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Tag: Clinician’s Digest
Reading Emotions
By Jared DeFife
When it comes to the craft of conversation, most of us believe that some face-to-face interaction is the key component of emotional communication. For social engagement, we connect with our social network over Facebook or use our various iDevices for a little FaceTime with relatives. But new research is questioning how we actually process and interpret the emotional reactions of others. The findings might make us take an about-face turn on conventional wisdom regarding facial expressions and emotions.
For decades, researchers have relied on the “Ekman faces” for studying how we process emotional expressions. In the 1970s, psychologist Paul Ekman created a set of black and white photographic images of actors portraying six “universal emotions”: happiness, sadness, anger, disgust, fear, and surprise. Although the stimuli have varied over time (to incorporate actors of varying ethnicity, for example) and the universal emotions have expanded (to include emotions such as pride, guilt, and shame), the fundamental reliance on facial expressions as a primary indicator of emotional state has remained. Now it appears that, when it comes to intense real-world emotional experiences—such as the joy and relief of seeing your first child born or the agony and disappointment of a crushing defeat—our faces may not be as revealing as once believed.
To examine the role of facial expressions and body language in how we interpret the intense emotional displays of others, researchers at Princeton, New York, and Radboud universities captured photographic images of peak emotional expressions from a variety of powerful real-life situations, including high-stakes tennis matches, sexual orgasms, home-makeover reveals, and navel or nipple piercing. After manipulating the images to isolate facial expressions, bodily expressions, or bodily and facial expressions combined, the researchers asked study participants to rate the type and intensity of emotional experience they thought they saw in each image.
As published in the journal Science, the results demonstrated that when viewing facial expressions alone, viewers were no better than chance at identifying whether the expression indicated a positive or negative experience. Viewers were much better able to identify positive or negative experiences when viewing the images of bodily expressions of emotions (with or without the corresponding facial display).
In case you’re tempted to read these results and think you knew it would turn out that way all along, the researchers actually described their methods to a separate group of participants beforehand. Of those asked, 80 percent thought viewing the face alone would be most accurate, whereas only 20 percent thought the body/face images would be most effective, and zero people predicted that the body image alone would be the most useful indicator. Furthermore, by manipulating the body image, the experimenters successfully manipulated viewer perceptions of the emotions shown. For example, when putting the face of someone undergoing piercing on the body of a tennis victor, viewers were more likely to rate the photograph as someone experiencing intense joy.
“These results show that when emotions become extremely intense, the difference between positive and negative facial expression blurs,” said the lead researcher Hillel Aviezer in a released statement. “From a practical-clinical perspective, the results may help researchers understand how body/face expressions interact during emotional situations. For example, individuals with autism may fail to recognize facial expressions, but perhaps if trained to process important body cues, their performance may significantly improve.”
Beyond that, the study’s results may have implications for therapist practice and training by overcoming our natural inclination to pay attention to facial expressions and highlighting more focused attention on body language and physical cues. Videotaped supervision sessions might need to zoom back to incorporate the body posture of therapists and their patients. Also, teletherapy through Skype, which focuses primarily on the face, might be improved with more attention to the whole-person image.
Resources
Reading Emotions: Science 338, no. 6111 (November 2012): 1225–29; http://www.eurekalert.org/pub_releases/2012-11/thuo-bln112912.php.
Can Video Games Power Up Your Practice?
By Jared DeFife
Wonder if Pac-Man and Ms. Pac-Man ever needed couples therapy? What might a family therapist say about the sibling rivalry of the Super Mario Bros? It’s time to get serious about gaming, because some suggest that video games and psychotherapy fit together like a well-placed Tetris block.
Surveys suggest that between 95 and 97 percent of American teenagers have played video games at some point in the recent past, and most of them play games on a regular basis. Adolescents aren’t the only ones gaming, however. More than 50 percent of adults play video games, too, whether they’re launching Angry Birds on their phones or questing in multiplayer online universes like World of Warcraft.
