and love, violating the fundamental expectation that gives us the courage to connect deeply—the belief that the person we love won’t intentionally hurt us. Whether the betrayal is through infidelity, emotional abuse, verbal aggression, or domestic violence, the psychological wound that cuts deepest is the perception that, ultimately, the person we love doesn’t care about our well-being. When humans feel betrayed, we tend to withdraw from contact or furiously lash out in distress, just as do other mammals suffering intense pain.

Cases of intimate betrayal require therapists to reach a balance between validating their clients’ pain and empowering them to improve their lives. If you don’t validate their experience enough, betrayed clients will resist your best therapeutic efforts, feeling you don’t understand their pain. However, if you validate their emotional suffering too much, they may get stuck in their intense and immediate pain. They may even feel that moving on in their lives means losing their identities, since many of them can’t imagine themselves as anything except depressed, anxious victims.

Finding this particular balance was my challenge with Debbie, who’d been married for more than 13 years to a resentful, highly critical man, who’d recently taken most of their retirement savings and left her for a younger woman. Seven months after her divorce was final, Debbie came to see me following an incident in which she’d burst into angry tears after a harried grocery checker had sighed at her for swiping her debit card backwards. Her instantaneous expression of remorse and embarrassment had only made the situation more awkward for her, the cashier, and the shoppers in line behind her.

This dramatic overreaction was one of many such incidents that had plagued Debbie since her divorce. Her previous therapist had tried to help her by exploring her emotions around her husband’s multiple betrayals and linking her anger, resentment, shame, and feelings of abandonment to childhood events. But her flare-ups over everyday occurrences had only increased. Finally, the therapist suggested she use medications, which she refused to do.

Taking a different tack, I assured Debbie that her feelings and reactions were normal—a natural response when a heart is scraped raw by a devastating betrayal. Rather than delving into her childhood, I proposed that we work on increasing her sense of self-worth while teaching her to embrace her deepest values. Through the process of becoming the person she wished to be, I said, she’d learn how to disarm her hair-trigger defense system.

Establishing a Healing Identity

The first therapeutic challenge with Debbie was to help her overcome her victim identity. Like so many who’ve suffered intimate betrayal, she’d come to identify with the bad treatment she’d suffered and all the defects and weaknesses she saw in herself as a result of it. To establish an alternate, healing identity—one that tapped into her resilience, deep values, and desire to improve her life—we began with an inventory of her strengths, which she decided were intelligence, curiosity, resourcefulness, adaptability, and integrity. Then we explored her deeper values, which she said were honesty, responsibility, spirituality, fairness, compassion, love, and appreciation of nature. When we sought out evidence of her resilience, she remembered a time several years before, when she’d recovered from a serious illness while dealing with the loss of her closest friend from breast cancer.


As this healing identity came into focus, Debbie could see clearly that she’d become bitter, anxious, and irritable during her marriage, not the kind of person she wanted to be. It isn’t unusual for people to cope by mirroring the unwanted behaviors of those who’ve betrayed them. To combat this tendency and remind clients of who they want to be, I ask them to write a letter to themselves, stating how they’ll behave differently from their betrayers. Debbie wrote, “He lied all the time; I’ll be truthful in all my relationships. He cheated on me; I’ll be loyal and sensitive to the well-being of those I love. He abused me; I’ll be compassionate to those I love. He was manipulative; I’ll be kind and supportive to those I love. He criticized me for reading too much; I’ll enjoy learning.”

Soon after writing her letter, Debbie decided to pursue a forgotten dream of launching an online macramé outlet, and she set a goal of volunteering at an animal-rescue operation once a month, which she’d enjoyed doing before her husband had ridiculed the activity as a “waste of time.”

Reconditioning the Mind

Emotional healing happens when the brain associates painful images of injury or damage with restorative images of personal symbolic significance. Restorative images motivate behavior that encourages growth and enhances a sense of safety and well-being. For most people, this process occurs naturally over time, as is evident in the normal grieving process following the death of a loved one. In the beginning, memories of the deceased amplify the sense of loss and inhibit emotional investment in others; over time, however, the focus shifts from what’s been lost to what’s been gained from knowing the loved one. This shift allows positive memories, or restorative images, of the deceased to dominate the mind.

