Tag: Case Study

Evoking the Inner Artist

How to replace pathology with creativity

By Lisa Mitchell

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

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

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

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

Identifying a Creativity Goal

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

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

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

The Five Stages of Creativity

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

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

Shrugging she said, “I’ll try.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CASE COMMENTARY

By Jay Efran and Jonah Cohen

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

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

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

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

AUTHOR’S RESPONSE

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

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

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

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

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

Life After Betrayal

By Steven Stosny

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

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

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

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

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

Establishing a Healing Identity

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


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

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

Reconditioning the Mind

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

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

Guilt and Shame vs. Compassion

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

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

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

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

 


The Ability to Love Again

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

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

When Disappointment Feels Like Betrayal

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

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

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

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

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

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

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


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

Case Commentary

By William Doherty

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

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

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

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

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

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

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

Women Who Cheat

By Tammy Nelson

Understanding the message of the affair

Even though our ideas about sex and sexuality have greatly advanced over the last half-century, our culture still holds a double standard about infidelity. While no one is entirely surprised by the behavior of a Bill Clinton, an Elliot Spitzer, or a Tiger Woods—men will be men, after all—we still tend to pathologize women or shame them (or both) for having affairs.

In my view, far from being evidence of pathology or marital bankruptcy, a woman’s affair can be a way of expressing a desire for an entirely different self, either separate from the marriage altogether or still in it. An affair can be what I call “a can opener” for women unable to articulate for themselves why they’re unhappy in their marriages, much less empower themselves to leave or begin an honest conversation with their husbands about what they feel is wrong. In my practice, I’ve heard many women say, “I didn’t even know what I wanted until the affair was over and I realized that I really wanted to end my marriage,” or “I had no idea that I used the affair as a way to wake up our relationship.”

Many infidelity treatment approaches today are based on the idea that the unfaithful spouse is a perpetrator, someone who wronged the other person. While the pain caused by infidelity can’t and shouldn’t be denied, it generally isn’t understood well enough that many women cheat because they struggle with their self-identity in their lives and lack of empowerment in their marriages. To some extent, the affair makes up for a felt lack of an adult self. Sometimes, understanding an affair as an unconscious bid for self-empowerment, relief from bad sex, or a response to a lack of choices or personal freedom is an important first step toward a fuller, more mature selfhood.

Searching for the Bartered Self

Sarah came to therapy with her husband, Rob, for couples therapy after he caught her cheating. Married for 10 years, he felt hurt, angry, and hopeless about the marriage. He sat across from Sarah on the couch, with his head in his hands. “I have no idea how we’re going to get past this. Sarah says she wants to work this out, but I don’t know if we can put this marriage together again after what she’s done.”

Rob had read emails between Sarah and her boyfriend that explained in detail how much they were enjoying virtual sex—watching each other masturbating over a webcam—which had both shocked and devastated him. He’d thought their sex life was good, but admitted that having kids had gotten in the way of their relationship. He thought they still loved each other, and Sarah agreed. They were both unclear why the affair had happened, but said they wanted to recover their marriage, if possible.

At the end of their first joint session, Sarah asked whether she could see me individually. Rob consented, so I asked if they’d be OK with an open secrets policy: what’s said in the individual session stays in the session. They agreed that whatever Sarah said could be kept private, though she could share with Rob what she wished to from our individual sessions.

In our first individual session, Sarah asked if therapy could be a place where she could talk honestly about the affair. This led to a discussion of the difference between privacy and secrecy, both in her marriage and in her sessions with me. Keeping secrets in her marriage had given Sarah a sense of space—a secret place where she could grow her sexuality, dream her dreams, and keep a part of her that no one else had control over. Our first conversation revolved around how the space she’d created could be shifted from secret to private, and how she could keep a differentiated, individuated boundary around herself in her relationship. This could give her a healthy degree of separation from her husband without having to lie or be deceptive to stake out her space.

I then explained to Sarah that, in my view, infidelity recovery has three phases: crisis, insight, and vision. The crisis stage occurs right after disclosure or discovery, when couples are in acute distress and their lives are in chaos. At this point, the focus of therapy isn’t on whether or not they should stay together or if there’s a future for them, but on establishing safety, addressing painful feelings, and normalizing trauma symptoms.

In phase two, the insight phase, we talk about what vulnerabilities might have led to the extramarital affair. Becoming observers of the affair, we begin to tell the story of what happened. Repeating endless details of the sexual indiscretion doesn’t help, but taking a deeper look at what the unfaithful partner longed for and couldn’t find in the marriage—and so looked for outside of it—as well as finding empathy for the other, who was in the dark, can elicit a shift in how both partners see the affair and what it meant in their relationship.

Phase three is the vision phase, which includes seeking a deeper understanding of the meaning of the affair and moves forward the experience and resulting lessons into a new concept of marriage and, perhaps, a new future. In this phase, partners can decide to move on separately or stay together. This is where the erotic connection will be renewed (or created) and desire can be revived. In this phase, the meaning of monogamy changes from a moralistic, blanket prohibition on outside sex to a search for deeper intimacy inside the marriage. A vision of the relationship going forward includes negotiating a new commitment.

Establishing Safety

During early sessions in the crisis phase of treatment, Sarah’s view of the world was shifting, and she didn’t know what she wanted. She wavered about whether she wanted to stay with Rob, wondering whether she should move on and seek genuine emotional independence alone or stay and try to be both fully herself and fully married to Rob. She wasn’t sure she could trust me to understand her and didn’t trust her husband, either, even though she herself had acted in a way that wasn’t trustworthy.