“They’re a part of our patients’ lives,” says Mike Langlois, a clinical social worker in Cambridge, Massachusetts, and author of the eBook Reset: Video Games & Psychotherapy. “Anything that much of the population is doing is something that psychotherapists need to know about.”
Unlike the arcade games of the past, modern video games offer an immersive social experience that therapists can use to build relationships with young clients. Forget about the dusty old board games like checkers and Parcheesi! “If I’m doing play therapy with adolescents in the 21st century,” Langlois says, “I should be playing the games of adolescents in the 21st century.”
More and more, gaming consoles are making their way out of parents’ basements and into our offices. “As I’ve learned in my child and adolescent psychiatry practice, the focus should be not only on what kids play, but also, perhaps more so, on how they play,” writes psychiatrist T. Atilla Ceranoglu in an editorial for the Boston Globe. Ceranoglu’s research on the use of video games in psychotherapy suggests that by playing video games with their patients, psychotherapists can build relationships with their gamer clients. In the process, they can learn valuable information about frustration tolerance, creative problem-solving, competition, and collaboration.
Even if you don’t have an Xbox set up in your office, it’s important to be aware of and sensitive to gaming-related issues, says Langlois, who brands his clinical practice as “gamer-affirmative.” By talking to everyone from adolescents to active-duty military veterans in Iraq and Afghanistan about their gaming experiences, Langlois says he started to hear stories about how people used video game communities to get help when they were depressed or even suicidal. “It was very different than the media hype I was hearing about how video games are all addictive and cause isolation.”
Now researchers and practitioners are starting to catch on to the power-up potential of video games for clinical practice. Research studies have found that playing video games improves pain management during medical procedures, while some specially designed psychoeducational video games have been used to increase treatment adherence in managing chronic diseases, such as diabetes and sickle-cell anemia. Businesses such as San Diego–based SmartBrain Technologies and Atlanta-based Virtually Better are headed by psychologists to develop, test, and use special therapeutic video game programs for everything from brain injuries to AD/HD and panic disorder. Even major commercial entities like Nintendo’s Wii gaming system and Microsoft’s Xbox Kinect platform are marketing games to improve physical activity and mental coordination.
Meanwhile, if you want to improve your own gamer-practice competence, try video gaming yourself. “I don’t think you need to play every single game, but you do need to be willing to have the experience of playing a game and learning to play,” says Langlois. He’s started a class on social work and technology in which one session requires students to attend in the online environment of World of Warcraft. Some students new to the game environment (gamers might call them newbies or noobs) find themselves fumbling around and frustrated as they learn the intricacies of navigating a new world. “I tell them to pay attention to that, because that’s exactly how their patients feel. For them, life is as difficult to negotiate as learning how to navigate this video game is for you.”
Resources
Video Games: Review of General Psychology 14, no. 2 (June 2010): 141-46; http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2011/07/05/video_games_can_be_healthy/.
What Causes Borderline Personality Disorder?
By Jared DeFife
Do childhood trauma and a chaotic family environment cause adult borderline personality disorder (BPD)? Common clinical wisdom says yes, but new results are leading some researchers to insist that it’s more complicated than that.
Investigators from the Minnesota Twin Family Study, first begun in 1983, collected data about childhood abuse and adult personality from 1,382 pairs of same-sex twins, followed over time from ages 11 to 24. By examining differences in abuse exposure and genetic overlap (whether the twins were identical and thus had the same DNA, or fraternal, and thus had only about 50 percent genetic overlap), the authors, led by Marina Bornovalova of the University of South Florida, concluded that childhood abuse in itself isn’t a direct cause of adult BPD traits. But since childhood abuse is seen so frequently in individuals with BPD (some studies suggest in as much as 90 percent of cases) why the overlap? According to the study, common genetic factors contribute to both childhood abuse and BPD.
