Category: Insights and Tools

Is Technology Changing Our Minds?

What therapists need to know in the Digital Age

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.

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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: rhowes@mindspring.com; website: www.ryanhowes.net.

A Review of Jared Diamond’s New Book

Is Now Really Better? Lessons from Traditional Societies

By Diane Cole

The World until Yesterday: What Can We Learn from Traditional Societies?
By Jared Diamond
Viking. 499 pp.
ISBN: 9780670024810

“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: djcole86@gmail.com.

Reading Emotions

By Jared DeFife

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.

Resources

Reading Emotions: Science 338, no. 6111 (November 2012): 1225–29; http://www.eurekalert.org/pub_releases/2012-11/thuo-bln112912.php.

Mentalization: Something New?

By Steven Krugman

Something new or just old wine in new bottles?

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: stevenkrugman@gmail.com. Tell us what you think about this article by e-mail at letters@psychnetworker.org.

Sex, Lies, and the Long Road Back


Recovering from an extramarital affair

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.

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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.

The Assessment

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.”


Getting Real

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.


CASE COMMENTARY

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: mccarthy160@comcast.net.

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: michelescheinkman@gmail.com.

Tell us what you think about this article by e-mail at letters@psychnetworker.org.

Finding the Hero Within with Ken Hardy

Exploring the link between trauma and oppression

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: rhowes@mindspring.com; website: www.ryanhowes.net. Tell us what you think about this article by e-mail at letters@psychnetworker.org.

Can Video Games Power Up Your Practice?


By Jared DeFife

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.”

Resources

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/.

Increasing Sensitivity to Nonverbal Feedback

By Steve Andreas

Are you in step with your clients?

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 letters@psychnetworker.org, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.

Treating the Dissociative Child

By Joyanna Silberg

She wasn’t responsive to my voice or my soft touch. Her face was pale, her body was limp, her breathing was rhythmic and shallow. Should I call the medics, I wondered, or have her mother carry her out of my office? Luckily, she was my last client for the day, so I had time to figure out what to do with this unresponsive teen. I was seeing dissociation in its extreme form: the body shutting down in a “freeze” position, the way some wild prey respond when threatened by a predator. But what in our session had 17-year-old Trina perceived as “predatory”?

Though there had been a casual conversation about college plans and a boyfriend, there had been no talk of her early sexual abuse memories with a grandfather with whom she no longer had contact. After three years of treating her for dissociative behaviors, including sudden regressions, amnesia, and dazed states, I thought we’d moved beyond such an extreme response to stress on her part.

Trina was demonstrating a “dissociative shutdown,” a symptom often found in children faced with a repeated, frightening event, such as being raped by a caregiver, for which there’s no escape. Over time, this response may generalize to associated thoughts or emotions that can trigger the reaction. Although the child’s body may be immobilized, her mind remains active and can invent solutions, often retreating into an imaginary world, where bad things aren’t happening. With time and practice, the mere thought of needing to escape a situation may trigger a self-induced hypnotic retreat, along with a primitive freeze response.

According to Bruce Perry, senior fellow of the ChildTrauma Academy in Houston, these kinds of episodes are best understood as a dysregulation of the central nervous system’s opioid systems, which have been repeatedly activated by extreme stress. This response then becomes an enduring “trait,” so that small reminders of trauma can stimulate these dramatic alterations in consciousness. Perry points out that medical professionals often are puzzled by this kind of shutdown and may diagnose it as “syncope of unknown origin,” “conversion reactions,” or “catatonia.”

Working with dissociative children and teens can be unnerving for therapists, particularly in view of such extreme symptoms. A basic theoretical understanding of dissociation can demystify even this kind of sudden in-session event. But as important as it is to have a theoretical understanding of what’s happening, a clinician needs a pragmatic, strength-based, problem-solving focus to feel prepared to treat such entrenched dissociative reactions in children and teens.

Most children experiencing dissociation don’t have as little control as Trina did at this juncture. Usually, signs of dissociation can be as subtle as unexpected lapses in attention, momentary avoidance of eye contact with no memory, staring into space for several moments while appearing to be in a daze, or repeated episodes of short-lived spells of apparent fainting. As they move along an intensity spectrum, some young clients may have alterations in identity, with sudden regressions or rage-filled episodes, and little awareness of their behavior.