To move on from her negative memory loops, Debbie made a list of all the multiple betrayals in her marriage, and then she chose restorative images—such as holding both her children when they were babies, her favorite necklace made by a close friend, and helping her arthritic neighbor weed his garden—to counteract each negative item on her list. To begin the reconditioning process, she put aside 15 minutes every day to go over her practice of pairing restorative images with each painful memory on the list. For most people, this activity becomes easier after a few days, but Debbie was still having difficulty after several weeks. So she tripled her list of restorative images and increased her practice sessions to seven times a day, repeating the associations for as long as it took to feel calm—usually around 10 to 12 minutes. Within six weeks, as she succeeded in training her mind to invoke her restorative images automatically, the intrusive images of betrayal waned in frequency and intensity. For the first time in her life, she felt as though she could control her thoughts and feelings.

Guilt and Shame vs. Compassion

In the aftermath of intimate betrayal, people often experience deep guilt and shame, but the key to healing is for clients to develop self-compassion and an understanding that their worth isn’t a reflection of how they’ve been treated. Instead, their self-value is ultimately connected to their deeper values and feeling of compassion for others.

To help Debbie find an alternative to the negative emotional states that dominated her life, I asked her to list the things causing her to feel guilt or shame and then to explore possible ways of expressing self-compassion and compassion for others. The following example of the process is one of several she came up with.

  • Guilt/shame: I lied to my family about the abuse I suffered all through my marriage, falsely assuring them that things were fine.
  • Self-compassion: I was so ashamed that I couldn’t face the truth myself. I’ll embrace the power of truth in the future, because I’m a truthful person.
  • Compassion for others: I’ll assure my loved ones that they deserve the chance to be compassionate and helpful to me. I’ll be honest and open with them.

It took several sessions, with plenty of homework, for Debbie to finalize her lists, but soon she was incorporating what she wrote into her actions on a daily basis. The process of extending compassion to herself and others helped her clarify and embrace her deepest values.

 


The Ability to Love Again

In the final phase of Debbie’s treatment, the focus changed from developing a healing identity to making new connections, particularly with men. With clients at this stage, I often focus on the distinction between wise trust and its opposites: blind trust and suspiciousness. Wise trust recognizes that we’re all frail creatures capable of betrayal in weaker moments. Blind trust denies this darker characteristic of human nature; suspiciousness exaggerates its presence. Wise trust in action involves a measured assessment and recognition that, despite the alarms triggered by old hurts, the actual probability of betrayal may be quite low if a person has demonstrated trustworthiness over time and under stress.

When Debbie was ready to start dating, we spent time carefully going over the signs of trustworthiness—or a lack of it—in potential partners. We discussed how to determine the likelihood of betrayal by ascertaining how someone responds to feeling vulnerable. When someone responds to a feeling of vulnerability by becoming angry, resentful, or depressed, he or she is likelier to betray you by shutting down, punishing, controlling, or seeking some kind of temporary ego boost through infidelity, impulsive indulgence, or deception. By contrast, someone who responds to feeling vulnerable by trying to improve the situation, connect, or instinctively protect is far less likely to betray you. Eventually, as Debbie began going on dates regularly, I gave her a sheet of paper to fill out to help her assess the probability of future betrayal, asking her to circle all the words that applied. One example from this paper is: “When feeling vulnerable (e.g., anxious, devalued, rejected, powerless, inadequate, unlovable), he tries to improve the situation, connects with me, shuts down emotionally, gets angry, deceives, abuses others, abuses me.”

When Disappointment Feels Like Betrayal

After several months, Debbie began dating a man with whom she felt a strong connection. One day, however, when they were grocery shopping together, he paid too much attention to a young woman in tight shorts in the produce aisle. The fact that he’d failed to “control his eyes” while knowing her sensitivities after her ex-husband’s infidelities seemed like a full-fledged betrayal to Debbie. Since that episode, she’d found herself increasingly irritated and critical with this man when they disagreed about things like politics, books, movies, and other preferences.