The researchers suggest two possible genetically influenced reasons for the connection between childhood abuse and adult BPD. In the first model, called “passive genetic mediation,” children not only inherit genes from their parents, but are raised in an environment that’s an expression of the parents’ own genetic influences. In this model, children inherit genetic tendencies toward aggression, impulsivity, and emotional dysregulation from their parents and are raised by parents who are themselves aggressive, impulsive, and dysregulated. Abuse and BPD are thus different manifestations of the same emotionally dysregulating factors.
In a second, more controversial scenario, known as “evocative genetic mediation,” children who inherit difficult genetic temperaments from their parents tend to behave as moody or impulsive children. Emotionally intense and difficult to raise, these children strain their parents’ own genetically limited coping resources, contributing to parenting failures characterized by childhood abuse and neglect.
If the second scenario sounds like blaming the victim, the authors are quick to point out that their results “don’t support the idea that [childhood abuse] is inevitable, justified, or without harm.” However, their work raises possibly provocative questions about the causes and effects of childhood abuse and adult borderline personality disorder, once again putting science at odds with facile, politically correct perspectives on complex psychological phenomena.
Resources
What Causes Borderline Personality Disorder? Journal of Abnormal Psychology, doi: 10.1037/a0028328.
“Manpocalypse” Now: Today’s Masculinity
By Jared DeFife
Psychologist Philip Zimbardo knows a thing or two about tough guys. In 1971, his notorious Stanford prison experiment, originally planned for two weeks, had to be shut down after only six days when college students acting out roles as prison guards started to play a little too rough with their mock inmates. In 2007, he tried to understand the military abuses at Abu Ghraib prison in his book The Lucifer Effect: Understanding How Good People Turn Evil. Now he turns his attention to a different kind of prisoner: the average American male shackled by the constraints and demands of societal expectations.
In a new eBook titled The Demise of Guys: Why Boys Are Struggling and What We Can Do about It, Zimbardo and his coauthor psychologist Nikita Duncan paint a dire picture of dudes in this country, asserting that boys are increasingly failing to measure up academically, socially, and sexually. The blame, they say, lies with the Internet, television, and video games. According to their view, a new Lost Generation has grown up, addicted to arousal and constantly seeking stimulation and novelty through digital means: “The excessive use of video games and online porn in pursuit of the next thing is creating a generation of risk-averse guys who are unable (and unwilling) to navigate the complexities and risks inherent to real-life relationships, school and employment.” More young men are supposedly languishing in their parents’ basements, aimless, asocial, and out of touch.
The signs of the decline, they say, are everywhere: falling test scores, violent video gaming, and a buxom pornography industry. Zimbardo describes a “social intensity syndrome” in which men are driven to engage in intense, male-dominated social interactions leading to an endorphin rush that the rest of their dull daily lives just can’t match. During a popular TED talk, Zimbardo said “Guys would rather be in a bar with strangers, watching a totally overdressed Aaron Rodgers of the Green Bay Packers, than Jennifer Lopez totally naked in the bedroom.”
Boys aren’t the only ones struggling, suggests psychiatrist Boadie Dunlop, director of the Mood and Anxiety Disorders Program at Emory University. With the economic downturn’s hitting men particularly hard, they’re relying more heavily on women as the primary household earners. While traditionally female-populated fields like healthcare and social services are experiencing burgeoning demand, “manly” occupations like construction and manufacturing are being scaled back and reorganized for greater efficiency. Many men are finding themselves outsourced, obsolete, and out of work. “Compared to women, men attach greater importance to their roles as providers and protectors of their families,” Dunlop says, “and men’s failure to fulfill the role of breadwinner may lead to greater depression and marital conflict.”
