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.
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.
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.
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.
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!”
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.
By Ryan Howes
Right now, we’re all subjects of what’s arguably the most widespread, fastest-paced, unplanned experiment on human psychology ever conducted in history. The research question is: what happens to the human brain when, within a few short decades, it’s introduced—in fact, saturated in—a radically new, instantaneous communications technology that links up billions of people and expands access to untold quantities of information over the entire globe? Does this revolution in technology genuinely enhance human connection or just the opposite? Does it make us smarter in some ways, dumber in others?
Gary Small, a UCLA psychiatrist, neuroscientist, expert on memory and aging, and author, with his wife Gigi Vorgan, of iBrain: Surviving the Technological Alteration of the Modern Mind, is on the cutting edge of research about how our digital world is transforming the human brain. In this interview, he discusses how technology is changing our minds and suggests when therapists should respond to clients whose relationship with technology has become unbalanced.
RH: How did you get started looking at how technology influences the brain?
SMALL: My field is geriatric psychiatry, and I’ve done a lot of research over many years on brain function, brain structure, brain aging, and mood and memory. As a tech geek myself, I was drawn to the question of how all these new technologies are affecting the brain. At some point, the question that most interested me changed from “How can we use technology to measure the brain as it ages” to “Let’s find out what this other technology is doing to the brain at every age.”
RH: Speaking of all ages, you were recently quoted in a New York Times article about the impact of easy-to-use tablet computers on toddlers. What’s your take: good or bad?
SMALL: Basically, we don’t know, but there’s a growing concern because a lot of parents are increasingly using tablets and other digital technology as pacifiers. Is that going to inhibit children’s development of language skills? Some studies suggest that too much screen time could contribute to AD/HD symptoms and lower performance in school, but there’s also a lot of individual variation: some children are more sensitive than others to large amounts of screen time.
RH: Speaking of the impact of technology, how about adults? Is it true that my cell phone is destroying my capacity to remember phone numbers?
SMALL: It’s not destroying it, but basically what you’re describing is a nonissue. The reality is that you don’t need your brain to remember phone numbers in today’s world. For that and many other things, you can use your digital devices to augment your biological memory—for remembering names and faces, and for focusing your attention when you’re having a conversation. In fact, your brain power is better spent learning the apps to use so you can take advantage of the computer as an extension of your biological brain.
RH: So don’t go overboard in seeing computers as having a damaging effect on our cognitive capacities?
SMALL: Exactly. [Phone rings in background.] Please excuse me for a moment [On hold. Four minutes of Muzak.] Hi. I’m sorry about that. I’m afraid I’ve got a fundraiser right now that needs a little bit of my attention. I don’t usually take calls like this, but this underlines part of the whole problem with technology.
What I was just doing in taking that call is called continuous partial attention—scanning the environment for something that’s more imminent than what’s going on. It’s actually a stressful thing that’s not good for our brains or for our relationships. In fact, right now I feel a little guilty that I wasn’t paying full attention to you.
RH: No harm done! Actually, I’m so used to being interrupted by technology that I hardly even notice it.
SMALL: This is one of the issues that people frequently experience in face-to-face conversations these days. They’re talking with someone who won’t look at them because the other person is texting at the same time. So they think, “Eh? Does this person really care about me?” This is having more and more of an impact on the level of social connection people feel.
RH: How’s the influence of technology different from any other factors on social connection?
SMALL: We don’t exactly know, but the principle is this: your brain is sensitive to mental stimuli from moment to moment. If you spend a lot of time with a repeated mental stimulus, neural circuits that control that stimulation will strengthen at the cost of weakening other neural circuits. Basically, most of us are logging too much technology time, and we’re paying a price. We’re not engaging this powerful brain in activities like looking people in the eye, noticing nonverbal cues and emotional expressions, empathizing with other people. That’s a big concern in today’s technological world.
RH: So it’s not technology itself that’s the issue: it’s the fact that technology takes us away from so many other important social activities?
SMALL: Right. And there’s the very real issue of technology and addiction. Some people are addicted
to video games or to shopping online or gambling online, and that
can be destructive to their lives. Studies suggest it can worsen AD/HD, and it may even contribute to the development of autism spectrum disorders.
RH: When should therapists be concerned about a client’s relationship with technology?
SMALL: My alarm goes off if clients keep interrupting a therapy session because they’re answering texts or making calls or checking websites. Any time I see a patient with an inability to unplug for a while—someone who can’t have a conversation because he’s too busy messing with technology—I consider it an issue worth discussing.
RH: What impact might technology have on the future of therapy?
SMALL: Of course, many therapists already use technology in their
practice. Video conferencing and the use of virtual-reality therapy for people with post-traumatic stress and phobias or obsessive-compulsive disorders are increasingly common. There are applications you can download to help with mood and anxiety disorders. Clients can even wear sensors that will alert their therapist when they’ve reached a certain threshold point of anxiety. I think we can take advantage of technology to enhance therapy and increase its effectiveness.
RH: So you’re optimistic about our future with technology?
SMALL: I have faith in humans, and I think we’re going to make the right decisions. We need to bear in mind that technology is neither all good nor all bad. The challenge is to integrate it into our lives, rather than let it become something that enslaves and controls us.
But with young kids, I do have a special caution. The parents of small children have a responsibility to make sure they don’t overuse it and that they spend plenty of time offline. For adults, same thing: don’t spend hours and hours just answering your email. As with so many other issues in life, it’s a question of balance and putting things in perspective.
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: email@example.com; website: www.ryanhowes.net.
By Diane Cole
The World until Yesterday: What Can We Learn from Traditional Societies?
By Jared Diamond
Viking. 499 pp.
“NOW IS BETTER.” The bold logo, emblazoned on a stylish tote bag, caught my eye recently at a favorite museum shop. The tote cleverly served as both self-help logo and advertisement for the contemporary art exhibition I’d just viewed. The high-concept show had centered on the psychology of human happiness, and this was one of its chief precepts. But as appealing as the slogan was at first sight, upon further reflection, it seemed insufferably smug.
I’d just read the multidisciplinary scientist and bestselling author Jared Diamond’s provocative new book, The World until Yesterday: What Can We Learn from Traditional Societies? and one of his first lessons is that we don’t all live in the same “now”—or even necessarily share the same psychological assumptions or expectations. Indeed, he writes, “Psychologists base most of their generalizations about human nature on studies of our own narrow and atypical slice of human diversity.” As a result, he continues, “Most of our understanding of human psychology is based on subjects who may be described by the acronym WEIRD: from Western, educated, industrialized, rich, and democratic societies.”