There’s still little consensus about how dissociation develops in traumatized children, but it’s been linked to disorganized attachment, often characterized by blank looks, avoidant eye gaze, and shifting affect. Frank Putnam, director of the Mayerson Center for Safe and Healthy Children at Cincinnati Children’s Hospital, has theorized that, while most infants learn to shift flexibly between emotional states over time, trauma-based states are marked by inflexibility and impermeability. According to psychologist Silvan Tomkins, children learn to rely on “affect scripts,” sequences of automatic behaviors that help them avoid experiencing such painful affects as fear, shame, or disgust—the kind of deeply disturbing feelings aroused during sexual abuse or other traumatic experiences with caregivers. The traumatized child learns to avoid overwhelming emotional pain through dissociation. As a consequence, these children can fail to develop the basic building blocks of identity and consciousness.

The reversal of dissociative states requires a therapeutic relationship in which the child can feel safe and clearly distinguish between the present environment and the traumatic past, while developing the deep, embodied conviction that the future doesn’t have to mirror what he or she has already been through. From years of experience working with children like Trina, I knew that my job was to help her discover alternatives to her avoidance response, understand and learn to tolerate its triggers, and find ways to override the automatic physiological escape tendency over time.


Handling the Emergency

When I asked Trina’s mother to come into my office, she first gently shook her daughter, saying “Trina, session is over” in a singsongy, motherly tone. No response. In a quiet, hypnotic tone, I suggested to Trina that she’d find herself growing more and more awake, ready to face hard roadblocks in her life. No response. Then Trina’s mother and I decided to call 911. Her mother, apparently accustomed to this strange behavior, was surprisingly calm. When the medics took Trina to an emergency room, I expected that she’d wake up as they transferred her to the stretcher and then the ambulance, but she didn’t.

Two hours later, my cell phone rang. It was Trina. “Dr. Soybean (her playful name for me),” she implored, “Please tell the hospital doctor that I don’t need psychiatric admission, and that I’m not crazy!” As relieved as I was to learn that she’d awakened from her dissociative slumber, I saw a great opportunity to move her forward therapeutically. Whenever my child clients ask me for something, I find a way to ask them to do something in return that will be a therapeutic advance for them. So I asked Trina to come to my office first thing in the morning, and explained that if she could successfully describe what happened right before her dissociative shutdown, she could avoid the hospitalization. If, however, she was unable to uncover the feelings that led to this self-defensive reaction, it would make sense for her to go the hospital after the session. Trina agreed to this.

The next session centered on the kind of “fishing expedition” often required with dissociative patients. Blocked from the feelings that usually help people string together a coherent narrative explaining their experiences, dissociative clients’ responses often appear as mysterious to them as they do to others. Trina remembered that we’d talked about her high-school science project, her ambition to be a biochemist, and a boyfriend she was outgrowing. I suggested that something else in our conversation had awakened her old feelings of being helpless, frozen, and unable to move forward. She acknowledged that was true, but remained mystified about what had triggered the old sense of being trapped.

I asked her to focus on that feeling of being trapped and as Trina got in touch with it, she became agitated and nearly mute. As she struggled, I modeled slow, rhythmic breathing and softly said, “Breathe with me. We’ll get through this together.” She took my cue and followed my slow breathing. “Where are you feeling this in your body I asked?”

“In my chest—it’s tight,” she said.

I used a familiar image to help her counter the sense of constriction in her chest. “Let’s imagine together that you’re out in the woods near your house and breathing the fresh fall air,” I said. We stayed with this image for about five minutes, and then I redirected her.

“Whatever’s happened, we can work together so you can handle it. We can find a solution, no matter how scary the trap feels.” I’ve learned that blocked memory usually returns when the therapist provides safety and confident reassurance that the information is tolerable, so I asked, “If you had to guess who it was about, would you guess your mother, your boyfriend, or your father?” Sometimes “guesses” allow the unconscious mind to express itself.

“I don’t really know,” she said, “but if I had to guess, it would be about my father,” she said.

“Something he did or something he said?” I wondered with her.

“I don’t know,” she said, “but he always says stupid things to me, so he probably did say something.”

“Think about your father saying stupid things, and tell me what you feel,” I said.

“My chest feels tight” she said, “and I feel trapped.”

“You aren’t trapped,” I reassured her. “Your whole life is ahead of you. Every day you’re more and more free. Soon you’ll be 18, and have the freedoms of an adult.” My comment about her future, which she faced with both anticipation and anxiety, was right on target.