Zimbardo and Duncan may be sounding an alarm about masculinity in crisis, but concerns about the death of manhood have been around for decades, if not centuries. Pornography isn’t new, even if it’s now more accessible on the Internet. Many video gamers would protest that gaming is more interpersonally interactive today than ever, and our wired world is used much more for social networking than social detachment. Are entertainment addictions really a more pervasive societal concern for men than rising housing costs and ballooning student loan bills? Is the fact that men are living with their parents longer and postponing marriage and childrearing a sign of “Arma-guy-ddon” or just a smart social adaptation to an economic “man-cession”? Only time will tell.
Resources
Manpocalypse: http://www.demiseofguys.com; British Journal of Psychiatry 198, no. 3 (March 2011): 167-68.
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Is Resistance Dead...
Read more...
Or have the rumors been exaggerated?By Clifton Mitchell
With all the recent developments in research, theory, and practice, we have more treatment options to choose from than ever before. Why then do so many practitioners still find client “resistance” a regular companion in their consulting rooms?
Insights and Tools
In Consultation
Peer Supervision Groups that Work
By Eleanor Counselman
Three steps that make a difference
Q: I’d like to organize a peer supervision group, but I’ve heard their failure rate is high. What do you recommend? A: Peer supervision groups provide a welcome respite from the isolation of private practice and an informal, nonevaluative setting after years of formal supervision, particularly for young therapists. They offer valuable guidance on difficult cases and tough ethical dilemmas to therapists at any level of experience. And they’re free! However, as you note, many of them fail. In my experience, careful attention to the initial contract and the ongoing group process can make a huge difference in helping them sustain their membership and thrive. Though they’re often called peer supervision groups, it would be more accurate to call them peer consultation groups. Members don’t have direct supervisory responsibility for one another’s cases: they simply offer suggestions, which members can accept or reject. They typically have four to six members who have approximately the same level of professional experience or share a specific area of interest. Members meet on a regular, usually biweekly, basis. Group consultation, with or without a leader, offers advantages over individual consultation. It includes the possibility of multiple perspectives on the same problem and the reduction of clinicians’ shame about confusions and mistakes as they share similar stories about their struggles with difficult cases. Another benefit is peer interaction, which develops one’s professional sense of self. The hall-of-mirrors effect—seeing yourself as others see you—which is so potent in therapy groups, is a major component of the supervision group experience. Nevertheless, despite the many benefits, it’s challenging to start and maintain a consultation group, particularly if it’s a leaderless one. They can fail to thrive or suffer from “task drift,” moving them away from discussing clinical material and into a form of therapy. It can be difficult to integrate new members and maintain clarity about the group’s own process. Presenting cases in supervision in any format poses obvious risks to one’s self-esteem, and group dynamics add additional risks: issues of power, competition, exposure, and shame can lead members to drop out. It’s especially challenging to manage group dynamics in leaderless groups, as it’s usually the leader’s role to remain aware of what’s happening within the group, and without a leader in charge, shame or fear of being judged may silence members. The most successful leaderless groups seem to be those in which the group members find a balance between a focus on cognitive and emotional issues—talking about cases and about the feelings that arise when seeing clients—while consciously managing the functions that a designated leader would serve. These include protecting the group contract, setting and maintaining appropriate norms, and handling gatekeeping matters, such as bringing in new members. A crucial component of maintaining an atmosphere of group safety is regular, dependable member attendance. Without this, a group will never feel like a place to take risks. Members need to be willing to bring up concerns about irregular attendance because, just as in a therapy group, member lateness and absences can indicate issues that need exploring. Chronic irregular attendance can be demoralizing and cause a group to fail. When it comes to group safety and cohesion, Woody Allen was right: 90 percent of supervision group success is about showing up. A significant issue in any supervision group is shame and the reluctance to expose oneself. To make supervision groups feel safer, therapist David Altfeld developed a model of group consultation in which all group members simply share their emotional reactions and associations to a