Gradually, Sarah revealed that she’d felt that she had no space of her own in the marriage, literally or figuratively. Her husband had a home office, but she had no comparable space for herself. Her dependence on Rob was nearly total: he balanced the checkbook, paid the bills, earned the money, and told her when she could make ATM withdrawals. He even counted the cash in her wallet and decided how much she should spend at the hair salon. She’d never been encouraged or allowed to feel empowered and independent. As a result, she’d started rebelling against her husband like an adolescent against a too-strict father, sneaking out at night or during the day when he was at work and having clandestine sexual encounters.

Sarah’s affair consisted primarily of quick liaisons in the back of her car. Her boyfriend met sexual needs not being fulfilled at home. Although the sex was quick, furtive, and secret, he gave her orgasms and oral sex and was willing to experiment in ways she found exciting. But while buoyed by the thrill and energy of this new relationship and her long-buried ability to feel pleasure—even wondering if she might be falling in love—she also felt guilty. Frightened by the growing intimacy with her lover when they were together, she began meeting him online, masturbating with him through a webcam.

After Rob discovered the affair, he’d demanded Sarah’s email and voice mail passwords, which she gave him. Although this made her feel exposed, vulnerable, and humiliated, she thought her husband deserved the transparency—as the “innocent” party—and that she should be punished. All these thoughts conformed with many of society’s constructs about women who have affairs, but they reinforced her long-brewing resentment that her marriage wasn’t an equal partnership: she was the “bad child”; her husband, the aggrieved parent.

At this point, I reframed the affair for Sarah in a way quite different from her own perspective (and that of many therapists). I asked whether it was possible that the infidelity was less a transgression than a move toward self-respect and self-empowerment. Could she have been seeking autonomy and individuation, as well as a more mature state of sexual development? Was she trying to find her voice, maintain a stronger sense of herself, create a personal boundary that no one could cross, and remain in her marriage? Yes, she’d betrayed her husband; this was beyond doubt, I added. And this method for finding herself was clearly not working if she wanted the marriage to survive. But perhaps she’d paradoxically tried to sabotage the marriage as a desperate attempt to develop more emotional maturity and become a more independent and grown-up wife.

As we spoke, Sarah realized that, while her intentions in having the affair hadn’t been conscious, she did want to grow into a fuller woman and mature sexual adult. She admitted she thought she could bring that woman back into the marriage and into the relationship. This made one point crystal clear: she could no longer be satisfied with the marriage as it was.

Gaining Awareness

Having gotten a clearer portrait of Sarah’s marriage, we moved on to the insight phase of treatment. What did the affair mean about her? What did it mean about Rob? And what did it mean about their marriage?

As we explored these questions, Sarah discovered quickly that the affair had far more to do with her marriage than with her husband, whom she said she loved and with whom she wanted to stay—but only if it could become a more equal partnership. When I asked what the affair told her about Rob, she said, “I felt that he wanted me to fill a certain kind of role; it wasn’t just about replaying my mother’s position. Rob liked being in charge, liked bossing me around and being a kind of father. I know why, too. He recently lost his job, and the only place he felt any power or control was at home. He was mad that they’d fired him and took it out on me. In a way, he’s always done that: when people reject him, he gets angry and controlling. But with us, the more he tried to control me, the more I wanted independence from him.”

We worked in sessions to identify some key areas where she could feel more autonomy and still be in relationship with Rob. She started small, choosing their television shows, making decisions on where to go to dinner, instead of saying, “I don’t care where we go. Where do you want to go?” When Rob asked her to have sex, she told him she wasn’t ready yet, but would let him know when she was. Although Rob felt he had little or no control in these situations, he did begin to appreciate signs of the new, more adult Sarah, someone equal to him, with whom he could have a conversation and negotiate choices. He realized it was a relief that he didn’t have to do it all himself, and he actually felt less lonely in the marriage.

When I asked Sarah what the affair meant about her marriage, she said, “In the affair, I felt stronger, more mature, sexier, calmer, more charming, and more alive.” We talked about whether she could integrate her sexier, more mature self into the marriage or whether the relationship was fundamentally flawed. To her, being in her marriage meant giving up a sense of personal power, while having an affair gave her a sense of independence, choice, and more control. She didn’t know how to have a grown-up relationship with her husband that encompassed safety and desire.

Reenvisioning a Marriage

Treatment in the third phase included helping Sarah get in touch with her fantasies and reconnect with pleasure—one of her greatest challenges in therapy. She felt guilty when she thought about her own pleasure, and had compartmentalized her needs into the affair, as something separate, wrong, and forbidden. Her fantasies and desires were something she felt shame about sharing with her husband. Bringing that sexual part of her into the marriage was the beginning of erotic recovery for her and for her marriage, but she still had to learn to connect with her desires and to communicate them to Rob.

I asked her to write down some of her sexual fantasies and share what she thought the desire or longing underneath them was. For instance, if the fantasy was to have someone grab her hair and kiss her, was this spurred by a longing to be held, to be out of control, to know that she was wanted and desired, or all of the above? The goal was to normalize her sexual needs: her affair had been a breach of monogamy, not a sexual pathology.

“If you could have anything you wanted, what would you ideally expect from your sex life with your husband?”

Sarah answered shyly, “That he’d pursue me and we’d try new things in bed.”

When I asked her if she knew what the longing underneath might be, she said, “My real longing underneath is to be totally special to him.”

Sarah went on to work on a vision of a more intimate and adult sexuality. This included asking Rob to behave in ways that made her feel special and trying to make him feel special as well. By this point, she was committed to creating a mutual vision of a new monogamy with her husband, and I suggested they return for couples therapy and focus together on their erotic recovery.