I explained to her that after intimate betrayal, it’s easy to misinterpret the anxiety signals that occur with feelings of common disappointment and think that you’re being betrayed once again. To distinguish the difference between disappointment and betrayal for Debbie, I put it this way: “Disappointment is about the way the house looks at a given moment, but betrayal is a gaping crack in the foundation. We can’t assume that displaced furniture signals a crack in the foundation, just as we can’t improve the foundation by rearranging the furniture. Some disappointments can be corrected through negotiation or compromise. Others must be accepted and tolerated if the relationship is otherwise healthy and viable. However, betrayal is nonnegotiable and intolerable, and it should never be accepted without significant relationship repair.”

I went on to offer Debbie a series of specific questions she could ask herself whenever her anxiety was triggered by disappointments in a relationship.

Was the behavior a violation of trust? Debbie’s answer regarding the incident in the grocery store was “Not really, though it seemed so at the time.”

What else might it have been? Debbie replied, “I read that men are more susceptible to visual stimulation, and that sometimes they aren’t immediately aware of where their eyes go. In fact, that’s exactly how my boyfriend described it.”

In the future, what might you say to your boyfriend about how you’d like him to handle similar situations? Debbie said, “I know it’s not that big a deal for you to glance at other women and that sometimes you might not know that you do it, but I’d really appreciate it if you’d be more mindful about it when you’re with me.”

I suspect that Debbie responded well to the approach presented in this case because she was tired of feeling like a victim—a condition that was inadvertently strengthened by her previous therapist, who’d overvalidated her painful experience and tried to relate it to childhood events. In our initial work, although we discussed why her highly emotional reactions were a completely normal response to intimate betrayal, we began to focus on how she could have a greater sense of identity and self-worth by connecting with her deeper values. I began to encourage a sense of empowerment, more so when my efforts to get her to focus on her deeper values and the life she wanted to have in the future had yielded some results. At that stage of therapy, I could point out to her that her straighter posture, more resonant voice, and increased confidence indicated that she was experiencing increased well-being.


Most clients eventually learn the difference between an internal sense of authenticity (who they are at the deepest level) and the self-righteous satisfaction of feeling wronged by the disappointments and abuses they’ve endured. When they experience that tipping point, many are finally ready to do the hard, repetitious work of building new habits of emotional regulation and commit themselves to their deeper values. At that point, they can let go of their sense of victimhood and embrace the rewards—and risks—of living and loving fully as they move forward in their lives.

Case Commentary

By William Doherty

There are a dozen admirable features of Steven Stosny’s work with this client, but I’ll focus on just one here. A key challenge to conventional psychotherapy with clients who’ve been betrayed by a loved one is the risk that we’ll inadvertently encourage them to remain stuck in a victim identity. When we spend session after session on the betrayal experience and related events going back to childhood, we may think we’re helping them work through and transcend their painful experiences, but the reverse may occur: they may come to see themselves as lifelong victims of bad or flawed people, ultimately becoming tragic figures in their own life dramas.

Stosny deftly avoids this risk by taking another path. After the necessary first step of showing deep empathy for Debbie’s feelings of betrayal, he moves quickly to work the resilience side of her experience, her “healing identity.” Although this may seem like conventional psychotherapy (don’t we all work on our clients’ strengths?), he also helps Debbie confront how badly she’s treating other people around her. My therapist colleagues Noel Larson and James Maddock, who’ve worked extensively with trauma, have observed that victim and perpetrator are often paired identities, with the victim identity giving permission to the inner perpetrator to lash out or take advantage of others. Stosny talks about it as mirroring the unwanted behavior of the one who’s hurt us.

In working with Debbie, Stosny demonstrates how we heal ourselves by understanding how we treat other people when we’re in pain, and how self-compassion must be paired with compassionate, fair treatment of others. Therefore, he highlights the importance of helping clients access their core values for how they want to live in the world. Stosny is that rare therapist who talks explicitly about values (dare I say moral values?) and invites clients to live consistently with their deepest values. Since the days of Freud, therapists have been ambivalent about values-talk in therapy, seeing it either as intellectualization not worth exploring, or as something imposed by the superego or society, to be deconstructed.

