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The Politics of PTSD

How a Diagnosis Battled Its Way into the DSM

by Mary Sykes Wylie

In retrospect, it seems bizarre that hundreds of thousands of veterans, all suffering from similar, dramatic symptoms, could be largely ignored by the Veterans Administration (VA) and psychiatry in general. But before the 1970s, almost no mental health authorities--military or civilian--imagined, much less expected and prepared for, traumatic reactions to war to emerge years after the conflict ended. There was yet no official traumatic stress diagnosis, and the VA assumed that any psychiatric problem occurring more than one year after discharge couldn't be related to military service.

During the Korean War, for the first time, clinicians provided frontline treatment for psychiatric breakdowns, returning the soldiers to battle as soon as possible afterward. Because this approach had worked so well--only 6 percent of Korean War evacuations were for psychiatric reasons, compared with World War II, when 23 percent were--the military was prepared to use the same approach in Vietnam. Only, nobody sought help. In fact, during Vietnam, there were proportionately far fewer reported cases of trauma on the actual battlefield than there'd been in previous wars. The primary reason seems to have been that soldiers had one-year rotations and knew that if they could just hold themselves together for 12 months--often with a little help from their friends, marijuana and heroin--they'd be free.

But after they returned stateside full of relief and happy to be alive, many of them--up to 50 percent according to the National Vietnam Veterans Readjustment Survey of 1988--began breaking down, months or even years later. Why? In spite of its time-limited nature for any individual vet, this war was in many ways even more stressful than others in the nation's history. First, troops were deployed individually, not in cohesive units, which undermined a sense of social support and increased their feelings of personal isolation and alienation. Second, troops were younger and less mature; Vietnam was often referred to as a "teenage war." Third, all wars are nasty, but this one had the special kind of nastiness that goes with a brutal guerilla war. There was an air of murderous futility about what soldiers were expected to do, and little experience of victory or accomplishment. A unit would take a hill one day, suffering massive casualties, only to have to take it again the next day.

And the Vietnamese didn't appreciate being "saved" and "liberated"; it was often impossible to tell friend from foe. As one vet said, "We are the unwilling, working for the unqualified, to do the unnecessary, for the ungrateful."

And the coup de grace: when they got home--deposited in the States maybe 36 hours after seeing a buddy's head shot off--they were unloved, unwanted, unappreciated, and often regarded as a kind of embarrassment. The U.S. had just lost its first war, and by the time it was over, a huge number of people thought the whole thing had just been a terrible mistake and wanted to forget about it. They also wanted to forget about the vets--the ones most visibly associated with the debacle, who kept reminding America that the war wasn't really over. Even veterans organizations were prejudiced against Vietnam vets, sometimes closing their doors to them.

Also, many PTSD symptoms didn't show up as the pitiful twitches and tremblings and motor paralysis that had afflicted the shell-shocked or combat-fatigued soldiers of earlier wars. The symptoms Vietnam vets experienced often appeared far more aggressive and less sympathetic. As public support for the war declined, so did the public perception of veterans, who were often undeservedly portrayed as drunk, drug-addled, brawling, wife-beating, unemployable, whacked-out guys. So it was easy for people to think, as one Vietnam vet wrote, "The Vietnam War was a disgusting and useless mess to which we had sent some of our most disgusting and useless people."

Whatever the VA's official position, however, by the early '70s, there were vast, underground rumblings about something going round the country--some strange, debilitating constellation of symptoms that seemed to be afflicting tens of thousands of returning Vietnam veterans. Trauma specialist Charles Figley, whose 1978 book, Stress Disorders Among Vietnam Veterans, was the first to address the problem, remembers when he became aware of this nameless phenomenon. A Vietnam vet himself and antiwar advocate, he recalls circulating among other vets at the massive 1971 peace rally in Washington, D.C., and listening to men talk about their nightmares, their violent rages and irrational fears, their alcoholism and drug addiction, their difficulty holding onto jobs. It was this experience, he says, that convinced him to go back to school and study psychology to find out what was happening to so many of his fellow soldiers.