Several months later, Rob and Sarah are still working on an agreement for a new, monogamous marriage together. Sarah is committed to sharing her real thoughts and feelings with Rob. In this way, her adult self and her adult needs become a priority that can be talked about and negotiated in the relationship. She feels they’re now given as much importance as Rob’s needs.

Rob’s commitment to Sarah is that he tries harder to share his feelings and work on creating a more emotionally intimate relationship. They both try to be conscious of the distant and disconnected roles learned in their childhoods, and focus instead on the emotional intimacy they really want from the relationship.

Their new monogamy includes a focus on their erotic recovery. The affair created an erotic injury to their relationship, and Rob and Sarah continue to work on this as a goal of healing. They’ve made a commitment to sharing their fantasies and talking about what’s working in their love life. When they feel distant or dissatisfied, they want to learn to talk about it and turn toward each other instead of shutting down or turning to someone else outside the marriage.

Sarah now understands that her journey to self-empowerment and freedom can happen at the same time that she’s a wife and partner. Her adult choices include staying in a mature, monogamous relationship, while creating space for working on her own self-identity. Her worth in the relationship continues to be a focus of our couples therapy. Her cheating makes sense to her now in the context of her life issues, but she has a new empathy for Rob and how it affected him.

As therapists, it’s important to discern what our goal is for the women we treat in infidelity therapy. Are we helping them end an affair or end their marriage? Is it our job to remind them of their vows or simply to help them heal? By viewing women’s infidelity as a possible search for a new way of being, we can help them reenvision a fully committed relationship with greater empowerment and equality.

CASE COMMENTARY

By David Treadway

While I admire the sensitive work Tammy Nelson did in rejuvenating Sarah and Rob’s marriage, both emotionally and erotically, I believe that zooming in too quickly to examine the root causes of an infidelity without addressing the emotional impact of the betrayal on both parties usually leads to incomplete healing. Although I say to couples that each partner is 50 percent responsible for what’s not working in a marriage, I always add that choosing to have a secret affair is 100 percent the responsibility of the unfaithful spouse. Most of the time, couples need a way of healing the fundamental breach of trust before being able to fully repair the relationship.

In working with couples following a secret affair, I use a four-step model based on the treatment approach of clinical psychologist Janis Abrahms Spring:

Step 1: The betrayed partners have as much time as needed to share their hurt, anger, and sense of devastation while unfaithful partners listen as nondefensively as possible without explaining or rationalizing their behavior. The therapist helps the partner who had the outside relationship to be compassionate and caring about the impact of the affair. Needless to say, this may take more than a single session.

Step 2: The unfaithful partners are then taught to write a letter in which they take full responsibility for having done harm, indicating what they’ll do to ensure it won’t happen again and what concrete steps they’ll take to make amends. In addition to agreeing never again to see the other party in the affair, other ways to make amends might include giving up drinking for a year or getting rid of the boat where the affair took place.

Step 3: The letter of amends is read in session, and the concrete actions that constitute an attempt at atonement are agreed upon by both partners.

Step 4: Only at this point is the challenge of learning how to forgive discussed, and only if betrayed partners are ready to begin to work on it. If so, they’re coached on how to write a forgiveness letter that involves accepting the attempts at atonement and expressing a willingness to let go of a sense of injury. This all takes place with the understanding that forgiveness can’t be legislated; it has to grow over time.

It’s my experience that patiently and thoroughly working through this difficult process without shaming and blaming is what allows a couple to move on to achieving a level of intimacy and trust that they typically never had before. I remember a man named Paul who’d gone on to transform his relationship with his wife after her affair and referred to their new sense of connection as his “second marriage.” In one of our last sessions, he put his arm around his wife, smiled at me conspiratorially, and said, “You know what I like best? Here I have this extraordinary woman and a brand new ‘second marriage,’ and the lawyers didn’t get a dime!”

AUTHOR’S RESPONSE

I agree with David Treadway’s observation that working with couples after an infidelity takes lots of finesse and that, of course, the feelings of the person who’s been deceived and betrayed need to taken into account and addressed. Like Treadway, I think Janis Spring’s “secrets policy” can be invaluable, offering helpful clinical guidelines for individual work when necessary.

Since this case study was told from Sarah’s point of view, it doesn’t delve into Rob’s feelings, nor do we get to see much of the couples work. Instead, the focus is on the special issues of identity and empowerment for women who have affairs. If I’d told the fuller story of the therapy with this couple, I’d have devoted more attention to the third phase of treatment—the attempt to help them develop a new vision of their marriage, which I call the “new monogamy.”

However, the most important message I hope readers take away from this case is that even after the wrenching pain of an affair, therapists still have an opportunity to help troubled couples create a new relationship with better communication, fuller intimacy, and realistic hope for a better future together.

Tammy Nelson, Ph.D., M.S., a board-certified sexologist, licensed professional counselor, certified sex therapist, and Imago therapist, is the founder and executive director of the Center for Healing. She’s the author of The New Monogamy; Getting the Sex You Want; and What’s Eating You?

David Treadway, Ph.D., is director of the Treadway Training Institute. He’s the author of Home Before Dark: First Year with Cancer and Intimacy, Change, and Other Therapeutic Mysteries: Stories of Clinicians and Clients.

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.

——

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.

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.

Tell us what you think about this article by e-mail at letters@psychnetworker.org. Log in and you’ll find the comment section on every page of the online magazine.

Distinguishing Behavior from Identity

By Ronald Soderquist

Debbie, who’s in her fifties, called: “I’m so upset about my relationship with my daughter. She and I are always in conflict, and my husband agrees this needs to be changed.”