However, we now know more about how closely interpersonal values and a healthy sense of self are intertwined. Forming healthy personal boundaries—a primary goal for anyone who’s been abused and betrayed—means learning to respect the boundaries of others. In the hands of therapists like Steven Stosny, psychotherapy heals by bringing out the healer in clients.

Steven Stosny, Ph.D., is the director of Compassion Power. He’s the author of Love without Hurt and the coauthor of How to Improve Your Marriage without Talking about It. His forthcoming book is Living and Loving after Betrayal: How to Heal from Emotional Abuse, Deceit, Infidelity, & Chronic Resentment. Contact: stosny@compassionpower.com.

William Doherty, Ph.D. is director of the Minnesota Couples on the Brink Project at the University of Minnesota and cofounder, with his daughter Elizabeth Doherty Thomas, of the new Doherty Relationship Institute. Contact: contact@drbilldoherty.org.

Tell us what you think about this article by email at letters@psychnetworker.org.

Religion as a Therapeutic Experience

By Ryan Howes

Can a connection with God offer the kind of support and affirmation that a relationship with a therapist can? New research by Stanford University anthropologist Tanya Luhrmann indicates that it can, at least for some American evangelical Christians.

Many therapists are wary of the therapeutic value of prayer or the role of religion in clients’ lives. But people have been turning to religion for comfort, healing, and understanding for far longer than they’ve been making appointments with therapists. Perhaps it’s because, as Luhrmann points out in her new book, When God Talks Back: Understanding the American Evangelical Relationship with God, people with a certain psychological makeup can create a “real” experience with God. Rather than feel God in an esoteric way, they audibly hear God addressing them personally, sometimes from across the breakfast table or in the produce aisle of their grocery store. Reports of this type might raise alarm bells for some therapists, but for some churches, this type of connection isn’t cause for concern—it’s encouraged.

In this interview, Luhrmann explains how she came to spend time in the evangelical church to study the ways members communicate with God, and how this communication can be therapeutic, particularly when people tap into their imagination and hear God talk back.

—–

RH: What led you to study evangelicals?

LUHRMANN: I actually started with researching magicians and how magical tricks can become quite real for some of the people watching them. I was interested in how ordinary people could come to experience the world as if magic actually worked, even when it seemed to violate the rules of everyday reality. I found there were certain heuristics and narratives that, with a little suggestion, allowed some people to enter a frame of mind that would enable them to experience the “reality” of magic.

RH: Not so different from religious experience.

LUHRMANN: Right. This led to my getting interested in the mental state of “absorption”—the capacity to shift your attention from the external, everyday, instrumental dimension of life to become immersed in your own mental imagery. That shift seems to be central to the experience of religion.

Religion requires us to take what’s usually experienced internally and both imagine it as having an external reality and see a quality of goodness as real and palpable out in the world. In the evangelical churches where I spent my time researching my latest book, it was important to be able to experience God as both very loving and absolutely real. At the same time, it was recognized that some people were going to be better at it than others, and that it was something you had to learn and practice.

RH: Do you mean better at engaging in public prayer or better at feeling an internal connection with God?

LUHRMANN:Among the evangelicals I spent time with, many people would talk about hearing directly from God, but others found that difficult or impossible. Many reported talking with God and going for a walk with God as an everyday experience. It was easy for them: they weren’t embarrassed about it, and didn’t find that it was difficult to carve out time for it. And they insisted that it was a two-way interaction. But the church clearly identified them as different from people who have a really tough time hearing God.


RH: I’ve heard the term prayer warriors used for folks who are seriously committed to prayer.

LUHRMANN: Yes, exactly. I was really interested in finding out more about what was happening for them psychologically. I found that they scored high on the absorption scale, which predicted which members of a church were more likely to report that they had a back-and-forth experience with God, that God addressed them like a person, and that they could feel God’s love directly. It would also predict whether people said they heard God talk audibly or whether they experienced God with their other senses.

RH: How did you measure this?