situation being discussed, instead of one person presenting a specific case issue and everyone else giving advice as resident “experts.” This procedure levels the playing field by not allowing members to compete for the best case analysis. It leaves room for highlighting emotional issues, countertransference reactions, and parallel process. Making everyone vulnerable in this manner avoids opportunities for excessive criticism (or its counterpart, excessive niceness) and encourages emotional sharing. Another group consultation model, developed by Irish therapist Bobby Moore, focuses only on minimal case information, such as a patient’s age, length of time in therapy, and perhaps a little demographic information. Then the presenter talks about his or her thoughts, fantasies, feelings, and associations about the patient and the therapy. Group members then share their associations. Following that, the initial presenter is invited to share any further associations. Only at this point does the presenter give the facts of the case and the clinical dilemma. Finally, the group thinks together about what’s been discussed and what it indicates about the case. For those interested in the power of the collective unconscious, this is a fascinating process to experience. To succeed, a consultation group must feel safe and useful to its members. Here are a few simple principles to follow: Clarify the group structure. The group needs to agree on the frequency and length of meetings, which is best accomplished with a predictable schedule. The group needs to agree on its task and focus: is this group for any clinical issue or just for couples, or trauma, or group therapy? How much time will the group spend on “schmoozing,” and will there be one or more than one case presented each time? What will be the presentation format? While most groups use verbal presentation, some groups are now using videoclips—which makes the discussion much livelier. Agree on membership issues. How many members will the group have, and how will new members be integrated? Once a group has formed, I believe that decisions about adding more members should be a group decision. While it may be tempting to accept a request from someone who wants to join the group, a total of six members seems to be the maximum number for each member to have enough opportunities for presentations. Attend to the group process and dynamics. While groups should build in a “schmooze” or “check-in” time, there needs to be an agreed-upon limit to the socializing, so that the group doesn’t become a therapy group or a coffee klatch. Without a leader, the members themselves must monitor the group’s procedures and raise any important issues. Some groups do this ad hoc; others schedule a regular review meeting to evaluate how things are going. Leaderless peer supervision groups can help clinicians at any stage further clinical learning and combat professional isolation. They’re likeliest to succeed when the group members have a clear working agreement, maintain regular attendance, and create an environment in which both emotional and cognitive learning occurs. Eleanor Counselman, Ed.D., is a past president of the Northeastern Society for Group Psychotherapy and an assistant professor of psychiatry at Harvard Medical School. She’s published numerous articles on psychotherapy and has a private practice in Belmont, Massachusetts.Case Study
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.Point of View
Is Technology Changing Our Minds?
What therapists need to know in the Digital Age
By Ryan Howes Right now, we’re all subjects of what’s arguably the most widespread, fastest-paced, unplanned experiment on human psychology ever conducted in history. The research question is: what happens to the human brain when, within a few short decades, it’s introduced—in fact, saturated in—a radically new, instantaneous communications technology that links up billions of people and expands access to untold quantities of information over the entire globe? Does this revolution in technology genuinely enhance human connection or just the opposite? Does it make us smarter in some ways, dumber in others? Gary Small, a UCLA psychiatrist, neuroscientist, expert on memory and aging, and author, with his wife Gigi Vorgan, of iBrain: Surviving the Technological Alteration of the Modern Mind, is on the cutting edge of research about how our digital world is transforming the human brain. In this interview, he discusses how technology is changing our minds and suggests when therapists should respond to clients whose relationship with technology has become unbalanced. ----- RH: How did you get started looking at how technology influences the brain? SMALL: My field is geriatric psychiatry, and I’ve done a lot of research over many years on brain function, brain structure, brain aging, and mood and memory. As a tech geek myself, I was drawn to the question of how all these new technologies are affecting the brain. At some point, the question that most interested me changed from “How can we use technology to measure the brain as it ages” to “Let’s find out what this other technology is doing to the