When she came in, she reported feeling sad because she couldn’t enjoy visiting her daughter, an only child who lives nearby. “It’s such a noisy household. The children scream and squabble; there are two of them under the age of 6. I wish my daughter would be more organized and keep them quiet, so I could enjoy being there. I get so tense, I have to leave her home in the middle of a visit.”

I didn’t have a clear strategy, so I asked her to bring her daughter, Emmy, next time. Then the dynamics became clear. Emmy is a high-energy, outgoing, modern, in-your-face 35-year-old woman. Mother Debbie is quiet, somewhat distant, a loner, who needs her space. I was reminded of the movie My Big Fat Greek Wedding. Mom is a lot like the uptight couple who come into the vibrant Greek gathering.

During the hour with Mom and daughter, it became clear that Emmy wanted her mother to change and just enjoy her high-energy household. “Why can’t you be like other grandmothers, and just come in and enjoy the family?” And Mom wanted Emmy to change. “Why can’t you be more organized and quiet, so I can be comfortable with you? I can’t stand all that commotion.”

First, I tried some conventional strategies, like helping them listen nonjudgmentally to each other, but there was no movement in their relationship. I didn’t see any point in seeing them together again, so I asked Debbie to come in alone.

Again, she told me, “It just isn’t me to be like other grandmothers who get on the floor and play with the children and enjoy all the noise. And I like me the way I am. She’s asking me to be someone I’m not.”

I assured her: “You’re fine just as you are, and Emmy is fine the way she is. You just happen to be very different personalities. She’s AM, and you’re FM: she’s rock-and-roll, and you’re chamber music.” She agreed.

“Fortunately, there’s a solution. I’m thinking about Meryl Streep, and how she takes on a different personality for every role, but off-stage, she’s still Meryl Streep: she doesn’t have to change who she is. I wonder if you’d enjoy inventing a role that works well when you’re with Emmy and her family? (Here, I slowed to my hypnotic voice and watched her slip into a trance.) When you open the door to her home, you can see it like a stage. You pause at the door, view the scattered toys, and listen to the active children as part of a stage set. You may find it amusing. You’re Meryl Streep slipping into a role. Your creative inner mind will be alongside your conscious mind, enjoying the flow as you engage with your daughter and your grandchildren in fun ways, and every time you enter that stage, that family stage, you’ll find yourself expanding into your new role in satisfying ways, sometimes surprising yourself, always enjoying your secret strategy. It’s OK to let your husband in on it. Afterward, you and your husband may chuckle about the relaxed grandmother character you’ve created. You’re both director and actor on this stage. Really enjoy surprising them.”

She came out of her trance and exclaimed: “I can do that!” After some additional mental rehearsal, she left in a very good mood. Three days later, my phone rang: “This is Meryl Streep calling. I just earned an Oscar. I spent a whole day with Emmy and her family, and at the end of the day, my husband asked Emmy, “How did your mother do today?” Emmy said: “She did great!”

It was their first pleasant, relaxed day together in many years, a day without tension and conflict. I asked Debbie what she found interesting while playing her new role. She replied, “I felt so calm–very different–calm and comfortable.” ;

A well-deserved Oscar!

A few weeks later, she called to say, “I’m so excited and happy because I entertained my entire high-stress clan, and did my Streep thing, and enjoyed myself!”

A couple of months later, she said, “I’m so glad I did it. Strangely, now I feel more motherly and understanding toward my daughter than ever.”


Case Commentary

By Steve Andreas

This is a really lovely example of many different important aspects of change work, and the importance of a careful choice of words.

The first session doesn’t offer a clear direction for intervention, so Ronald Soderquist wisely brings in the daughter, so he can observe them interacting, rather than knowing the daughter only through the filter of the mother’s perceptions and report. Although the interaction becomes much clearer when the daughter joins the mother for the second session, having them both together makes it difficult to intervene usefully.

In that session, it becomes clear that, for both of them, the issue is one of identity, in contrast to behavior. Both want the other to change, and each speaks of this change in terms of being different–in contrast to acting different. The daughter says, “Why can’t you be like other grandmothers,” and the mother says, “Why can’t you be more organized and quiet.” (Most answers to either of those questions would lead only to justifications and rationalizations, neither of which would be useful.)

For most people, being different seems to be much more difficult than doing something different. If you describe a certain behavior as “being different,” most clients will object, as both mother and daughter do in this case, and this is one source of what many therapists describe as “resistance.”

As long as both mother and daughter think of their differences in terms of the other having to be different, not much is possible. Demanding that someone else be different is an ill-formed outcome that gets many of us stuck and frustrated, because while you have at least some choice about your own behavior, you really don’t have any choice about what someone else does. That’s why having them “listen nonjudgmentally to each other” in the second session went nowhere, despite how useful that intervention often is.

But if you describe the same behavior as “doing something different” or “acting different” a client will often be willing to consider it. This distinction between identity and behavior is one that many therapists have never learned, and it’s often a crucially important reframe. In this case, it’s the key understanding that allows the mother to change her behavior and have a new internal response to the chaos of her daughter’s household.

In the third session, the mother states even more blatantly that her understanding of the issue involves her identity, “It just isn’t me to be like other grandmothers. . . . I like me the way I am. She’s asking me to be someone I’m not.” That brief utterance makes six references to her identity and five to her being: isn’t, me, be, I, me, I, am, me, be, I’m.

Soderquist begins his intervention by exquisitely pacing her focus on her identity, assuring her, “You’re fine just as you are,” relieving her of any pressure to change who she is, and implying that her daughter’s attempt to change her isn’t valid. He follows this up immediately with saying, “And Emmy is fine the way she is,” which implies that the mother’s attempts to change her daughter are just as invalid. Since the mother already agrees with the first statement, she has to agree with the second, which only reverses the direction of the logic. Abandoning her attempts to get her daughter to be different closes a door that leads nowhere, and opens a door to a more useful alternative.