By contrast, his decades of living for extended periods among traditional peoples in isolated regions of the Pacific Islands has taught Diamond just how weird Western societies can seem when seen through the lens of small-scale societies. To begin with, he writes, “Many of my New Guinea friends count differently (by visual mapping rather than by abstract numbers), select their wives or husbands differently, treat their parents and their children differently, view danger differently, and have a different concept of friendship.”
To Diamond, who’s a serious scholar (a professor of geography at UCLA) and a master of making scholarly ideas accessible (as in his Pulitzer Prize–winning book, Guns, Germs, and Steel) these differences provide an opportunity to rethink how our particular WEIRD “now” evolved—and the benefits and losses incurred in that journey. Yet Diamond’s purpose in taking us with him as he explores the organizational structures, cultural practices, and ways of living that have been forgotten or just plain jettisoned by Western modernity is neither to wistfully romanticize traditional cultures as “simpler” nor to discredit Western progress as soulless consumerism. He’s not about to advocate that we give up modern hygiene and medical resources, and has no desire to revive indigenous practices that strike us as nothing less than heinous—like infanticide, strangling widows, or abandoning the old to die when they’ve outlived their usefulness.
His goal is to sift through old ideas for reconsideration, with clear eyes and an open mind. With one foot planted in the “now” of Western culture and the other spanning the traditional cultures he’s studied, he makes a compelling case for the ways in which reincorporating at least some of these old ways can pay off—in wisdom and perhaps even economically—in our modern-day world.
He begins with the ways in which small-scale societies of New Guinea maintain law and order and regulate disputes, both among members of one tribal group and between different groups. Precisely because these societies are so small, both parties in a dispute—whether related to land, theft, or accidental death—are likely to know each other, and may even be members of the same extended family. Unlike in litigation in large cities, where the two parties will most likely be strangers, in these villages, the disputants will continue to encounter each other and farm, hunt, or trade together in the normal course of daily life. That’s why, in these societies, pointing blame, deciding who’s right or wrong, and meting out punishment through the kind of lengthy, adversarial trial system we practice in the West would be counterproductive. It would likely divide village members against one another, disrupt the smooth functioning of the community necessary for its survival, and even risk a cycle of revenge killings.
Instead, for New Guineans, finding “justice” hinges on restoring the previous relationship to what it had been before, with both sides being able to save face, reconcile, and clear the air so they can get on with their individual and communal lives. To avoid lingering grievances, this all should happen as quickly as possible, through mediation (often with the help of mutually respected leaders) and rituals of compensation—such as gifts of food and goods, or a shared feast.
How is this applicable for the West? Putting reconciliation and mediation first surely could serve families in civil law cases having to do with divorce, family inheritance feuds, and other domestic issues, Diamond suggests. “Far from helping to resolve feelings, court proceedings often make feelings worse than they were before.” As he points out, “All of us know disputants whose relationship became poisoned for the rest of their lives by their court experience.” It’s a sentiment with which many psychotherapists and lawyers would heartily agree, and which some states have already signed on to, in terms of requiring mediation prior to divorce. This is an area that cries out for more study by both the legal and the psychotherapeutic communities.
Moving on to family life, Diamond notes that children in hunter-gatherer societies seem more emotionally secure, independent, and curious than kids reared here—not just to him, but to other Westerners who’ve spent time in traditional cultures. He has no studies to back up this impression, but he nonetheless wonders if this greater self-confidence is due, at least in part, to such traditional practices as “the long nursing period, sleeping near parents for several years, far more social models available to children through allo-parenting [provided by adults in addition to the biological parents], far more social stimulation through constant physical contact and proximity of caretakers, instant caretaker responses to a child’s crying, and the minimal amount of physical punishment.” Despite the lack of scientific proof, he avers that the long-term success of these methods in these societies makes them worth a try. In this, he seems a bit behind the Western “now,” where some of these practices have been gaining traction for decades.
At the same time, unfortunately, too many of the current realities in Western life—parents’ overly long working hours, the lack of funding for community support systems, and overuse of digital games that double as babysitters—make the goal of more interactive parent–child time seem admirable rather than realistic. One possibility: take a lesson from the positive ways in which some traditional societies value their elders and organize programs that regularly bring seniors into more direct contact with young people to be potential mentors. It would be a new twist on allo-parenting that could be beneficial to many generations simultaneously.
Diamond is particularly persuasive in his case for a mindset he calls “constructive paranoia.” The idea is that it’s self-protective to become vigilant to the signs of the many low-risk but frequent hazards we face repeatedly. For traditional societies, this encompasses the possibility of lion attacks, dead trees falling over, or an enemy ambush in the forest; for us, traffic accidents, heart attack warnings, and icy sidewalks. While traditional societies learned the importance of continuous awareness to potential danger from life-and-death experiences, too often we in the West take our continued well-being for granted—at our own peril. We assume that we won’t fall asleep at the wheel, no matter how little we’ve slept the night before, or that the taxi will stop at the red light, rather than speed through and catch us, texting unawares, as we cross the street. Diamond speculates that, in addition to training themselves to be alert as a survival instinct, traditional societies further help guard against negative occurrences by continually and constantly talking to one another about every last detail of their daily lives, including minute observations about any change in behavior, weather pattern, strangers approaching, newly fallen trees, or animal tracks. Rather than being boring, such conversations serve up information that helps instill and refine the instinct for caution as they go about their lives. In our case, adopting such a mindset—and listening for nuggets of advice in someone’s seemingly endless tale of medical ills—might help us bypass an avoidable pitfall.
Diamond continues with a (literally) stomach-churning chapter about the public health crisis wrought in traditional societies by the Western diet. When he visited New Guinea in the early 1960s, Diamond reports, “The non-communicable diseases that kill most First World citizens today—diabetes, hypertension, stroke, heart attacks, atherosclerosis, cardiovascular diseases in general, and cancers—were rare or unknown among traditional New Guineans living in rural areas.” But the introduction of Western lifestyles into many of these areas has brought, within decades, high rates of these diseases. The culprits, as he sums them up, are “salt, sugar, fat and sloth.”
We all need to teach—and learn from—each other to eat less, consume more healthfully, and exercise. How to do that is the subject for another book entirely. But in the meantime, the lessons Diamond distills in this book provide plenty of food for thought.
Contributing editor Diane Cole is author of the memoir After Great Pain: A New Life Emerges, and writes for The Wall Street Journal and other publications. Contact: firstname.lastname@example.org.
When it comes to the craft of conversation, most of us believe that some face-to-face interaction is the key component of emotional communication. For social engagement, we connect with our social network over Facebook or use our various iDevices for a little FaceTime with relatives. But new research is questioning how we actually process and interpret the emotional reactions of others. The findings might make us take an about-face turn on conventional wisdom regarding facial expressions and emotions.