“That’s it!” she said, “I remember.”

Trina’s parents were divorced, with joint custody. With a shaking voice, she told me that her father had threatened to withdraw college funding if she didn’t agree to overnight visits at his house, where her early abuse had occurred. She’d visited him willingly over the years when he put no real pressure on her, but the controlling nature of his new demand aroused the hopeless feeling she’d experienced when her grandfather’s abuse had seemed so inescapable. The overwhelming fear she’d experienced the day before seemed to encapsulate a central dilemma faced by all child survivors, now heightened by her approaching transition to adulthood: could she grow up, go to college, and be normal? or was she stuck forever in the traumatic past? It was crucial to find a way to support her belief that she could move on in life and escape the traps of her past.

Now that Trina had explained her dilemma, we began to brainstorm practical solutions, discussing ways she could stand up to her father. Ultimately, she decided she’d like me to serve as an intermediary to help him understand why presenting his demand in this authoritarian way triggered her old symptoms. In a subsequent session, I told him how she experienced his attempt to influence her through his control of her college money. He insisted he hadn’t really intended to withhold the funds, he was only emphasizing to her that he “could.” In a subsequent family session, with my prompting and direction, he promised her he’d pay for college, and that he’d never use this threat again. For her part, Trina promised him she’d visit him as her schedule allowed. She never experienced that degree of dissociative shutdown again.

Follow-Up

Over time, Trina learned to believe that the brighter future she dared imagine for herself was possible. Her treatment revolved around learning to combat her automatic tendency to dissociative avoidance and repeated recommitment to her belief in a positive future, whatever challenges she faced in her life. Through her college and postgraduate education, she succeeded, using her skills in affect tolerance, identifying emotional triggers, and self-awareness to navigate dismissive teachers, rude boyfriends, and even the tragic death of a close friend. She stayed in my practice for six years, maturing from a frightened, avoidant girl who had trouble attending school to an aware, insightful survivor.

Today, Trina is an accomplished medical professional, married, with a young child of her own. When asked about her recollections of her early treatment, she says, “Yes, I was a weird kid, but you knew what to do about it.” She quickly changes the subject, but proudly shows me pictures of her new son, who she assures me is developing beautifully, “without dissociation or other wacky stuff.”


Case Commentary

By David Crenshaw

Working with extreme forms of dissociation is a demanding and often anxiety-provoking therapeutic challenge. In the face of extreme symptoms that can seem quite bizarre, the therapist must have the experience, skill, and emotional steadiness to communicate both a clear sense of direction and a conviction about what needs to be done. In the morning-after crisis interview with Trina, Joyanna Silberg displays all those qualities as she creates the kind of emotional bond and sense of safety that enables Trina to return to adequate coping. I question, however, whether the same qualities might have been more patiently employed the night before to help Trina avoid her trip to the emergency room.

In crisis moments, seemingly small shifts in language and affect can have major impact. I was struck by the difference in Silberg’s intervention the night of Trina’s dissociative shutdown and her more effective response in the next day’s follow-up session. In the first instance, Silberg describes her response in this way: “In a quiet, hypnotic tone, I suggested to Trina that she’d find herself growing more and more awake, ready to face hard roadblocks in her life.” The following day, Silberg is far more concrete and makes better use of her strong therapeutic alliance with Trina, as clearly conveyed in her instruction, “Breathe with me. We’ll get through this together.” I can’t help but wonder if the ER trip the previous night could have been avoided if Trina had heard something as powerfully reassuring as, “Breathe with me” and “We’ll get through this together.”

In the session the following morning, Silberg, with conviction and evident affect, simply and unequivocally says to Trina, “You aren’t trapped.” It’s then that Trina is empowered to remember the conversation with her father that had triggered her dramatic shutdown. Silberg reinforces her forceful statement with some powerful suggestions, including: “Your whole life is ahead of you. Every day you’re more and more free. Soon you’ll be 18, and have the freedoms of an adult.”

I was puzzled by Silberg’s response to Trina’s call from the ER. She describes Trina’s request to help her avoid hospitalization as an example of a “client ask[ing] me for something.” Silberg explains that in such situations she “find[s] a way to ask [child clients] to do something in return that will be a therapeutic advance for them.” This leads her to ask Trina to come for a session the following morning and identify the exact moment that triggered her “dissociative shutdown.” I didn’t understand the rationale that identifying the exact trigger moment would determine whether or not psychiatric hospitalization was needed. If the therapist is asking the client to come to her office the next day to pinpoint the exact moment of being triggered, surely she believes her patient is capable of outpatient therapy. If the client was unable to identify the exact trigger moment in that session, would that really be an adequate justification of psychiatric hospitalization?