brain at every age.” RH: Speaking of all ages, you were recently quoted in a New York Times article about the impact of easy-to-use tablet computers on toddlers. What’s your take: good or bad? SMALL: Basically, we don’t know, but there’s a growing concern because a lot of parents are increasingly using tablets and other digital technology as pacifiers. Is that going to inhibit children’s development of language skills? Some studies suggest that too much screen time could contribute to AD/HD symptoms and lower performance in school, but there’s also a lot of individual variation: some children are more sensitive than others to large amounts of screen time. RH: Speaking of the impact of technology, how about adults? Is it true that my cell phone is destroying my capacity to remember phone numbers? SMALL: It’s not destroying it, but basically what you’re describing is a nonissue. The reality is that you don’t need your brain to remember phone numbers in today’s world. For that and many other things, you can use your digital devices to augment your biological memory—for remembering names and faces, and for focusing your attention when you’re having a conversation. In fact, your brain power is better spent learning the apps to use so you can take advantage of the computer as an extension of your biological brain. RH: So don’t go overboard in seeing computers as having a damaging effect on our cognitive capacities? SMALL: Exactly. [Phone rings in background.] Please excuse me for a moment [On hold. Four minutes of Muzak.] Hi. I’m sorry about that. I’m afraid I’ve got a fundraiser right now that needs a little bit of my attention. I don’t usually take calls like this, but this underlines part of the whole problem with technology. What I was just doing in taking that call is called continuous partial attention—scanning the environment for something that’s more imminent than what’s going on. It’s actually a stressful thing that’s not good for our brains or for our relationships. In fact, right now I feel a little guilty that I wasn’t paying full attention to you. RH: No harm done! Actually, I’m so used to being interrupted by technology that I hardly even notice it. SMALL: This is one of the issues that people frequently experience in face-to-face conversations these days. They’re talking with someone who won’t look at them because the other person is texting at the same time. So they think, “Eh? Does this person really care about me?” This is having more and more of an impact on the level of social connection people feel. RH: How’s the influence of technology different from any other factors on social connection? SMALL: We don’t exactly know, but the principle is this: your brain is sensitive to mental stimuli from moment to moment. If you spend a lot of time with a repeated mental stimulus, neural circuits that control that stimulation will strengthen at the cost of weakening other neural circuits. Basically, most of us are logging too much technology time, and we’re paying a price. We’re not engaging this powerful brain in activities like looking people in the eye, noticing nonverbal cues and emotional expressions, empathizing with other people. That’s a big concern in today’s technological world. RH: So it’s not technology itself that’s the issue: it’s the fact that technology takes us away from so many other important social activities? SMALL: Right. And there’s the very real issue of technology and addiction. Some people are addicted to video games or to shopping online or gambling online, and that can be destructive to their lives. Studies suggest it can worsen AD/HD, and it may even contribute to the development of autism spectrum disorders. RH: When should therapists be concerned about a client’s relationship with technology? SMALL: My alarm goes off if clients keep interrupting a therapy session because they’re answering texts or making calls or checking websites. Any time I see a patient with an inability to unplug for a while—someone who can’t have a conversation because he’s too busy messing with technology—I consider it an issue worth discussing. RH: What impact might technology have on the future of therapy? SMALL: Of course, many therapists already use technology in their practice. Video conferencing and the use of virtual-reality therapy for people with post-traumatic stress and phobias or obsessive-compulsive disorders are increasingly common. There are applications you can download to help with mood and anxiety disorders. Clients can even wear sensors that will alert their therapist when they’ve reached a certain threshold point of anxiety. I think we can take advantage of technology to enhance therapy and increase its effectiveness. RH: So you’re optimistic about our future with technology? SMALL: I have faith in humans, and I think we’re going to make the right decisions. We need to bear in mind that technology is neither all good nor all bad. The challenge is to integrate it into our lives, rather than let it become something that enslaves and controls us. But with young kids, I do have a special caution. The parents of small children have a responsibility to make sure they don’t overuse it and that they spend plenty of time offline. For adults, same thing: don’t spend hours and hours just answering your email. As with so many other issues in life, it’s a question of balance and putting things in perspective. Ryan Howes, Ph.D., is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs “In Therapy” for Psychology Today. Contact: rhowes@mindspring.com; website: www.ryanhowes.net.Bookmarks
