Tag: Couple’s Therapy

David Schnarch On How Confrontation Speeds Up Couples Therapy.

Couples therapist, David Schnarch, is not interested in having a couple feel secure in the consulting room.

In fact, David asserts that therapy is the one place where partners should be able to be uncomfortably honest, and take responsibility for their problematic behavior and actions. The couples therapist’s role is to challenge them to do just that.

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Jette Simon on Breaking Through in Couples Therapy

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Bill Doherty On An Approach For Unaligned Relationships

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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.

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Treating the Anxious Client

By Rich Simon Back in the 1970s, as boomers like me came out of grad school and flooded the psychotherapy field, the big challenge to the mainstream tradition of psychodynamic orthodoxy was posed by the iconoclastic family therapists like Salvador Minuchin, Virginia Satir, and Carl Whitaker. Their version of therapy seemed like a thrill-a-minute joyride in comparison to the staid predictability of therapy-as-usual. Read more

Sex, Lies, and the Long Road Back


Recovering from an extramarital affair

By Barry McCarthy

Recovery from an extramarital affair asks a lot of partners. They must not only process painful feelings, repair the rupture of trust, and share their deepest vulnerabilities, but also take steps to build a new, resilient bond, both emotionally and sexually. Allocating the right amount of time to deal with the affair and determining when partners are ready to focus on the present and future marital bond is a struggle for both clinicians and couples.

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Cheryl and Justin, a couple in their mid-thirties, were both demoralized and alienated when they arrived in my office. Two years earlier, Cheryl had discovered that her husband of nine years had been spending some $700 a month on Internet sex sites, massage parlors, strip clubs, and prostitutes. When she’d furiously confronted him, he’d refused to admit that his behavior constituted an extramarital affair, dismissing it as normal male fooling around. Cheryl had considered leaving the marriage, but she didn’t want her son and daughter to suffer the same pain, loss, and family fracturing she’d experienced as a result of her mother’s three divorces.Cheryl and Justin had received lots of conflicting advice from family and friends during the past two years. Some thought they should end the marriage and get a lawyer, while others encouraged them to see a pastoral counselor or marriage therapist. A friend of Cheryl’s even recommended that she forgive her husband in exchange for $5,000 worth of jewelry.

As their mutual bitterness escalated, the couple’s sex life ground to a halt. Cheryl accused Justin of being an irresponsible sex addict who was bankrupting the family, and Justin shot back that she was acting like the sex police. For two years, they remained stuck in mutual recrimination, unable to decide how to move forward. Finally, Cheryl’s older brother, an accountant, confronted them with the reality that they were spending more money on counselors, computer surveillance equipment, and a private detective than Justin had spent on all the sex sites, clubs, and prostitutes. Shocked by this realization, the couple accepted the brother’s suggestion that they see a clinician who specialized in marriage, sexuality, and extramarital affairs.

The Assessment

My approach to affairs is heavily influenced by the work of clinician–researchers Douglas Snyder, Donald Baucom, and Kristina Coop Gordon, who advocate that partners go through a three-phase process: (1) focus on self-care, slow down the process, and do no harm to each other; (2) make personal and relational meaning of the affair; and (3) decide to either recommit to the marriage or achieve a “good divorce.” In my work, I emphasize an additional phase: sexual recovery from the extramarital affair. Few theoretical and clinical models include this vital aspect of treatment.

Justin and Cheryl came in for a four-session assessment that included an initial couples session, an individual session focusing on each partner’s psychological, relational, and sexual history, and a couple feedback session with a recommended therapeutic plan. Not surprisingly, our initial session was difficult, since both were still trapped in a blame/counterblame cycle. Cheryl fluctuated between raging at Justin—calling him a jerk who was destroying her life and family—and begging him to love her and be a trusted partner. Justin barely looked at Cheryl, at one point muttering, “This is useless.” It was hard sitting with their pain, but such raw suffering is frequently part of the initial couple session.

The subsequent individual sessions were more productive. In listening to Justin’s story, it was clear that he brought a number of strengths to the marriage: he loved Cheryl, valued sex, cared about their family, and wanted to heal the marriage. But while Justin loved his wife and found her attractive, he was an anxious sexual performer and didn’t value marital sex. He couldn’t imagine his wife in the erotic role that most turned him on—that of a dominatrix. Justin eroticized transgressive sex, specifically the role of being a sexual submissive. “I’ve struggled with this my whole life,” he said, adding that he’d never revealed this part of himself to any intimate partner, including Cheryl.