To strengthen this understanding, Soderquist first offers a generalization about two of them being different. “You just happen to be very different personalities.” Then he follows this up with two metaphors that express this difference in who they are, “She’s AM, and you’re FM: she’s rock-and-roll, and you’re chamber music.” Both metaphors are drawn from contexts in which differences clearly don’t need to change.

He begins his description of Meryl Streep, and the difference between her self and the roles she plays, with the word, “Fortunately,” a cognitive qualifier that creates an expectation of good things to come. If he’d used a different adverb, such as “unfortunately” or “sadly,” the mother would have had a very different expectation about what he’d say next. Saying “there’s a solution,” further directs her attention away from the problem and builds even more positive expectation.

“I wonder if you’d enjoy inventing a role that works well when you’re with Emmy and her family,” is called an embedded question, a hypnotic linguistic form often used by Virginia Satir, one of the greatest therapists who ever lived. Although it’s a statement, it elicits an internal response as if it were a gentle question, but without demanding an overt response the way most questions do. This invites the mother to consider changing her behavior without any demand that she do so, and with no need to respond verbally.

Notice how different an overt question with the same content would be. “Would you enjoy inventing a role that works well when you’re with Emmy and her family?” would demand a verbal answer, and keep her externally focused on Soderquist, making it harder to turn inward and consider whether she could enjoy doing that. The embedded question focuses her attention on whether she’d enjoy playing a role, implying that she can do it; the question is merely whether she’d enjoy it or not. Before, she demanded that the daughter change; now she’s invited to change her own behavior (while keeping her identity intact)–an enormous shift in attitude that most clients can benefit from.

As she begins to consider this possibility, she’ll naturally become more internal, a perfect time for Soderquist to slow his voice to be more hypnotic and set up the specific cues for her new role play–all in present tense, so that she can rehearse it as if it’s happening at the moment. “When you open the door to her home, you can see it like a stage. You pause at the door, view the scattered toys, and listen to the active children as part of a stage set.”

Then he permissively suggests a response she might have, “You may find it amusing,” and follows with even more detailed suggestions that continue to encourage a rehearsal of new behaviors. “You’re Meryl Streep slipping into a role.” The use of “slipping” implies that it will be easy and effortless. Think how different it would be for her if he’d said “trying to get into role” or “struggling to act differently”! He then goes on to suggest other behaviors, and possible pleasurable responses for her.

When he says, “Your creative inner mind will be alongside your conscious mind,” it implies that the creative mind is unconscious and will assist her. As he goes on to say, “enjoying the flow as you engage with your daughter and your grandchildren in fun ways,” it implies that much of this will occur unconsciously and spontaneously. Notice all the words that make this rehearsal an enticing prospect: enjoying, flow, engage, fun, expanding, satisfying, surprising, enjoying, secret.

A bit later, when Soderquist says, “Afterward, you and your husband may chuckle about the relaxed grandmother character you’ve created,” it invites her to take a future vantage point and look back on what she’s imagined, as if it had already happened, further cementing its reality as something she can do. With all this elegant hypnotic language, it’s not surprising that when she emerges from her trance, she says, “I can do that!”

This entire intervention probably took less than four minutes, showing that when you know what to do–and how to do it–change is easy.

I think Ronald Soderquist deserves an Oscar, too!

Ronald Soderquist, Ph.D., a hypnotherapist and licensed Marriage and Family Therapist, is the director of Westlake Hypnosis in the Los Angeles area. He’s served on the staff of California Lutheran University and other universities and graduate schools. Contact: eldaron@earthlink.net.

Steve Andreas, M.A., has been learning, teaching, and developing personal-change methods for more than 53 years. His books include Virginia Satir: The Patterns of Her Magic; Transforming Your Self; and Six Blind Elephants: Understanding Ourselves and Each Other. His new book is Transforming Negative Self-Talk: Practical, Effective Exercises. Contact: andreas@qwest.net.

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.

Stop the Merry-Go-Round: Angry Couples


Strategies for angry couples

By W. Robert Nay

It’s one thing to help an easily incensed individual learn to manage a too-easily-aroused temper. It’s entirely another thing to help partners in a troubled relationship deal with the kind of anger that gets triggered primarily when they’re with each other. Yet therapists often focus too narrowly on helping individuals manage their personal anger, rather than helping partners reduce the anger that repeatedly arises between them.

In chronically angry couples, differences of opinion rapidly become arguments, which escalate to raised voices, raised blood pressure, and sometimes raised fists. Repeatedly, the anger itself, rather than the initial disagreement, becomes the issue, shooting back and forth, intensifying with each volley. As the emotion rises, and as ordinary inhibitions fall away, the likelihood of verbal abuse and/or physical aggression grows. Aggressive feelings drown out any attempt at addressing the underlying conflicts or problems in the relationship.

Partners riding this merry-go-round of anger almost inevitably blame each other for the problem. Typically, one or both portray the other as having “started it,” ignoring the fact that their conflict occurs within a system of two. The partners pass the anger back and forth like a shared virus.

My Way or the Highway

Adam and Sarah sought my help after what Sarah called “years of fighting over nothing,” which had sapped the life from their marriage. Sarah, 38, told me her anger was triggered only by Adam’s temper. “I’m fine with other people,” she said, adding that the only time she got mad was when she felt Adam had invaded her space. “With him, it’s always ‘my way or the highway.’ He gets extremely loud, intense, and sarcastic when we don’t do what he wants, when he wants it.”