For decades, researchers have relied on the “Ekman faces” for studying how we process emotional expressions. In the 1970s, psychologist Paul Ekman created a set of black and white photographic images of actors portraying six “universal emotions”: happiness, sadness, anger, disgust, fear, and surprise. Although the stimuli have varied over time (to incorporate actors of varying ethnicity, for example) and the universal emotions have expanded (to include emotions such as pride, guilt, and shame), the fundamental reliance on facial expressions as a primary indicator of emotional state has remained. Now it appears that, when it comes to intense real-world emotional experiences—such as the joy and relief of seeing your first child born or the agony and disappointment of a crushing defeat—our faces may not be as revealing as once believed.
To examine the role of facial expressions and body language in how we interpret the intense emotional displays of others, researchers at Princeton, New York, and Radboud universities captured photographic images of peak emotional expressions from a variety of powerful real-life situations, including high-stakes tennis matches, sexual orgasms, home-makeover reveals, and navel or nipple piercing. After manipulating the images to isolate facial expressions, bodily expressions, or bodily and facial expressions combined, the researchers asked study participants to rate the type and intensity of emotional experience they thought they saw in each image.
As published in the journal Science, the results demonstrated that when viewing facial expressions alone, viewers were no better than chance at identifying whether the expression indicated a positive or negative experience. Viewers were much better able to identify positive or negative experiences when viewing the images of bodily expressions of emotions (with or without the corresponding facial display).
In case you’re tempted to read these results and think you knew it would turn out that way all along, the researchers actually described their methods to a separate group of participants beforehand. Of those asked, 80 percent thought viewing the face alone would be most accurate, whereas only 20 percent thought the body/face images would be most effective, and zero people predicted that the body image alone would be the most useful indicator. Furthermore, by manipulating the body image, the experimenters successfully manipulated viewer perceptions of the emotions shown. For example, when putting the face of someone undergoing piercing on the body of a tennis victor, viewers were more likely to rate the photograph as someone experiencing intense joy.
“These results show that when emotions become extremely intense, the difference between positive and negative facial expression blurs,” said the lead researcher Hillel Aviezer in a released statement. “From a practical-clinical perspective, the results may help researchers understand how body/face expressions interact during emotional situations. For example, individuals with autism may fail to recognize facial expressions, but perhaps if trained to process important body cues, their performance may significantly improve.”
Beyond that, the study’s results may have implications for therapist practice and training by overcoming our natural inclination to pay attention to facial expressions and highlighting more focused attention on body language and physical cues. Videotaped supervision sessions might need to zoom back to incorporate the body posture of therapists and their patients. Also, teletherapy through Skype, which focuses primarily on the face, might be improved with more attention to the whole-person image.
Reading Emotions: Science 338, no. 6111 (November 2012): 1225–29; http://www.eurekalert.org/pub_releases/2012-11/thuo-bln112912.php.
Q: One of my European colleagues is excited about “mentalization” and Mentalization-Based Treatment. What is it?
A: Mentalization refers to the mind’s innate capacity to make sense of social experiences and implicitly know how to respond to them. Think about the following examples. You arrive home and say, “Hi” as you open the door. Your partner says, “Hi” back. Without a second thought, you’re aware of the tension in his voice that suggests he’s had a hard day. Or after a meeting with an old friend, you experience an uneasy feeling. Reflecting on your time together, you realize that you’re feeling bad because your friend takes a superior attitude with you.
Mentalization enables us to understand the intention or purpose behind other people’s behavior from their tone of voice, facial expression, and body posture. Therefore, when someone comes toward us wearing a grimace and hunched shoulders, we “get” that he or she is upset and perhaps angry. We instinctively recognize that mental states—thoughts, feelings, beliefs, or attitudes—underlie almost all behaviors.
This concept was introduced into the clinical literature by Peter Fonagy of the Anna Freud Centre in London in the 1990s. In a series of papers, including “Thinking about Thinking” in 1991 and “Playing with Reality” with Mary Target in 1996, he explored the theory of mind’s central role in the development of a sense of self. Drawing on clinical studies of borderline personality disorder and violent behavior, he argued that the failure to read and get the implicit meaning of another’s actions led to the loss of impulse control, an unstable sense of self, and problematic relationships. In the last 20 years, the mentalization model of mind has gone from being an obscure aspect of Attachment Theory to the centerpiece of Mentalization-Based Treatment (MBT) for borderline personality disorder. It’s now being integrated into treatments for addiction, trauma, eating disorders, and other conditions. But how does it work?
While mentalization fosters an empathic awareness of the moods and mindsets of others, it also enables us to know what our own states of mind and body mean. Our brain–minds assemble information about the state of our body, the input of our senses, and our associative memories to grasp our own intentionality. We mentalize explicitly by reflecting on experiences, conscious narratives, and empathic communication with others. Our “social brains” have evolved over the eons to become highly specialized in “reading” others’ minds, and our own. Menninger Clinic psychologist and mentalization expert Jon Allen and colleagues believe that mentalization is at the heart of emotional and social intelligence, and is central to all interpersonal experience.
Fonagy asserts that mentalization represents the epitome of human cognitive evolution and is the foundation of all effective psychotherapy. In fact, research has shown that when people lose their ability to mentalize their experience—usually in the context of high affect and threats to emotional security—they have a hard time making sense of other people’s behavior and their own. They become reactive, impulsive, and self-centered, and lack perspective.
Fonagy’s early work examined the development of borderline personality disorder. He found that people who became borderline had fragile mentalizing capacities and were vulnerable to breakdown in close interpersonal situations. The research also revealed that these people had often grown up in families that inhibited mentalization skills. In abusive families, for instance, high levels of frightening feelings overwhelm and shut down children’s capacity to think about what’s happening. In addition, children may avoid reflecting on their parents’ intentions, since it could be terrifying to understand their confusing and, at times, hateful feelings toward them.
These findings dovetail with similar data generated by the Adult Attachment Interview, developed by psychological researcher Mary Main. She found that individuals who are able to reflect on their relationships with their parents with perspective and understanding were likelier to be secure in their attachments to others and have securely attached children.
Rather than being an entirely new form of treatment, mentalization-based therapy contributes to our understanding of what happens in many different approaches. Fonagy argues that achieving more stable and robust mentalization constitutes success in most treatments because it enables people to regulate their own moods more effectively and think coherently about themselves and what they want. By focusing on mentalization as a skill, therapists help clients understand more of the connection between how they feel, what they want, and how they act by themselves or with others.
Mentalization encourages a nonjudgmental attitude of curiosity, inquisitiveness, and open-mindedness toward the client’s subjectivity. Rather than assuming a role of expert, the therapist adopts a “not-knowing” stance, founded in the belief that we come to know what it’s like for another by inquiry, not by assumptions or formulations or by explaining clients to themselves. It’s a here-and-now, process-oriented approach. The therapist encourages the client to think about his or her experience, the goal being to learn to “think about feeling, and feel about thinking.” The therapist guides the client to step back and take perspective on their experience together in therapy: “Yes, that’s one possible meaning; what are others?” “How do you imagine it looks from my point of view?” He or she listens to the client’s narrative and seeks to explore the aspects that are being neglected.