Justin continued to resist labeling his secret sexual life as an extramarital affair. He rightly noted that a large percentage of men use porn and get turned on by socially unacceptable images and scenarios. Feeling my empathy and respect, he gradually grew less defensive and began to examine both the healthy and unhealthy components of his sexuality. While maintaining eye contact and reflecting how difficult this sexual split must be for him, I said, “You owe it to yourself to resolve these conflicts.” Once we acknowledged his sexual strengths—valuing sex, enjoying eroticism, and having regular orgasms—I looked him in the eye again and said, “Be honest with yourself. What don’t you like about what’s happening with you sexually?”

After a silence, Justin said in a low voice, “I’m embarrassed about spending so much money on sex clubs and all the rest.”

Gently, I pressed the issue: “After a sexual encounter, what do you think and how do you feel?”

More silence. Then he answered: “I just want to get away.”

After a moment, I suggested to Justin that keeping his sex club encounters a secret and de-eroticizing his wife were part of the problem. “Your sex is controlled by high secrecy, high eroticism, and high shame, isn’t it?” I asked. When he nodded agreement, I added, “Don’t you feel that’s a poison that you’re taking into yourself?” This was a new, non-shaming way for Justin to understand himself, the role of his secret sex life, and how it affected Cheryl. For the first time, he understood that his secret sexual activity did negate marital sexuality and, therefore, was an extramarital affair. His voice shaking, he said, “Dammit, Cheryl’s right. It is like an affair.”

In her individual session, Cheryl revealed that she’d grown up feeling fearful and inadequate in the sexual realm. Her mother had raised her to link sexuality with pregnancy and being labeled a slut. She never felt pretty or sexy enough and feared that no one would ever want to marry her, so when Justin pursued a relationship with her and proposed marriage, she felt she’d been saved. Now she was devastated by her husband’s lack of erotic interest. “I feel like a sexual neuter,” Cheryl said. “I can’t imagine that any man would think I’m attractive or want to go to bed with me.”


Getting Real

A crucial component of our sex therapy model is the couple feedback session. The goals of this 90-minute session are: the development of a new, more genuine narrative about each partner’s strengths and vulnerabilities, especially regarding sexuality; the creation of a therapeutic plan addressing the relationship, the affair, trust, and the couple’s sexuality; and assigning the first psychosexual skill exercise to be completed at home. As both partners confront painful personal, relational, and sexual realities during the feedback session, the clinician must be particularly empathetic, respectful, and caring.

I started the session by turning my chair to face Cheryl as Justin looked on. “Cheryl, you bring great psychological, relational, and sexual strengths to this marriage,” I began. “You want a marriage that’s satisfying, stable, and sexual. You’re committed to developing a healthier family than the one you grew up in, and you’ve survived the painful last two years and haven’t given up trying to understand what’s happening to you and Justin sexually. But you also bring major vulnerabilities. You deal with hurt feelings by becoming angry and attacking, your sexual self-esteem is low, and you’re now Justin’s worst critic.” I then turned to Justin and addressed the particular strengths and vulnerabilities that he brought to the marriage.

During this session, both partners learned new and valuable information about the other. Cheryl hadn’t been aware of Justin’s desire to be sexually submissive or his performance anxiety during sex. For the first time, she understood that her husband’s affair had been driven by his own internal sexual conflicts, rather than his judgment of her sexual desirability. Rather than having to defend herself by attacking him, she felt freed to be more emotionally present with Justin in a new way.

For his part, Justin hadn’t realized how desperately Cheryl needed his love and sexual desire, nor did he know how devastated she was by his loss of sexual interest in her and his avoidance of marital sex. For the first time, he took some responsibility for the impact of his secret sexual life. “I never wanted this to happen to you or to us,” Justin gently told his wife. “I never intended to hurt you.” Then, with my urging, Justin took her hand, looked into her eyes, and said, “I love you and want to be with you.”