LUHRMANN: I ran an experiment in which I asked people to listen to a piece of scripture on an iPod for half an hour a day for a month. Then, while the control group was just asked to listen to lectures from a teaching company on the gospels, the experimental group was led through the scripture again and encouraged to use their imagination.

For example, with “The Lord Is My Shepherd” psalm, they were asked to look directly at the shepherd, to look in his eyes, and to see how he held himself. They were more likely to report sharper mental images, a more vivid internal experience, a fuller sense of God’s love and presence. They also reported more hallucination-like experiences—not actual hallucinations, but vivid religious experiences outside of everyday reality. For instance, they’d report, “I thought that I saw the edge of an angel’s wing” or “God spoke to me.” It seemed that by following the instructions we gave them, they learned a different way of perceiving God.

RH: Is there any way to distinguish what some people see as delusion from a faith in the intangible?

LUHRMANN: I’ve done research on psychosis, and I know a lot about the internal experience of people who meet the criteria for schizophrenia. The phenomenological accounts of that experience are quite different from those of the people I spent time with in these churches. For the evangelicals, the experience of nonordinary reality are rare and brief and filled with a sense of “goodness.” Somebody might hear God saying, “I’ll always be with you” from the back seat of a car, and they find it comforting rather than deeply disturbing.

RH: Someone shared with you that God told them to vote for George H. W. Bush in 1988.

LUHRMANN:Yes, exactly. That’s quite different from the frightening experience of someone with schizophrenia. I think many people in the evangelical churches are invited to allow some of their thoughts to become more external, but those are the good and loving thoughts.

RH: Why would they do that?

LUHRMANN: Well, I don’t think the church would describe what they do in that way. I think the church would describe that as prayer. But I think that process is really therapeutic.

RH: Self-talk is a central concept in many therapeutic modalities. Is prayer with a loving God something like talking to an affirming therapist all day long?

LUHRMANN: Yes. I think that there’s actually evidence for that. I ran one experiment in which we gave everyone a series of measures,including the statement “I feel God’s love for me directly.” The more highly they affirmed that statement, the less lonely they were and the fewer symptoms they reported on a brief psychiatric scale. Clearly, this can be quite a powerful experience for people.


RH: So as a nonevangelical outsider, how were you received by the people you studied?

LUHRMANN: Often I felt like I was trying to get academic information while they were trying to get my soul, which at times was an exhausting experience. But most of the time, people were supportive and generous and refrained from ending every conversation with an exploration of where I was in my walk with Jesus.

I did have one long conversation with the president of a Southern Baptist seminary who loved my book, but he couldn’t stand the kind of Christianity I was describing. He believed that what’s gone wrong in American Christianity is that God has become so loving that people aren’t paying attention to judgment.

RH: Not enough fire and brimstone!

LUHRMANN: Exactly. The folks I studied don’t do brimstone. They were overall pretty accepting and appreciative, especially the people who don’t hear God speak. In fact, they found my work really interesting because they were wondering if they’re doing something wrong and even questioned whether God loved them. They took some comfort from the fact that I was a respectable scientist who was saying there are these temperamental differences that make a difference in people’s experience of religion.

RH: Rather than “ye of little faith,” you’re discussing personality characteristics, telling them it’s not their fault.

LUHRMANN: Yes, and they appreciated that there was no stake in it for me to say that.

RH: Is there any hope that religious and nonreligious people can work together in harmony?

LUHRMANN: Many of my academic colleagues who look at evangelical Christianity are just horrified. At the most fundamental level, they don’t get why anyone would participate in it. As an anthropologist, I was eager to see if I could put politics aside and contribute to a sort of bridging process. I found that it’s not that people are just cut from a different human cloth, but that like other kinds of behavior, religious behaviors are learned. This learning is part of what makes religious faith satisfying, exciting, and joyful. I found that you can be a reasonable human being and still want to have those kinds of experiences.

Ryan Howes, Ph.D., is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs “In Therapy” for Psychology Today. Contact: rhowes@mindspring.com; website: www.ryanhowes.net.

Tell us what you think about this article by email at letters@psychnetworker.org.

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.