Some critics have wondered what’s gained in using the term mentalization as opposed to empathy, psychological mindedness or affect awareness. Some find Daniel Siegel’s idea of mindsight a friendlier term referring to many of the same functions. But in my own practice, a focus on mentalization has deepened my understanding of the balance between affect and cognition and the need to integrate these aspects of experience. Of course, we all know, theoretically, that the therapeutic connection is at the heart of all good therapy, but understanding the moment-to-moment processes of mentalization can deepen a therapist’s understanding of just how shifts in the relationship can lead to lasting therapeutic change.
Steven Krugman, Ph.D., is a psychotherapist in Boston. He teaches about Attachment Theory and interpersonal neuroscience, and is on the faculty of the Psychoanalytic Family and Couples Institute of New England. Contact: email@example.com. Tell us what you think about this article by e-mail at firstname.lastname@example.org.
By Barry McCarthy
Recovery from an extramarital affair asks a lot of partners. They must not only process painful feelings, repair the rupture of trust, and share their deepest vulnerabilities, but also take steps to build a new, resilient bond, both emotionally and sexually. Allocating the right amount of time to deal with the affair and determining when partners are ready to focus on the present and future marital bond is a struggle for both clinicians and couples.
Cheryl and Justin, a couple in their mid-thirties, were both demoralized and alienated when they arrived in my office. Two years earlier, Cheryl had discovered that her husband of nine years had been spending some $700 a month on Internet sex sites, massage parlors, strip clubs, and prostitutes. When she’d furiously confronted him, he’d refused to admit that his behavior constituted an extramarital affair, dismissing it as normal male fooling around. Cheryl had considered leaving the marriage, but she didn’t want her son and daughter to suffer the same pain, loss, and family fracturing she’d experienced as a result of her mother’s three divorces.Cheryl and Justin had received lots of conflicting advice from family and friends during the past two years. Some thought they should end the marriage and get a lawyer, while others encouraged them to see a pastoral counselor or marriage therapist. A friend of Cheryl’s even recommended that she forgive her husband in exchange for $5,000 worth of jewelry.
As their mutual bitterness escalated, the couple’s sex life ground to a halt. Cheryl accused Justin of being an irresponsible sex addict who was bankrupting the family, and Justin shot back that she was acting like the sex police. For two years, they remained stuck in mutual recrimination, unable to decide how to move forward. Finally, Cheryl’s older brother, an accountant, confronted them with the reality that they were spending more money on counselors, computer surveillance equipment, and a private detective than Justin had spent on all the sex sites, clubs, and prostitutes. Shocked by this realization, the couple accepted the brother’s suggestion that they see a clinician who specialized in marriage, sexuality, and extramarital affairs.
My approach to affairs is heavily influenced by the work of clinician–researchers Douglas Snyder, Donald Baucom, and Kristina Coop Gordon, who advocate that partners go through a three-phase process: (1) focus on self-care, slow down the process, and do no harm to each other; (2) make personal and relational meaning of the affair; and (3) decide to either recommit to the marriage or achieve a “good divorce.” In my work, I emphasize an additional phase: sexual recovery from the extramarital affair. Few theoretical and clinical models include this vital aspect of treatment.
Justin and Cheryl came in for a four-session assessment that included an initial couples session, an individual session focusing on each partner’s psychological, relational, and sexual history, and a couple feedback session with a recommended therapeutic plan. Not surprisingly, our initial session was difficult, since both were still trapped in a blame/counterblame cycle. Cheryl fluctuated between raging at Justin—calling him a jerk who was destroying her life and family—and begging him to love her and be a trusted partner. Justin barely looked at Cheryl, at one point muttering, “This is useless.” It was hard sitting with their pain, but such raw suffering is frequently part of the initial couple session.
The subsequent individual sessions were more productive. In listening to Justin’s story, it was clear that he brought a number of strengths to the marriage: he loved Cheryl, valued sex, cared about their family, and wanted to heal the marriage. But while Justin loved his wife and found her attractive, he was an anxious sexual performer and didn’t value marital sex. He couldn’t imagine his wife in the erotic role that most turned him on—that of a dominatrix. Justin eroticized transgressive sex, specifically the role of being a sexual submissive. “I’ve struggled with this my whole life,” he said, adding that he’d never revealed this part of himself to any intimate partner, including Cheryl.
Justin continued to resist labeling his secret sexual life as an extramarital affair. He rightly noted that a large percentage of men use porn and get turned on by socially unacceptable images and scenarios. Feeling my empathy and respect, he gradually grew less defensive and began to examine both the healthy and unhealthy components of his sexuality. While maintaining eye contact and reflecting how difficult this sexual split must be for him, I said, “You owe it to yourself to resolve these conflicts.” Once we acknowledged his sexual strengths—valuing sex, enjoying eroticism, and having regular orgasms—I looked him in the eye again and said, “Be honest with yourself. What don’t you like about what’s happening with you sexually?”
After a silence, Justin said in a low voice, “I’m embarrassed about spending so much money on sex clubs and all the rest.”
Gently, I pressed the issue: “After a sexual encounter, what do you think and how do you feel?”
More silence. Then he answered: “I just want to get away.”
After a moment, I suggested to Justin that keeping his sex club encounters a secret and de-eroticizing his wife were part of the problem. “Your sex is controlled by high secrecy, high eroticism, and high shame, isn’t it?” I asked. When he nodded agreement, I added, “Don’t you feel that’s a poison that you’re taking into yourself?” This was a new, non-shaming way for Justin to understand himself, the role of his secret sex life, and how it affected Cheryl. For the first time, he understood that his secret sexual activity did negate marital sexuality and, therefore, was an extramarital affair. His voice shaking, he said, “Dammit, Cheryl’s right. It is like an affair.”
In her individual session, Cheryl revealed that she’d grown up feeling fearful and inadequate in the sexual realm. Her mother had raised her to link sexuality with pregnancy and being labeled a slut. She never felt pretty or sexy enough and feared that no one would ever want to marry her, so when Justin pursued a relationship with her and proposed marriage, she felt she’d been saved. Now she was devastated by her husband’s lack of erotic interest. “I feel like a sexual neuter,” Cheryl said. “I can’t imagine that any man would think I’m attractive or want to go to bed with me.”