A Review of Jared Diamond's New Book
Is Now Really Better? Lessons from Traditional Societies
By Diane Cole The World until Yesterday: What Can We Learn from Traditional Societies? By Jared Diamond Viking. 499 pp. ISBN: 9780670024810 “NOW IS BETTER.” The bold logo, emblazoned on a stylish tote bag, caught my eye recently at a favorite museum shop. The tote cleverly served as both self-help logo and advertisement for the contemporary art exhibition I’d just viewed. The high-concept show had centered on the psychology of human happiness, and this was one of its chief precepts. But as appealing as the slogan was at first sight, upon further reflection, it seemed insufferably smug. I’d just read the multidisciplinary scientist and bestselling author Jared Diamond’s provocative new book, The World until Yesterday: What Can We Learn from Traditional Societies? and one of his first lessons is that we don’t all live in the same “now”—or even necessarily share the same psychological assumptions or expectations. Indeed, he writes, “Psychologists base most of their generalizations about human nature on studies of our own narrow and atypical slice of human diversity.” As a result, he continues, “Most of our understanding of human psychology is based on subjects who may be described by the acronym WEIRD: from Western, educated, industrialized, rich, and democratic societies.” By contrast, his decades of living for extended periods among traditional peoples in isolated regions of the Pacific Islands has taught Diamond just how weird Western societies can seem when seen through the lens of small-scale societies. To begin with, he writes, “Many of my New Guinea friends count differently (by visual mapping rather than by abstract numbers), select their wives or husbands differently, treat their parents and their children differently, view danger differently, and have a different concept of friendship.” To Diamond, who’s a serious scholar (a professor of geography at UCLA) and a master of making scholarly ideas accessible (as in his Pulitzer Prize–winning book, Guns, Germs, and Steel) these differences provide an opportunity to rethink how our particular WEIRD “now” evolved—and the benefits and losses incurred in that journey. Yet Diamond’s purpose in taking us with him as he explores the organizational structures, cultural practices, and ways of living that have been forgotten or just plain jettisoned by Western modernity is neither to wistfully romanticize traditional cultures as “simpler” nor to discredit Western progress as soulless consumerism. He’s not about to advocate that we give up modern hygiene and medical resources, and has no desire to revive indigenous practices that strike us as nothing less than heinous—like infanticide, strangling widows, or abandoning the old to die when they’ve outlived their usefulness. His goal is to sift through old ideas for reconsideration, with clear eyes and an open mind. With one foot planted in the “now” of Western culture and the other spanning the traditional cultures he’s studied, he makes a compelling case for the ways in which reincorporating at least some of these old ways can pay off—in wisdom and perhaps even economically—in our modern-day world. He begins with the ways in which small-scale societies of New Guinea maintain law and order and regulate disputes, both among members of one tribal group and between different groups. Precisely because these societies are so small, both parties in a dispute—whether related to land, theft, or accidental death—are likely to know each other, and may even be members of the same extended family. Unlike in litigation in large cities, where the two parties will most likely be strangers, in these villages, the disputants will continue to encounter each other and farm, hunt, or trade together in the normal course of daily life. That’s why, in these societies, pointing blame, deciding who’s right or wrong, and meting out punishment through the kind of lengthy, adversarial trial system we practice in the West would be counterproductive. It would likely divide village members against one another, disrupt the smooth functioning of the community necessary for its survival, and even risk a cycle of revenge killings. Instead, for New Guineans, finding “justice” hinges on restoring the previous relationship to what it had been before, with both sides being able to save face, reconcile, and clear the air so they can get on with their individual and communal lives. To avoid lingering grievances, this all should happen as quickly as possible, through mediation (often with the help of mutually respected leaders) and rituals of compensation—such as gifts of food and goods, or a shared feast. How is this applicable for the West? Putting