When I asked her how she usually reacted when Adam got angry, she looked embarrassed. “Lately, I’ve been telling him off,” she admitted. “I can’t take any more of his loudness and aggression. Last week, I screamed at him to ‘shut the hell up’ in front of our children. I don’t want to act this way, or for them to turn out like him!” I asked her if she’d be willing to be a part of the treatment, even though she believed Adam’s anger was the main problem. Although she wasn’t sold on this idea, she agreed when I told her that she needed to learn to change the way she reacted to Adam’s anger to help defuse it early, and to feel better herself.

Adam, 41, informed me right away that he’d do anything to save his marriage. He came from a family of shouters, he said, and often listened to his parents argue well into the night. While he’d vowed not to be like them, he found himself all too often “losing it” with Sarah—yelling and saying things he later regretted. But he saw his wife as a big part of the problem: “If she’d just leave me alone when I get stressed out, I wouldn’t get so mad. She needs to learn to back off.” He blamed much of his anger on stress resulting from long hours working for a demanding boss at a large insurance company. By blaming his wife and his work, he externalized his feelings. Like most of my angry clients, deep down, he believed that his anger originated outside himself.

Strategies for Arousal Management

I met with Sarah and Adam individually for three sessions to identify their individual patterns of anger arousal—the physical sensations each experienced when anger was triggered. From there, the focus shifted to specific strategies to derail their arousal pattern before they became so angry that calming thoughts and self-control were difficult or impossible.

In my first individual session with each of them, I asked each one to keep an anger log, recording the situations when anger was experienced, the thoughts or “self-talk” that arose in their minds, their body sensations (tight shoulders, heat in neck and face, jaw tension), and the actions or words they used to express their animosity. The logs and my clarifying questions helped me identify their triggers: the actions or statements that seemed to instigate arousal. As partners become aware of specific triggers, they can “preview” an upcoming encounter to think ahead about how to manage their temper, if it arises.

To assess how each got triggered, I reviewed what I call the “Five S’s”—life factors that contribute to instigating and intensifying anger arousal. These include: inadequate Sleep; ongoing life Stress; not eating properly, or inadequate Sustenance; use of Substances like alcohol, caffeine, or other drugs; and any health issue or Sickness that increases irritability (a bad cold, headache, lower back pain). Adam told me, for example, that he often stayed up until 1:00 a.m. to have some time alone, yet arose at 6:00 a.m., getting only five hours of sleep. He agreed to begin pushing his bedtime sequentially earlier by about 15 minutes a night, to work toward a 10:00 p.m. bedtime. We discussed making the bedroom extra dark to further aid sleep onset.

Adam’s stress level was heightened by his feeling that he had to work late to avoid a threatened layoff. We discussed a variety of coping strategies, including work breaks, a power nap, relaxation techniques, and ways to challenge scary self-talk—”How will I support my family?” “What if I can’t find another job?”—which fueled anxiety and sometimes contributed to insomnia. He told me he often skipped lunch or grabbed a snack from a machine, since he felt he was too busy for a meal. I encouraged him to take at least 30 minutes to eat a healthy lunch to sustain his blood-sugar level, since low blood sugar is related to irritability and general disinhibition.


As for substances, Adam told me he drank lots of caffeinated diet colas at work and had begun consuming two or three glasses of wine each evening as a way of “winding down.” I told him that while we all vary somewhat, even small amounts of alcohol and caffeine tend to be disinhibiting and could fuel anger arousal. We agreed it was best to avoid drinking alcohol during the work week and to limit other drinks to decaf versions and water. Sarah’s Five S’s included drinking wine with Adam in the evenings, as well as frequent headaches, which fueled irritability and negative self-talk. I encouraged her to limit her alcohol consumption and to seek medical guidance for her headaches.

From their anger logs, we identified the first physical sensations of anger arousal. Adam reported that his chest felt tight and his breathing would get heavy. In contrast, Sarah found that her first anger tell was when her jaw felt tight. Both reported that the next phase of anger arousal they noticed was heat in the neck and face. I encouraged them to learn to identify these feelings as signals to begin arousal management.

STOP

At this point, I taught both Adam and Sarah to employ an easily remembered protocol for dampening arousal, which I call the Stop method—Stop, Think, Objectify, Plan. The first step to controlling anger is to reduce initial arousal by internally stating the self-instruction to “Stop!” while mentally picturing an image and/or hearing a sound associated with cessation. For example, Adam would imagine a bright, red stop sign and his father’s voice saying “Stop immediately!”

Next, to derail anger escalation, it’s helpful to ask clients to sit down (assuming a physical position the brain associates with safety) and engage in deep, diaphragmatic breathing. Adam and Sarah learned to sit in a fully relaxed position while practicing a version of diaphragmatic breathing and exhaling to a slow, internal count from 10 to 1. The acts of sitting and consciously breathing interrupt angry thoughts, because they focus attention on these tasks. Each was instructed to continue taking relaxing breaths as needed until his or her anger signal diminished.

I then encourage each partner to focus on his or her most upsetting, angry thoughts, which usually sprang from common cognitive distortions. Some examples include: mindreading—”Sarah just loves to get me mad, so she can accuse me of being irrational”; personalizing—”Adam’s fury isn’t about his stress: it’s to put me down!”; overgeneralizing—”Adam can never cool it: he’s always just on the edge of losing it”; and thresholding—”If Sarah corrects me in front of the kids one more time, I know I’m going to lose it.” These distortions trigger fight-or-flight instincts and associated arousal, making it critical to develop the ability to step back and look at the situation through a more objective and calming lens.