A crucial component of our sex therapy model is the couple feedback session. The goals of this 90-minute session are: the development of a new, more genuine narrative about each partner’s strengths and vulnerabilities, especially regarding sexuality; the creation of a therapeutic plan addressing the relationship, the affair, trust, and the couple’s sexuality; and assigning the first psychosexual skill exercise to be completed at home. As both partners confront painful personal, relational, and sexual realities during the feedback session, the clinician must be particularly empathetic, respectful, and caring.
I started the session by turning my chair to face Cheryl as Justin looked on. “Cheryl, you bring great psychological, relational, and sexual strengths to this marriage,” I began. “You want a marriage that’s satisfying, stable, and sexual. You’re committed to developing a healthier family than the one you grew up in, and you’ve survived the painful last two years and haven’t given up trying to understand what’s happening to you and Justin sexually. But you also bring major vulnerabilities. You deal with hurt feelings by becoming angry and attacking, your sexual self-esteem is low, and you’re now Justin’s worst critic.” I then turned to Justin and addressed the particular strengths and vulnerabilities that he brought to the marriage.
During this session, both partners learned new and valuable information about the other. Cheryl hadn’t been aware of Justin’s desire to be sexually submissive or his performance anxiety during sex. For the first time, she understood that her husband’s affair had been driven by his own internal sexual conflicts, rather than his judgment of her sexual desirability. Rather than having to defend herself by attacking him, she felt freed to be more emotionally present with Justin in a new way.
For his part, Justin hadn’t realized how desperately Cheryl needed his love and sexual desire, nor did he know how devastated she was by his loss of sexual interest in her and his avoidance of marital sex. For the first time, he took some responsibility for the impact of his secret sexual life. “I never wanted this to happen to you or to us,” Justin gently told his wife. “I never intended to hurt you.” Then, with my urging, Justin took her hand, looked into her eyes, and said, “I love you and want to be with you.”
This larger focus on the couple’s marriage and sexual connection enabled them to begin addressing the fuller meaning of the affair. Until then, it was as though Justin and Cheryl had been speaking completely different languages about the affair’s significance, and now finally were able to communicate in English. Both understood that the affair had nothing to do with Cheryl’s erotic allure and everything to do with Justin’s need to act out a secret sexual life that was split off from his married life. This crucial shift helped them reengage emotionally and begin experiencing themselves as allies instead of the adversaries they’d been in the last two years.
By the end of the 90-minute feedback session, the three of us were emotionally drained, but Justin and Cheryl exuded a new sense of hope. They committed themselves to a therapeutic plan for trying to rebuild a new marital and sexual bond. Toward the end of the session, I described a psychosexual trust exercise and asked them to practice it at home. It focuses on nude, whole-body touching that promotes safety and attachment. The trust position that Cheryl and Justin chose was her lying in his arms as he stroked her hair. Over time, this exercise helped them experience being part of an intimate team in confronting the past and building a satisfying new sexual connection.
Building a New Bond
Our next several therapy sessions were emotionally challenging as Cheryl and Justin continued to reveal painful hurts and disclose their vulnerabilities. At the same time, I continued to offer them encouragement and tools for developing a new, positive connection. In one session, I asked them to engage in the attraction exercise, in which each shared what they valued about their spouse emotionally, relationally, physically, and sexually. When Justin told Cheryl that he found her to be “a smart, attractive, loving woman with whom I want to share my life,” she teared up, but didn’t look away. “I need you to love and want me,” she replied, holding his gaze. “And I love and want you.”
I continued to express my belief that they could build a new marital and sexual bond by acknowledging the past and learning new ways to experience the healing value of touch, trust, and attraction. Rather than relying on traditional sensate focus exercises, I taught psychosexual skill exercises that related directly to sexual desire. Developing healthy sexual desire involves not only valuing intimacy, but also a willingness to try out erotic scenarios and techniques, and engaging in “non-demand pleasuring”—affectionate, playful touch that may or may not lead to intercourse.
It was Cheryl who took the initiative to promote sensual and playful touch both inside and outside the bedroom. Though Justin hated the clinical-sounding term “non-demand pleasuring,” he greatly enjoyed touching and being touched by Cheryl. In one session, with tears in his eyes, he told her, “For the first time since I was a kid, I feel there’s someone who really knows me, accepts me, and loves me.”
Facing the Tiger
We still needed to confront the most sensitive issue facing the couple: Justin’s variant sexual arousal—his need to play a sexually submissive role and be demeaned in order to be turned on. I explained to the couple that they had to commit jointly to a therapeutic strategy to deal with Justin’s sexual pattern. They could choose to accept it, compartmentalize it, or give it up as a “necessary loss.” Clinicians remain split regarding which strategy works for which couples.
Justin spoke first. He told Cheryl how much he appreciated her empathy and support for his dilemma and made it clear that he didn’t want her to become his dominatrix. “I don’t want that for either of us,” he told her. His choice was to relinquish his submissive sexual pattern as a necessary loss.
Cheryl was deeply moved, seeing his willingness to change his lifelong arousal pattern as a tremendous gift and a symbol of how much he valued her, their marriage, and their family. “Thank you,” she whispered.
Acceptance of the necessary loss strategy was vital, but not sufficient. With my encouragement, Justin also acknowledged to Cheryl that the combination of secrecy, eroticism, and shame surrounding his behavior had been destructive to their marriage. He took hold of her hands, looked into her eyes, and said: “I’m so sorry I hurt you. I’m totally committed to being your intimate sexual spouse. You can trust me.” He’d arrived at a place where he genuinely and deeply regretted his betrayal, yet was no longer sunk in shame and self-hatred. He was ready to learn to value intimacy, pleasuring, and eroticism within his marriage.
The challenge for Cheryl was to discover the erotic scenarios and techniques that turned her on and to risk expressing her own wishes. By giving each other the freedom to experiment and express his or her sexual voice, the couple began to find a new path. Justin discovered that when Cheryl was sexually involved and responsive, it enhanced his own involvement and arousal. Meanwhile, Cheryl found that feeling wanted and needed by Justin was her most powerful aphrodisiac. Gradually, the couple began to enjoy sex as a team sport.
This doesn’t mean that Justin’s issues evaporated. In an individual session with me, he acknowledged that being sexually submissive with a controlling, dominant woman was still a 100 for him in terms of erotic intensity. He didn’t believe that he’d ever experience that same degree of erotic charge during intimate sex with Cheryl. However, he understood that it was still possible to create a rewarding new couple sexuality. “It’s already happening,” he told me. He rated his sexual bond with Cheryl as a solid 85 in terms of intimacy, intensity, pleasure, and sexual satisfaction. He added with a grin, “Who knows where it’ll go from here?” As this case demonstrates, I advocate the both/and path that Cheryl and Justin negotiated with courage and commitment. Helping couples fully express difficult feelings and process the affair to make meaning of it enables them to build a stronger trust bond and a more satisfying sexual connection.