Fortunately, the follow-up session is quite productive, reflecting the skills and strengths of both therapist and client. Ultimately, I think the validation of Silberg’s work with Trina and the quality that’s needed to help clients experiencing extreme symptoms like hers is embedded in the adult Trina’s retrospective comment on what her therapy experience meant to her: “Yes, I was a weird kid, but you knew what to do about it.” Clearly Silberg created the sense of safety, trust, and optimism that made it possible for Trina to move on with her life, despite her early abuse.

Author’s Response

I appreciate David Crenshaw’s thoughtful comments. Perhaps I described too quickly the efforts her mother and I made to awaken her the evening before. It was about 45 minutes of intense intervention before her mother and I made the decision to call the medics.

In most outpatient offices, I’d guess, therapists wouldn’t even be able to devote that much time in such an emergency. While it’s certainly possible that I might have hit on the right thing to say if I’d worked on it even longer, my focus at that time was arousing her so that she could safely leave my office, as the behavior occurred at the end of the session. This goal—to have her leave my office—probably came through in my tone and interventions, despite the reassurances that I tried to offer. I was mystified about the exact source of the shutdown, and reassurance alone wasn’t effective. Perhaps unconsciously, Trina was saying that her only safety was in my office, and she couldn’t “leave,” grow up, or achieve adulthood. Thus, my own goal to have her leave my office was incompatible with her goals.

Episodes of unpredictable shutdown, sometimes seen as psychogenic seizures, are sufficient for hospitalization since they can be dangerous. Young people in this state can fall down and hit their heads or not be responsive to the outside world for hours at a time. The question of whether Trina was a treatable inpatient or outpatient was debatable, in that the doctor in the ER thought she was eligible for admission the night before, having witnessed the shutdown state. Had she not been able to use the episode to gain further self-knowledge and increase control, the episode could have been classified as “unpredictable,” and an argument made that this behavior was too dangerous for her to be treated as an outpatient. Realistically, however, had she not been able to get to the bottom of this episode the next day, but seemed to be trying, I most likely would have made another “deal” with her to keep her out of the hospital.

Joyanna Silberg, Ph.D., a consulting psychologist at Sheppard Pratt Health System in Towson, Maryland, was past president of the International Society for the Study of Trauma and Dissociation. She’s the author of the recently released The Child Survivor: Healing Developmental Trauma and Dissociation. Contact: jlsilberg.@aol.com.

David Crenshaw, Ph.D., A.B.P.P., is the clinical director of the Children’s Home of Poughkeepsie (New York) and a faculty associate of Johns Hopkins University. He recently edited Reverence in the Healing Process: Honoring Strengths without Trivializing Suffering. Contact: dacrenshaw@frontiernet.net.

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Frederic Luskin on the Power of Forgiveness

By Ryan Howes

A new calendar inspires many to turn over a new leaf. For some of us, this may mean learning to turn the other cheek. In recent years, the biological benefits of forgiveness have been widely publicized: lower blood pressure and cholesterol, better sleep, and an improved immune system. Psychologically, people who forgive show lower levels of depression, anxiety, and anger, enjoy better relationships, and report higher levels of optimism and happiness. Sounds great, so why is forgiveness so damn difficult?

Frederic Luskin has some interesting thoughts on that subject. As director of the Stanford Forgiveness Project, he’s studied forgiveness for the past 20 years. He authored Forgive for Good: A Proven Prescription for Health and Happiness and has shared his wisdom with survivors in Northern Ireland, as well as those at Ground Zero in Manhattan.

Since he’s an expert on the psychology of forgiveness and on therapeutic pathways to achieving it, we thought the beginning of the year might be an especially good time to hear from him.

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RH: How did you become interested in forgiveness?

Luskin: In addition to the pain of being badly hurt by a close friend without having any idea how to deal with it, I needed to find a dissertation topic when I was graduating from Stanford. This was before there was a lot of research about forgiveness. I thought what I learned about getting over my own wounding might have a broader application, and it just seemed like a good opportunity to bring more psychological understanding to something that’s traditionally been such a spiritual concept.