After quickly identifying one or two distortions prominent in their thinking, each learned to rebut and replace anger-arousing thoughts with affirming facts. This is called objectifying. I typically teach clients a strategy I call “camera checking” to focus them on the observable facts of the anger-inducing situation. By emphasizing the facts, rather than perceptions colored by resentments, experiences, or faulty beliefs, partners learn to avoid demonizing and personalizing the other’s words and actions. This process diminishes the perceived threat and, typically, leads to an immediate decline in arousal. For example, instead of thinking “She loves to make me mad”—an irrational mindreading of Sarah, Adam was asked to focus on observable statements and actions devoid of interpretation: “The fact is that Sarah is telling me her opinion of how I handled our son Jake. She disagrees with me.” This thought—an objective statement, rather than an attack on the other’s character—sets the stage for a discussion of differences of opinion.

Each partner is encouraged to think of an immediate plan, focusing on the facts of the situation. Having a plan reduces perceived threat by increasing one’s sense of control. Adam’s plan was, “I’ll suggest we table this until I feel less exhausted,” or “I’ll look at her and listen until she expresses her ideas—seeing them as information and not criticisms or put-downs.”

Therapy often involves entirely too much talking about new skills the client should put into place, but not enough rehearsing. Clients often understand well enough what to do when life challenges arise, but often can’t recall and enact new skills in the heat of the moment. Accordingly, new coping behaviors need to be rehearsed enough to be automatic. I spend a full session with each partner, role-playing how to implement the Stop in mock situations of provocation. I model how to use the Stop, and then we reverse roles and have the client use it in the heat of role-plays that enact the most difficult and volatile situations each client can imagine.


Making a Commitment to Change

After Adam and Sarah had experienced applying Stop techniques, I met with them together to put these skills into practice. Adam echoed the doubts of most clients at this juncture: “I still feel that I’m going to lose it when Sarah and I really get into it. How can I remember to do all this stuff when the heat gets turned up?”

To segue into the next phase of our work, I asked them to discuss together the words and actions that had most quickly provoked anger escalation in the past. For Sarah, it was when Adam raised his voice, approached within two feet of her, and told her she was incompetent as a wife and mother (using words like lousy, lazy, and weak) and criticized her in front of the children. Adam responded strongly when Sarah raised her voice, questioned his sanity (“You’re nuts!” “You need help!” “I’m going to have you put away”), refused to speak to him for hours, and threatened divorce. They were encouraged to discuss how they felt when these threatening behaviors were directed at them, while their partner listened without interruption.

I asked each to make a commitment to change, based on what they’d learned in the individual sessions and from each other. Which behaviors were they willing to alter? Which behaviors would they agree to substitute when angry? I helped them be as specific as possible, to ensure well-defined, practical, and measurable goals. Adam agreed that when conflict arose, he’d sit down and use a softer voice, tell Sarah what behaviors he wanted her to alter without resorting to name-calling, and do all this in private. As in other cases, I said that if they wanted to, they could write down and sign their commitments to each other as a contract.

Circuit Breaking

We then spent two full sessions practicing “circuit breaking” to derail anger escalation. Each partner has two potential circuit breakers, warning signals that the system is getting dangerously hot. One, an inner physical feeling signaling anger arousal, originates in the self; the second, the partner’s anger actions, originates in the other. The activation of these circuit breakers signifies the need to shut down the discussion and begin using the Stop method.

The self-originating circuit breaker for Adam included a tightening of his shoulders and chest or warming of his face; his other-originating circuit breaker was when Sarah’s voice became significantly louder or she began criticizing him in front of the children. Sarah’s self-originating circuit breakers included a tightening jaw and a flushed, warm face; her other-originating circuit breaker was when Adam got loud, stood within two arm’s lengths of her, or called her a name.

These four levels of awareness (his and her self-signals and other-signals) warned that arousal was escalating and the action should be ended for as long as needed to employ the Stop techniques, calm down, and reassert control of arousal. As I encouraged them to discuss the hardest, most triggering topics that they could think of while practicing circuit breaking, they began readily to halt and derail their anger, and then redirect themselves back to calmer talking and listening about issues. I demonstrated these strategies for them, so they could practice during two sessions devoted exclusively to rehearsing together how to use circuit breaking.

As Adam and Sarah practiced using Stop with me, they not only became more proficient in derailing their anger arousal, but also less reactive to each other. Just as exposure training reduces anxiety to feared situations, these rehearsals helped them feel less threatened as they learned new ways of responding to old anger triggers. They felt more prepared for the next provocative encounter and more relaxed about how to handle each other’s actions.

A Vision of Relationship

Now that their anger arousal was under control, we could begin to discuss underlying relationship issues during our couples sessions. Through conversations emphasizing I-statements and active listening, I asked each to discuss their vision of how they’d like their lives to be in a year and beyond in major life areas: love and intimacy, friendships, activities/interests, spirituality, intellectual stimulation, family/parenting, financial. Once they each better understood the other’s vision and underlying needs, both could craft more-realistic expectations of their partner and a mutual vision for their relationship, reducing sources of future conflict.

During 10 additional sessions, they practiced using Stop to derail anger arousal that would emerge as they decided how to collaborate on implementing their individual visions and their common goals. For example, Adam wanted more time with his male friends, and Sarah wanted to visit her parents more frequently—something Adam had resisted in the past, which had been a source of arguments. They agreed that on the same weekend at least once a month, they’d fulfill these individual goals, removing a source of conflict. They reported using Stop and circuit breaking with much success at home. By mutually managing their arousal, they reported success in discussing and resolving differences as they worked on satisfying their needs.