By Michele Scheinkman
Traditionally, couples therapists have assumed that if they helped couples repair their emotional relationship after a betrayal, their erotic bond will somehow magically flourish. Lately, however, many therapists have questioned this idea, realizing that the couple’s sexual connection is a delicate matter that must be dealt with directly and skillfully. This case illustrates a therapist’s sustained effort to explicitly help a couple develop a lasting erotic connection in the aftermath of infidelity.
A central feature of Barry McCarthy’s approach is his assessment of the couple by sequencing conjoint, individual, and conjoint feedback sessions. In doing so, he illustrates the effectiveness of individual sessions in disarming defensiveness and creating a safe space to explore erotic details that might otherwise remain secret. While the initial conjoint session gives him a full picture of Cheryl and Justin’s history and dynamics, it’s only in the safe environment of the individual sessions that McCarthy is able to understand their hidden vulnerabilities and yearnings.
While respectful and empathic of Justin’s desires for transgression and submission as elements of his sexual arousal, McCarthy firmly challenges his defensive justification that his extra-marital behavior was nothing more than a “normal male fooling around.” McCarthy asks a masterful question: “Be honest with yourself. What don’t you like about what’s happening to you sexually?” As Justin is encouraged to reflect on his sexual split, he’s forced to come to terms with the consequences of his behavior—the empty feeling after his transgressions, the money spent on sex clubs and all the rest, his loss of sexual energy toward Cheryl. In the individual session with Cheryl, McCarthy is equally skillful at uncovering her inhibitions and lack of sexual entitlement.
The million-dollar question in this case is what McCarthy calls “facing the tiger.” Can Justin really abdicate his desire for submission and pain? While McCarthy seems convinced that Cheryl will keep learning to be assertive and take sexual risks, he admits that Justin’s “variant” pattern is more complicated. Once again, he skillfully creates a narrative for solving the couple’s problem by posing Justin’s dilemmas in terms of choice and will.
McCarthy discusses three different alternatives for them. One possibility is for Justin to continue compartmentalizing his sexual needs. But with Justin’s now-heightened awareness of the painful consequences of his pattern, this isn’t an option. Justin also rejects the possibility of inviting Cheryl to play the dominatrix. The third choice, the one that Justin ends up choosing, is for him to relinquish his desires as a necessary loss for him, but a gain for the marriage. However, McCarthy isn’t naïve. Despite this reasonable choice, he understands that Justin’s intensely erotic yearnings for submission and pain will not miraculously disappear, so he keeps on working with Justin individually.
What lies ahead for this couple? Do we believe that entrenched sexual blueprints like Justin’s ever really change with therapy? Reading this case, we can say that, with McCarthy’s help, Justin and Cheryl may have broken the spell of secrecy and forbidden pleasures, once Justin shared his sexual dilemma openly with Cheryl and they’d entered a positive cycle of sexuality and intimacy in the marriage. The therapy seems to have helped them create a strong enough bond to deter the forces that might otherwise pull them apart again. But more than anything, it’s clear that this couple found a special therapist who’ll help them face any new crisis.
Barry McCarthy, Ph.D., a professor of psychology at American University, is the author of Discovering Your Couple Sexual Style, Enduring Desire: Your Guide to Lifelong Intimacy, and Sexual Awareness. Lana Wald, M.A., and a Ph.D. candidate in clinical psychology at American University, collaborated in this treatment and the preparation of this case study. Contact: email@example.com.
Michele Scheinkman, L.C.S.W., is a faculty member of the Ackerman Institute for the Family and in private practice in New York City. She’s written extensively on the topic of affairs, including “Foreign Affairs,” published in the July/August 2010 Psychotherapy Networker. Contact: firstname.lastname@example.org.
Tell us what you think about this article by e-mail at email@example.com.
By Ryan Howes
One of the hallmarks of the family therapy movement of the ’60s, ’70s, and ’80s was the exploration of the power of social issues like race, class, and ethnic background in clients’ lives. Leading figures in this movement, like Salvador Minuchin, Braulio Montalvo, Marianne Walters, and Monica McGoldrick, were outspoken about the importance of paying attention to the impact of social issues in the therapy room. But these days, we don’t hear much about the connection between psychotherapy and the larger social issues of the day. It seems that, for most therapists today, multiculturalism is a required, four-hour CE workshop, not a cause worthy of attention. One exception is Kenneth Hardy, a professor of family therapy at Drexel University in Philadelphia, who’s dedicated himself to working with troubled inner-city adolescents and keeping alive psychotherapy’s social conscience.
RH: You once said: “My training prepared me to be a pretty good white therapist.” Could you elaborate on that?
HARDY: I did my graduate training in the early 1980s at the Medical Research Institute in Palo Alto, and spent time at the Family Therapy Institute in Washington, D.C., with Jay Haley. I learned a great deal at both places, but there was little that spoke to me as a person of color. Whatever discussion there was about race or culture tended to pathologize people of color without seeing their inherent strengths. When I left my graduate program and got a job at a psychiatric outpatient clinic in Brooklyn working with a population that was largely people of color, I saw the first day that there was a massive disconnect between what my training had taught me and what they needed from me. While I’d been well trained, I felt like I was a white therapist in black skin.
RH: Has training changed since that time?
HARDY: Well, I think there’s been improvement. You’ll certainly find more faculty of color in training programs—not a substantial number, but one or two people. You’ll find some course content focused on themes of race, class, and ethnicity. But when I talk with students of color, the kinds of experiences they describe today are chillingly similar to the ones I experienced some 30 years ago. They still don’t feel entirely safe bringing up issues of race or ethnicity. Is it better than when I was a student? Absolutely, it’s better.
RH: You described the shift in your work with inner-city teens as moving from, “What’s wrong with you?” to “What happened to you?” Could you elaborate on this?
HARDY: Lots of the young people I see have been perpetrators and done some pretty horrific things in the world. But as a therapist, I’ve found it most useful to start by getting curious about what happened in their lives that contributed to their violent behavior or other aspects of who they are. I see them not just as perpetrators, but perpetrators who were themselves victims before they became perpetrators. So I typically ask early on, “Who were you before you became who you are today?” I want them to think about the events in their lives that reshaped them and led them to be where they are today.
The lives of these kids are filled with trauma, and trauma can reshape every aspect of our lives. As a therapist, I begin by looking at what happened along the way to clients that’s incited this shift in them. I’ve found that doing that is a much more helpful place to begin than trying to decide what’s wrong with them.
RH: What does this approach look like?
HARDY: The kids I see are coming in for things like robbery, violent crime, or chronic truancy. I’ve found again and again that trauma provides a powerful backdrop to those presenting problems. It’s really important not to start the relationship by focusing on their criminal activity. So I’m asking them to talk about their experiences of being poor, black kids in a poor neighborhood of Philadelphia, for example.