RH: I’m reminded of the Alexander Pope quote: “To err is human; to forgive, divine.” Do we equate forgiveness with spirituality or God more than we do other virtues?

Luskin: I think so, because it’s so difficult. The human tendency is to deliver payback for any hurt that’s been experienced.

RH: The “divine” part of that statement suggests that it requires supernatural strength to forgive.

Luskin: I don’t believe that. I think it takes something more than the essential selfishness that most of us operate out of, but I don’t think it’s divine to understand that you don’t want somebody else to suffer just because you’ve suffered.

RH: As you’ve seen, it’s terribly difficult for a lot of people.

Luskin: That’s part of the reason why the research that we did is so important. Making a connection between enhancing one’s health and forgiveness gives people additional motivation to do something that they might not do otherwise. People may not worry about whether they’re going to heaven, but at least forgiveness reduces their blood pressure and their chance of having a heart attack.

RH: Your work calls into question several beliefs about forgiveness. I’ll toss out a few true-or-false statements here: “Forgiveness means forgetting.”

Luskin: That’s false. It’s actually remembering differently. While lack of forgiveness is remembering something with an edge or a grudge or a sense of injustice, forgiveness means remembering it more benignly, with compassion. It involves some purpose of moving ahead, rather than just being stuck in the past.

RH: “Forgiveness requires repentance from the other.”

Luskin: The fact is that you can forgive someone who’s dead. So it can’t require that.

RH: Isn’t it easier to forgive when the other person is repentant?

Luskin: Certainly, if somebody is really apologetic and takes responsibility—“My bad. I really hurt you. No excuses.” Then forgiveness is easier. It’s not just bad because you got hurt, but I did something wrong.

When someone says, “I’m sorry because you’re hurt,” well, that can make the person who’s been injured feel at fault because they were hurt.

That’s an offensive kind of apology. It’s different when you say: “Boy, I did wrong, independently of whether or not you got hurt. I also see how that wrong has impacted you, and I’m sorry for that.”

So there are two steps—“I did wrong, and that wrong hurt you.” Then the next step is, “Since it’s my responsibility, what can I do to make it better for you?” That’s a true apology, and that makes a real difference.

RH: Is that because it validates the feelings of the victim?

Luskin: Always.

RH: It says, yes, it really was your fault, I don’t have to blame myself or take some of that responsibility. You’re taking it.

Luskin: Well, you still have responsibility for living your life and moving on, but at least that person has said that they’re a significant contributor to the distress and the tears.

RH: Another belief: “Forgiveness is a one-time thing.”

Luskin: No. It’s a process we do over and over. Sometimes you’re reminded of painful situations when you least expect it. Sometimes the person comes back into your life, or you’re just remembering what they did and you have to go through it again.

RH: One final statement: “Forgiveness means everything returns to the way things were.”

Luskin: Sometimes it returns to the way it was, but sometimes you can’t go back. After all, how can you go back if someone close to you has been murdered? Nevertheless, if somebody makes a mistake and they say they’re sorry and ask forgiveness, you can go back to the same type of relationship that you had.

RH: I heard a talk at which you said: “Forgiveness is the experiencing of being at peace right now, no matter what happened five minutes or five years ago.” How is peace related to forgiveness?

Luskin: What is forgiveness except the experience of peace around your own life? It’s acknowledging that you’re OK. Forgiveness is all about people’s perception of their life. If I feel bad, that’s my experience. Just because bad things happen doesn’t mean that I have to behave badly. Understanding that can make a huge difference for many people.

RH: Why do you think we have such a tendency to perpetuate the bad?

Luskin: Part of that is the way our neurology is wired to look for things that are wrong in order to keep us safe. Part of it is the way many cultures foster revenge, retribution, payback, and total self-absorption.

RH: I’ve noticed that victimhood can make people feel like they’re in a position of power, one that they’re reluctant to give up.

Luskin: But feeling resentful and victimized is a highly limited form of power. The price you pay is feeling perpetually uncomfortable and off center. We get angry when life isn’t working; we don’t get angry when life is working.

If you see people who are angry or who are nursing a long-standing grudge, it’s probably because their life isn’t working, and they don’t know what else to do. The whole task of forgiveness comes down to redirecting energy from a preoccupation with helpless resentment to finding a better way to live one’s life.

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

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