This CBT based systemic approach to anger treatment acknowledges that couples inhabit an interdependent relationship, and that treating both of them, regardless of who’s the “angrier,” helps each identify and alter his or her contribution to the problem. Nevertheless, the approach I’m describing is no miracle cure. One partner frequently refuses to participate. When I’m forced to work with one partner alone, I employ the same methods for arousal management described above and use role-plays with me standing in for the partner to allow the client to practice circuit breaking. Safety is always the priority, and I routinely and ongoingly assess the degree of risk if violence is an issue. When the risk is too high, I refer the partners to separate therapists until they become comfortable with joint sessions.

The path to behavior change is often circuitous, and setbacks frequently occur, especially when one or both partners minimize the need to use Stop, rationalizing that “We’ve got this down and don’t need to do all those steps,” or returns to old thinking and actions when one or more of the Five S’s suddenly fuels arousal. Adam began working late and missing evening meals, driving home exhausted and out of sorts—which fueled irritability and rekindled old habits. At those times, it’s especially helpful to assess what exactly has taken place and recommit to new behavior. Thus, “booster” sessions are usually necessary.

Rather than becoming overfocused on the drama of anger or its roots in an individual’s life, it’s crucial to understand anger as part of an ongoing, interdependent system of expressed and unexpressed needs, which ultimately must be addressed in any relationship. Rather than something that must be managed by just one partner, it’s important to see it as being central to the dance of need fulfillment in a couple, and to help both partners learn new steps to convert this often destructive force into fuel for lasting relationship change.


Case Commentary

By Ronald Potter-Efron

Robert Nay presents a patient, thoughtful, and practical approach to the difficult task of working with angry couples. He’s quite thorough in his three-phase technique, and recognizes that a major concern in working with such couples is getting them to stick with the therapeutic program long enough to develop new habits of respectful communication. Brain research on neuroplasticity suggests that it takes at least six months of practicing new behavior to create permanent change.

My major critique of Nay’s approach is that it isn’t truly systemic in the classic sense of that term. Rather, he begins by separating the parties and working with them individually for several sessions. In my own work, I try to avoid individual sessions, because all too often, clients use them to share potentially explosive secrets—”I just want you to know that I’m having an affair with my secretary, but don’t tell my wife.” Individual sessions increase clients’ tendency to try to make the therapist their ally against their partner. At a deeper level, I believe that holding separate individual sessions implies that the real issues are individual, rather than systemic.

I prefer to keep the couple together in sessions so that they can focus on how they’re mutually creating their miseries. One approach I use helps couples chart the details of their here-we-go-again arguments—the fights that have occurred so frequently that both parties know all the lines, but still become so emotionally flooded that they seemingly can’t stop these conversations from happening. It’s critical, I believe, for the couple to realize that they’re mutually responsible for these minidramas. Although either partner can derail the scene by refusing to say the lines, these fights in reality usually don’t end until both parties decide to quit. Until that happens, most partners tell me that even when they try not to get sucked in, they quickly return to their habitual roles when their partner plays out the old drama.

It appears to me that, instead of a truly systemic approach, Nay does what I call side-by-side individual work. In essence, his goal is to help each partner inoculate himself or herself from their partner’s provocative words and deeds. His Stop method certainly will help them do exactly that, but I don’t see how it’ll lead to a significant change in the system.

This is most apparent in the individual approach Nay uses to elicit the couple’s sharing of personal visions of a presumably brighter and more constructive future. This attempt to get them out of their current quagmires and help them look ahead to a more positive future is certainly valuable, but, from a pure systemic perspective, I believe that much more emphasis should be placed on having partners craft a mutual vision together—a shared dream that offers a more cooperative direction.

In summary, I’d say that, despite his useful insights into the struggles of angry couples, Nay’s case description offers a side-by-side therapy approach, rather than truly systemic counseling.


Author’s Response

I appreciated Ronald Potter-Efron’s perspective that, for lasting change to occur, the couple must continue to rehearse new anger actions and reactions to each other over time, so that they become more automatic, particularly when anger arousal is triggered and old habits rear their heads. However, I was perplexed by his focus on the lack of purity in following a classic approach to working with a couples system of learned interactions.

This case clearly melds cognitive-behavioral methods with couples therapy and communication strategies. The thrust of the case is to move away from the individual-therapy approach to working with both partners, each of whom participates in the dance of anger. I thus agree that we must move beyond a side-by-side approach to anger treatment. After a few individual visits to instruct each partner in the rudiments of managing arousal—a CBT approach that can best be carried out individually—I work with both partners, if possible, to help them collaboratively craft an approach to attaining their individual needs.

As their needs are better fulfilled, anger arousal is likely to be reduced or eliminated. I’ve experienced few problems in making it clear that the goal of treatment is to alter how they manage anger arousal as a couple, not to do parallel, individual therapy. In particular, the circuit-breaking strategy, through which both partners learn to recognize and communicate early on that arousal is escalating, permits them to remain focused on clear communication and resolution of needs, without being derailed by recurrent anger patterns that defeat their best efforts at making necessary relationship changes.

W. Robert Nay, Ph.D., is clinical associate professor at Georgetown University School of Medicine and the author of Taking Charge of Anger: Resolving Conflict, Sustaining Relationships and Communicating Effectively Without Losing Control and Overcoming Anger in Your Relationship: How to Break the Cycle of Arguments, Put-Downs and Stony Silences. Contact: wrnay@comcast.net; www.wrobertnay.com.

Ronald Potter-Efron, Ph.D., is a clinical psychotherapist, co-owner of First Things First Counseling and Consulting, and director of its Anger Management Center. He’s the author of Rage: A Step-by-Step Guide to Overcoming Explosive Anger. Contact: pttrefrn@triwest.net.