This larger focus on the couple’s marriage and sexual connection enabled them to begin addressing the fuller meaning of the affair. Until then, it was as though Justin and Cheryl had been speaking completely different languages about the affair’s significance, and now finally were able to communicate in English. Both understood that the affair had nothing to do with Cheryl’s erotic allure and everything to do with Justin’s need to act out a secret sexual life that was split off from his married life. This crucial shift helped them reengage emotionally and begin experiencing themselves as allies instead of the adversaries they’d been in the last two years.

By the end of the 90-minute feedback session, the three of us were emotionally drained, but Justin and Cheryl exuded a new sense of hope. They committed themselves to a therapeutic plan for trying to rebuild a new marital and sexual bond. Toward the end of the session, I described a psychosexual trust exercise and asked them to practice it at home. It focuses on nude, whole-body touching that promotes safety and attachment. The trust position that Cheryl and Justin chose was her lying in his arms as he stroked her hair. Over time, this exercise helped them experience being part of an intimate team in confronting the past and building a satisfying new sexual connection.

Building a New Bond

Our next several therapy sessions were emotionally challenging as Cheryl and Justin continued to reveal painful hurts and disclose their vulnerabilities. At the same time, I continued to offer them encouragement and tools for developing a new, positive connection. In one session, I asked them to engage in the attraction exercise, in which each shared what they valued about their spouse emotionally, relationally, physically, and sexually. When Justin told Cheryl that he found her to be “a smart, attractive, loving woman with whom I want to share my life,” she teared up, but didn’t look away. “I need you to love and want me,” she replied, holding his gaze. “And I love and want you.”

I continued to express my belief that they could build a new marital and sexual bond by acknowledging the past and learning new ways to experience the healing value of touch, trust, and attraction. Rather than relying on traditional sensate focus exercises, I taught psychosexual skill exercises that related directly to sexual desire. Developing healthy sexual desire involves not only valuing intimacy, but also a willingness to try out erotic scenarios and techniques, and engaging in “non-demand pleasuring”—affectionate, playful touch that may or may not lead to intercourse.

It was Cheryl who took the initiative to promote sensual and playful touch both inside and outside the bedroom. Though Justin hated the clinical-sounding term “non-demand pleasuring,” he greatly enjoyed touching and being touched by Cheryl. In one session, with tears in his eyes, he told her, “For the first time since I was a kid, I feel there’s someone who really knows me, accepts me, and loves me.”

Facing the Tiger

We still needed to confront the most sensitive issue facing the couple: Justin’s variant sexual arousal—his need to play a sexually submissive role and be demeaned in order to be turned on. I explained to the couple that they had to commit jointly to a therapeutic strategy to deal with Justin’s sexual pattern. They could choose to accept it, compartmentalize it, or give it up as a “necessary loss.” Clinicians remain split regarding which strategy works for which couples.

Justin spoke first. He told Cheryl how much he appreciated her empathy and support for his dilemma and made it clear that he didn’t want her to become his dominatrix. “I don’t want that for either of us,” he told her. His choice was to relinquish his submissive sexual pattern as a necessary loss.

Cheryl was deeply moved, seeing his willingness to change his lifelong arousal pattern as a tremendous gift and a symbol of how much he valued her, their marriage, and their family. “Thank you,” she whispered.

Acceptance of the necessary loss strategy was vital, but not sufficient. With my encouragement, Justin also acknowledged to Cheryl that the combination of secrecy, eroticism, and shame surrounding his behavior had been destructive to their marriage. He took hold of her hands, looked into her eyes, and said: “I’m so sorry I hurt you. I’m totally committed to being your intimate sexual spouse. You can trust me.” He’d arrived at a place where he genuinely and deeply regretted his betrayal, yet was no longer sunk in shame and self-hatred. He was ready to learn to value intimacy, pleasuring, and eroticism within his marriage.

The challenge for Cheryl was to discover the erotic scenarios and techniques that turned her on and to risk expressing her own wishes. By giving each other the freedom to experiment and express his or her sexual voice, the couple began to find a new path. Justin discovered that when Cheryl was sexually involved and responsive, it enhanced his own involvement and arousal. Meanwhile, Cheryl found that feeling wanted and needed by Justin was her most powerful aphrodisiac. Gradually, the couple began to enjoy sex as a team sport.