RH: You mention that a big part of your work with these young folks is affirmation. What do you mean?
HARDY: I once overheard someone talking about how a periodontist had to impact his gum and create some sort of synthetic gum. Something like that happens in psychotherapy. Often we have to build up the underdeveloped parts of people and find strengths where we can—to lay a foundation for growth. Affirmation starts to rebuild or restore what’s been destroyed, to create a foundation from which therapy can actually take place.
That’s not always so easy, especially if someone’s life narrative as a result of trauma is that “I ain’t nothing.” That can be difficult to rewrite. If I dare to see something redeemable in such people, they may think I’m trying to manipulate them. How could I honestly see something valuable in them?
RH: You like to talk about seeking out our clients’ “untapped heroism.” What does that mean?
HARDY: It comes from my deep conviction that no matter how egregious our behavior, we still have in us some redeemable qualities—something that sets off a flicker of light in the midst of everything that’s awful. So I’m always looking for that quality of what I call heroism in these young people—that part within them that’s managed to survive against tremendous odds. Heroism is this undying will to keep on keeping on, despite all kinds of adversity.
Whether you find that quality in your clients depends on what you look for. A therapist who looks for pathology sees it. A therapist who looks for strength finds it. You have to change what you look for in order to change what you see.
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: firstname.lastname@example.org; website: www.ryanhowes.net. Tell us what you think about this article by e-mail at email@example.com.
Wonder if Pac-Man and Ms. Pac-Man ever needed couples therapy? What might a family therapist say about the sibling rivalry of the Super Mario Bros? It’s time to get serious about gaming, because some suggest that video games and psychotherapy fit together like a well-placed Tetris block.
Surveys suggest that between 95 and 97 percent of American teenagers have played video games at some point in the recent past, and most of them play games on a regular basis. Adolescents aren’t the only ones gaming, however. More than 50 percent of adults play video games, too, whether they’re launching Angry Birds on their phones or questing in multiplayer online universes like World of Warcraft.
“They’re a part of our patients’ lives,” says Mike Langlois, a clinical social worker in Cambridge, Massachusetts, and author of the eBook Reset: Video Games & Psychotherapy. “Anything that much of the population is doing is something that psychotherapists need to know about.”
Unlike the arcade games of the past, modern video games offer an immersive social experience that therapists can use to build relationships with young clients. Forget about the dusty old board games like checkers and Parcheesi! “If I’m doing play therapy with adolescents in the 21st century,” Langlois says, “I should be playing the games of adolescents in the 21st century.”
More and more, gaming consoles are making their way out of parents’ basements and into our offices. “As I’ve learned in my child and adolescent psychiatry practice, the focus should be not only on what kids play, but also, perhaps more so, on how they play,” writes psychiatrist T. Atilla Ceranoglu in an editorial for the Boston Globe. Ceranoglu’s research on the use of video games in psychotherapy suggests that by playing video games with their patients, psychotherapists can build relationships with their gamer clients. In the process, they can learn valuable information about frustration tolerance, creative problem-solving, competition, and collaboration.
Even if you don’t have an Xbox set up in your office, it’s important to be aware of and sensitive to gaming-related issues, says Langlois, who brands his clinical practice as “gamer-affirmative.” By talking to everyone from adolescents to active-duty military veterans in Iraq and Afghanistan about their gaming experiences, Langlois says he started to hear stories about how people used video game communities to get help when they were depressed or even suicidal. “It was very different than the media hype I was hearing about how video games are all addictive and cause isolation.”
Now researchers and practitioners are starting to catch on to the power-up potential of video games for clinical practice. Research studies have found that playing video games improves pain management during medical procedures, while some specially designed psychoeducational video games have been used to increase treatment adherence in managing chronic diseases, such as diabetes and sickle-cell anemia. Businesses such as San Diego–based SmartBrain Technologies and Atlanta-based Virtually Better are headed by psychologists to develop, test, and use special therapeutic video game programs for everything from brain injuries to AD/HD and panic disorder. Even major commercial entities like Nintendo’s Wii gaming system and Microsoft’s Xbox Kinect platform are marketing games to improve physical activity and mental coordination.
Meanwhile, if you want to improve your own gamer-practice competence, try video gaming yourself. “I don’t think you need to play every single game, but you do need to be willing to have the experience of playing a game and learning to play,” says Langlois. He’s started a class on social work and technology in which one session requires students to attend in the online environment of World of Warcraft. Some students new to the game environment (gamers might call them newbies or noobs) find themselves fumbling around and frustrated as they learn the intricacies of navigating a new world. “I tell them to pay attention to that, because that’s exactly how their patients feel. For them, life is as difficult to negotiate as learning how to navigate this video game is for you.”
Video Games: Review of General Psychology 14, no. 2 (June 2010): 141-46; http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2011/07/05/video_games_can_be_healthy/.
Q: I know that getting immediate, nonverbal feedback from clients is essential to knowing how they’re responding in a session. How can I increase my sensitivity to this?
A: Being sensitive to a client’s nonverbal shifts in facial expression, posture, voice tone, and other areas is certainly important in establishing and maintaining the therapeutic relationship, which much research shows is essential for successful therapy. However, noticing nonverbal shifts isn’t enough; it’s important to know what those nonverbal shifts are related to and what they mean. To do this, you need to be active in eliciting responses, both verbally and nonverbally.
For instance, if clients verbally assent to what you’re saying while nonverbally disagreeing, it’s important to pick this up immediately, so that you can address the incongruence. If you want to detect the nonverbal signs of agreement, disagreement, and ambivalence, you can say, “I’d like to ask you to do something that may seem a bit strange, but it can be useful to us in working together. I want you to think of something that you fully agree with; it doesn’t matter what it is, and don’t tell me what it is, just nod when you’ve thought of something.” Then notice any nonverbal shifts. The client’s attention will be focused on the task, while yours is on the response to it.
Some clients will immediately think of something, and respond quickly, often before they nod. Others may take a little longer as they go through a brief search process before deciding on something and nodding. You want to notice what’s different compared to their state before you gave them the instruction, and the speed of their response is useful information. If you want to be more covert, you can say, “So your name is Fred Freed, is that right?” and notice his response. If you don’t notice anything, you can ask about something else that you’re pretty sure he’ll agree with, until you do detect the nonverbal response.
Clients are likely to be aware of smiles, nods, frowns, and other facial expressions with commonly accepted meanings. Since these can be faked, they aren’t reliable indicators of unconscious signaling. Clients are much less likely to be aware of small shifts in breathing, posture, head position, and so forth, so these indicators are much more reliable. Many responses to positive states can be categorized as parasympathetic: relaxation, movement, leaning forward slightly, pinker skin color, slower breathing and heart rate. Other responses will be individual to the client, and may include slight head tilts or movements, change in direction of the gaze, and small movements of fingers or hands.