Beginning in the mid-'70s, vets all over the country became very active, forming hundreds of rap groups to talk about their war experiences and coalescing into large, politically powerful, organizations to struggle for financial, social, and medical recognition of their problems. Many of the psychiatrists and psychologists who treated these vets and led rap groups were Vietnam veterans themselves, and they became forceful allies in the drive to get better care from the VA. Finally, in 1979, Congress officially mandated the VA to provide a network of counseling centers for Vietnam vets, to treat their "readjustment problems," including the as-yet-named PTSD. Even so, VA hospitals didn't begin to provide treatment aimed at trauma until the early '80s, after PTSD was included in the DSM-III (the third edition of the  Diagnostic and Statistical Manual of Mental Disorders ).

By the late 1970s, it had become obvious to many therapists that the old diagnostic system had fatal flaws. DSM-II seemed to have been written for a world in which serious trauma virtually never occurred. If somebody did perchance experience what DSM-II called "overwhelming environmental stress" (details never specified), it was assumed that, once the stress had been eliminated, recovery would occur in short order without any special help. If recovery didn't speedily happen, "another mental disorder is indicated"--suggesting that the failure to get better lay in the patient's own inherent psychological weakness or vulnerability, and had nothing to do with the trauma.

While the veterans were struggling for recognition on one front, another campaign was being waged--which included some of the same people--on another, to get traumatic stress back into the DSM. In 1974, psychiatrist Chaim Shatan, who was in the vanguard of the fight for better mental health care for veterans, heard about a New Jersey public defender representing a Vietnam vet accused of committing violence against property--an action for which the vet claimed amnesia. The public defender tried to get his client declared not guilty based on traumatic war neurosis, but the judge rejected the defense, saying there was no such diagnosis.

Shatan told the public defender to contact Robert Spitzer, head of the task force that he knew was then beginning preparations for the new DSM-III, assuming that there'd be such a diagnosis in the upcoming manual. But Shatan and other veteran advocates were shocked to hear that Spitzer had no plans to include any diagnosis for war neurosis in the new edition.

So Shatan contacted other psychiatrists who'd studied the psychological impact of war and genocide--including Robert Lifton, author of a book about Hiroshima victims and later a book about Vietnam, as well as psychiatrists William Niederland and Henry Krystal, researchers studying Holocaust and concentration-camp survivors--to mobilize support to their cause. Eventually, they helped form the Vietnam Veterans Working Group, comprising vets, psychiatrists, mental health organizations, academics, antiwar activists, church groups, and the like to lobby the American Psychiatric Association on behalf of a PTSD diagnosis.

Meanwhile, Charles Figley, who'd founded the Consortium on Veteran Studies at Purdue University and had led several symposia on vets at psychological conferences, published Stress Disorders Among Vietnam Veterans, which also became ammunition in the effort. Eventually, Spitzer agreed to form a committee to study PTSD, and, in 1980, PTSD was finally included in DSM-III.

For the first time, an official DSM diagnosis assumed a psychological disorder was caused not by inner dynamics or neurotic predisposition, but by outer events that happened to the person. In fact, without the trauma, there's no diagnosis. And the trauma itself had to be something truly big and bad. DSM-III distinguished--as DSM-II hadn't--between life's ordinary vicissitudes that might generate a psychological "adjustment reaction" and traumatic events that would most likely overwhelm someone, like natural disasters, rape or assault, bombing, torture, death camps, military combat, plane crashes, and so on. The events had to be "outside the range of normal human experience," represent a threat to life and limb, and be experienced by the victim with intense feelings of fear, helplessness, and horror.

The diagnosis was as much a political victory as a shift in the terrain of mental health. For the first time, political advocacy and social consciousness overtly contributed to the creation of an official diagnostic category for a psychiatric illness, taking into specific account the recent man-made horrors of world history--war, torture, genocide. This was also the same DSM that, in another highly politicized process, removed homosexuality from the list of mental disorders. So it wasn't surprising that some critics maintained--and still contend--that both the inclusion of PTSD and the exclusion of homosexuality owed more to politics than science.