This doesn’t mean that Justin’s issues evaporated. In an individual session with me, he acknowledged that being sexually submissive with a controlling, dominant woman was still a 100 for him in terms of erotic intensity. He didn’t believe that he’d ever experience that same degree of erotic charge during intimate sex with Cheryl. However, he understood that it was still possible to create a rewarding new couple sexuality. “It’s already happening,” he told me. He rated his sexual bond with Cheryl as a solid 85 in terms of intimacy, intensity, pleasure, and sexual satisfaction. He added with a grin, “Who knows where it’ll go from here?” As this case demonstrates, I advocate the both/and path that Cheryl and Justin negotiated with courage and commitment. Helping couples fully express difficult feelings and process the affair to make meaning of it enables them to build a stronger trust bond and a more satisfying sexual connection.


CASE COMMENTARY

By Michele Scheinkman

Traditionally, couples therapists have assumed that if they helped couples repair their emotional relationship after a betrayal, their erotic bond will somehow magically flourish. Lately, however, many therapists have questioned this idea, realizing that the couple’s sexual connection is a delicate matter that must be dealt with directly and skillfully. This case illustrates a therapist’s sustained effort to explicitly help a couple develop a lasting erotic connection in the aftermath of infidelity.

A central feature of Barry McCarthy’s approach is his assessment of the couple by sequencing conjoint, individual, and conjoint feedback sessions. In doing so, he illustrates the effectiveness of individual sessions in disarming defensiveness and creating a safe space to explore erotic details that might otherwise remain secret. While the initial conjoint session gives him a full picture of Cheryl and Justin’s history and dynamics, it’s only in the safe environment of the individual sessions that McCarthy is able to understand their hidden vulnerabilities and yearnings.

While respectful and empathic of Justin’s desires for transgression and submission as elements of his sexual arousal, McCarthy firmly challenges his defensive justification that his extra-marital behavior was nothing more than a “normal male fooling around.” McCarthy asks a masterful question: “Be honest with yourself. What don’t you like about what’s happening to you sexually?” As Justin is encouraged to reflect on his sexual split, he’s forced to come to terms with the consequences of his behavior—the empty feeling after his transgressions, the money spent on sex clubs and all the rest, his loss of sexual energy toward Cheryl. In the individual session with Cheryl, McCarthy is equally skillful at uncovering her inhibitions and lack of sexual entitlement.

The million-dollar question in this case is what McCarthy calls “facing the tiger.” Can Justin really abdicate his desire for submission and pain? While McCarthy seems convinced that Cheryl will keep learning to be assertive and take sexual risks, he admits that Justin’s “variant” pattern is more complicated. Once again, he skillfully creates a narrative for solving the couple’s problem by posing Justin’s dilemmas in terms of choice and will.

McCarthy discusses three different alternatives for them. One possibility is for Justin to continue compartmentalizing his sexual needs. But with Justin’s now-heightened awareness of the painful consequences of his pattern, this isn’t an option. Justin also rejects the possibility of inviting Cheryl to play the dominatrix. The third choice, the one that Justin ends up choosing, is for him to relinquish his desires as a necessary loss for him, but a gain for the marriage. However, McCarthy isn’t naïve. Despite this reasonable choice, he understands that Justin’s intensely erotic yearnings for submission and pain will not miraculously disappear, so he keeps on working with Justin individually.

What lies ahead for this couple? Do we believe that entrenched sexual blueprints like Justin’s ever really change with therapy? Reading this case, we can say that, with McCarthy’s help, Justin and Cheryl may have broken the spell of secrecy and forbidden pleasures, once Justin shared his sexual dilemma openly with Cheryl and they’d entered a positive cycle of sexuality and intimacy in the marriage. The therapy seems to have helped them create a strong enough bond to deter the forces that might otherwise pull them apart again. But more than anything, it’s clear that this couple found a special therapist who’ll help them face any new crisis.

Barry McCarthy, Ph.D., a professor of psychology at American University, is the author of Discovering Your Couple Sexual Style, Enduring Desire: Your Guide to Lifelong Intimacy, and Sexual Awareness. Lana Wald, M.A., and a Ph.D. candidate in clinical psychology at American University, collaborated in this treatment and the preparation of this case study. Contact: mccarthy160@comcast.net.

Michele Scheinkman, L.C.S.W., is a faculty member of the Ackerman Institute for the Family and in private practice in New York City. She’s written extensively on the topic of affairs, including “Foreign Affairs,” published in the July/August 2010 Psychotherapy Networker. Contact: michelescheinkman@gmail.com.

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

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.