Then you can say, “Thanks, now think of something that you completely disagree with. Again it doesn’t matter what it is, and don’t tell me what it is, just nod when you’ve thought of something.” The contrast between the response to this and the previous instruction will highlight what was different in the responses. Many responses to negative states can be categorized as sympathetic ones: tension, stillness, moving backward slightly, whiter skin color, faster breathing and heart rate. But many other shifts will be individual to a particular client. One client showed a slightly open mouth in agreement, but a closed one in disagreement; another looked up for agreement and down for disagreement.
If you don’t detect any clear shifts, you can ask the client to think about agreement again, and the contrast will make it easier for you to notice more. Finally, you can say, “Now think of something you’re uncertain about,” and, typically, you’ll see a mixture of what you noticed for agreement and disagreement. By asking specific questions like these, you can discover what nonverbal reactions are involved when this particular client agrees, disagrees, or is uncertain. You can use the same kind of inquiry about anything else that you think is relevant to your therapy, dividing it into positive, negative, and neutral: like/dislike, curious/bored, commitment to carrying out a plan, and so on.
You can do many other things to increase your sensitivity, all of which involve shifting your attention. Many therapists need to pay more attention to the nonverbal expressive music of the clients’ voices, rather than the content of what they’re saying. If a therapist looks aside while clients are talking, it can be easier to notice tonal and tempo shifts. But if a therapist looks down while they’re talking, and then looks up only as they finish, most of the nonverbal responses have already occurred, and are thus impossible to notice.
It’s easier to detect your clients’ subtle nonverbal changes in position and movement with your peripheral vision than with central vision. This is why soft defocusing and becoming more aware of peripheral vision is taught in all the Asian martial arts. If you’re seated opposite your client, as most therapists are taught, most of the client’s body will not be in your peripheral field of vision. If you sit next to your client at a 45-degree angle, so that you’re facing in more or less the same direction—as Fritz Perls and Virginia Satir did—most of your client’s body will be in your peripheral vision, automatically increasing your sensitivity.
There are many other advantages to sitting next to clients, often involving your nonverbal signals and their impact on clients. Facing more or less in the same direction has nonverbal implications of alliance and support, working together toward a joint outcome—in contrast to sitting opposite, which has implications of opposition or confrontation.
When clients remember the past, or think about the future, they often look at images that are directly in front of them. If you’re sitting in front of them, you may be in the same location as these images, which can be confusing.
Assuming that you’re facing in much the same direction, would you put the client’s chair on your left side or your right? In most right-handed people, the right brain is more sensitive to nonverbal emotional expression. Since the right brain receives visual information from the left visual field, you’ll automatically be much more sensitive to the signals of your clients’ emotional states when they’re sitting to your left. The right brain detects threat faster, so if you’re working with potentially angry or dangerous clients, that’s another reason to seat them on your left.
The right brain expresses emotion more fully than the left brain, primarily through the movements of the left hand. Gesturing toward the client with your left hand implies an emotional connection, another reason to seat most clients on your left side. (If you or your client is left-handed, these generalizations may need to be adjusted. You can ask your clients whether they are right- or left-handed, or have them sign something and notice which hand they use.)
Sitting next to clients makes it easy to touch them spontaneously and naturally with your left hand, without leaning forward awkwardly or leaving your chair. Although many therapists are still taught that any touch is inappropriate or even unethical, it’s an effective nonverbal way to elicit responses. Satir, one of the greatest therapists who ever lived, said: “If I couldn’t have the energy that comes out with touch, I’m certain that I could not have the kind of really good results that I have.” If you’re sitting opposite clients, or behind a desk, it’s much more difficult to express this kind of simple human connection.
Experiments have found that when a sales or service person touches customers lightly and momentarily on the upper arm (one second or less), it substantially increases the purchases customers make in a store, the tips they give to waiters and waitresses, the evaluations of their shopping or dining experience, and the likelihood that they’ll return. A simple touch or two can work wonders for your relationship with your clients. If a client responds aversively to a touch, it could mean that your touch was awkward or incongruent, or that the client has significant issues with touch, or many other possibilities—all important to know about and address. Like most people, many therapists shackle themselves by worrying about how a client might respond, rather than trying something and finding out how it works. You can always apologize, and any response can be utilized.
Touch has many other uses. If you want to interrupt clients because what they’re doing isn’t useful, a touch can gently get their attention and distract them, as you offer them a new direction. If clients start to become angry, a light touch on the arm can instantly communicate alliance, safety, acceptance, and that you aren’t the target of their anger. If you want clients to pause and savor a newly emerging feeling or change in understanding or attitude, a touch on the forearm can amplify your request, “I’d like you to pause, and stay with what’s going on right now, so that you can experience it even more fully.”
When clients talk, they often gesture in space with one or both hands. If you’re sitting next to them, it’s easy to gesture in the same way and in much the same locations in space, giving clients an unconscious sense that you’ve really entered their world and fully understand their experience. If you don’t think this is important, try gesturing in ways different from what clients do and watch them become confused, tense, or withdrawn.
Sitting next to clients provides opportunities for the therapist to modify clients’ gestures to support changes in their experience. For instance, often clients gesture with one hand, while the other hand is motionless or gestures in a different way. Perls often asked clients to repeat the words, but to switch any gestures to the opposite side of the body, to engage the other brain hemisphere and facilitate integration between the verbal and nonverbal states. When this instruction is given while gesturing in clients’ personal space, it becomes even more compelling. Sitting opposite clients makes it difficult to make use of gestures in this way.
Without a video, it’s only possible in a short article like this to offer some general principles and ideas to try; however, I have an article describing the exquisite nonverbal gestures seen in a three-minute video clip of an interview with Diana Fosha. You can find both the article and the video clip at http://realpeoplepress.com/blog/nonverbal-expressiveness-the-key-to-relationship-and-change.
These are just a few aspects of the nonverbal interactions that you have with your clients—something usually far more important than the words you exchange or the content being discussed. There are many, many ways to become aware of how you interact with a client, and what turns the interactions into a dance or a wrestling match. Continuing to discover and explore these choices can make your work ever more sensitive, subtle, and effortless, as well as more interesting and enjoyable.
Steve Andreas, M.A., has been learning, teaching, and developing brief therapy methods for more than 45 years. His books include Virginia Satir: The Patterns of Her Magic; Transforming Your Self; and Transforming Negative Self-Talk. Tell us what you think about this article by e-mail at firstname.lastname@example.org, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.
Inevitably, given their history of trauma, many borderline clients will trigger their therapists from time to time. But forgoing the urge to blame these clients and taking responsibility for what’s happening inside you can become a turning point in therapy.