reconciliation and mediation first surely could serve families in civil law cases having to do with divorce, family inheritance feuds, and other domestic issues, Diamond suggests. “Far from helping to resolve feelings, court proceedings often make feelings worse than they were before.” As he points out, “All of us know disputants whose relationship became poisoned for the rest of their lives by their court experience.” It’s a sentiment with which many psychotherapists and lawyers would heartily agree, and which some states have already signed on to, in terms of requiring mediation prior to divorce. This is an area that cries out for more study by both the legal and the psychotherapeutic communities. Moving on to family life, Diamond notes that children in hunter-gatherer societies seem more emotionally secure, independent, and curious than kids reared here—not just to him, but to other Westerners who’ve spent time in traditional cultures. He has no studies to back up this impression, but he nonetheless wonders if this greater self-confidence is due, at least in part, to such traditional practices as “the long nursing period, sleeping near parents for several years, far more social models available to children through allo-parenting [provided by adults in addition to the biological parents], far more social stimulation through constant physical contact and proximity of caretakers, instant caretaker responses to a child’s crying, and the minimal amount of physical punishment.” Despite the lack of scientific proof, he avers that the long-term success of these methods in these societies makes them worth a try. In this, he seems a bit behind the Western “now,” where some of these practices have been gaining traction for decades. At the same time, unfortunately, too many of the current realities in Western life—parents’ overly long working hours, the lack of funding for community support systems, and overuse of digital games that double as babysitters—make the goal of more interactive parent–child time seem admirable rather than realistic. One possibility: take a lesson from the positive ways in which some traditional societies value their elders and organize programs that regularly bring seniors into more direct contact with young people to be potential mentors. It would be a new twist on allo-parenting that could be beneficial to many generations simultaneously. Diamond is particularly persuasive in his case for a mindset he calls “constructive paranoia.” The idea is that it’s self-protective to become vigilant to the signs of the many low-risk but frequent hazards we face repeatedly. For traditional societies, this encompasses the possibility of lion attacks, dead trees falling over, or an enemy ambush in the forest; for us, traffic accidents, heart attack warnings, and icy sidewalks. While traditional societies learned the importance of continuous awareness to potential danger from life-and-death experiences, too often we in the West take our continued well-being for granted—at our own peril. We assume that we won’t fall asleep at the wheel, no matter how little we’ve slept the night before, or that the taxi will stop at the red light, rather than speed through and catch us, texting unawares, as we cross the street. Diamond speculates that, in addition to training themselves to be alert as a survival instinct, traditional societies further help guard against negative occurrences by continually and constantly talking to one another about every last detail of their daily lives, including minute observations about any change in behavior, weather pattern, strangers approaching, newly fallen trees, or animal tracks. Rather than being boring, such conversations serve up information that helps instill and refine the instinct for caution as they go about their lives. In our case, adopting such a mindset—and listening for nuggets of advice in someone’s seemingly endless tale of medical ills—might help us bypass an avoidable pitfall. Diamond continues with a (literally) stomach-churning chapter about the public health crisis wrought in traditional societies by the Western diet. When he visited New Guinea in the early 1960s, Diamond reports, “The non-communicable diseases that kill most First World citizens today—diabetes, hypertension, stroke, heart attacks, atherosclerosis, cardiovascular diseases in general, and cancers—were rare or unknown among traditional New Guineans living in rural areas.” But the introduction of Western lifestyles into many of these areas has brought, within decades, high rates of these diseases. The culprits, as he sums them up, are “salt, sugar, fat and sloth.” We all need to teach—and learn from—each other to eat less, consume more healthfully, and exercise. How to do that is the subject for another book entirely. But in the meantime, the lessons Diamond distills in this book provide plenty of food for thought. Contributing editor Diane Cole is author of the memoir After Great Pain: A New Life Emerges, and writes for The Wall Street Journal and other publications. Contact: djcole86@gmail.com.
© 2013 Psychotherapy Networker
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