--Mary Sykes Wylie


Bessel Van der Kolk Wants to Transform the Treatment of Trauma

by Mary Sykes Wylie

Bessel van der Kolk likes to introduce his workshops on Post-Traumatic Stress Disorder (PTSD) with medical film clips from World War I showing veterans diagnosed with what was then called "shell shock." In these dramatic and riveting clips, one soldier sits hunched over on his hospital cot, staring blankly ahead, responding to nothing and nobody until the single word "bomb" is said, whereupon he dives for cover underneath the small bed. Another man lies almost naked on the bare floor, his back rigidly arched, his arms and hands clawing the air as he tries, spasmodically and without success, to clamber onto his side and stand up. Yet another, who once bayoneted an enemy in the face, now opens his mouth wide into a gaping yaw and then closes it, and opens it and closes it, over and over and over again.

The images are disturbing, heartbreaking, and all the stranger because these particular men, technically speaking, are physically unharmed. Their physical symptoms--paralysis, violent trembling, spasmodic movements, repetitive facial grimaces, zombielike demeanor--look exotic to our eyes because PTSD generally doesn't show up like this anymore in most clinicians' offices. Time and Western cultural evolution have changed the way traumatized people express their distress in a therapist's office. Now, trauma patients may look fine on the surface, but complain of nightmares, flashbacks, feelings of numbness, generalized fearfulness, dissociative symptoms, and other problems that aren't as visible to the world at large. But to van der Kolk, these old images still represent what he calls the "pure form" of PTSD. The appearance in these World War I film clips that the veterans are possessed, mind and body, by invisible demons still captures the fundamental truth about PTSD--that it can reduce its victims to mute, almost animal-like, creatures, utterly isolated in their fear and horror from the human community.

Van der Kolk first became aware of the world of trauma in 1978, when he decided to go work for the Veterans Administration (VA), not to study PTSD (it hadn't been recognized yet as a formal diagnosis), but to get the government benefits to pay for his own psychoanalysis. While there, he discovered the reality of PTSD--and the beginnings of a stunning, nationwide phenomenon. "At that time, tens of thousands of men who'd served in Vietnam suddenly seemed to come out of the woodwork, suffering from flashbacks, beating their wives, drinking and drugging to suppress their feelings, closing down emotionally," recalls van der Kolk. "It was a phenomenon that spawned a whole generation of researchers and clinicians fascinated by what had happened to these guys."

Van der Kolk himself soon became intrigued by the mysterious mental and emotional paralysis that seemed to afflict these traumatized veterans. Why, he wondered, did many of his patients seem so stuck emotionally in their horror that they relived it over and over in flashbacks and nightmares? What kept these men circling round and round on an endless treadmill of memory, unable to step off and resume life? In spite of their obvious suffering, why did they seem so obsessively attached to their traumatic experiences?

In the 25 years since then, the trauma field has gone from obscurity, if not disreputability, to become one of the most clinically innovative and scientifically supported specialties in mental health. Trauma researchers have led the pack in setting off an explosion of knowledge about psychobiology and the interaction of body and mind. And van der Kolk, as much as anyone else in the field, has defined the current framework for understanding trauma.

He's the author of more than a hundred peer-reviewed scientific papers on subjects such as self-mutilation, dissociation, the therapeutic efficacy of Eye Movement Desensitization and Reprocessing (EMDR), the developmental impact of trauma, and the nature of traumatic memories. He's also been a featured contributor in most of the standard textbooks in the trauma field. In addition to teaching at Boston University, Tufts, and Harvard, he directs the Trauma Center in Boston, possibly the largest trauma specialty center in the country, with 40 clinicians working with clients who range from infants to geriatrics, from incest survivors to international torture victims. Inhabiting both the world of the clinician and the researcher, he also runs a major research laboratory at the Trauma Center, staffed by 15 researchers who investigate everything from neuroimaging of treatment effects on the brain to the effects of theater groups on violent, traumatized teenagers.

Glowing testimonials about his contributions aren't hard to come by from the field's leading lights. "Very early on, more than anybody else, he introduced neurobiology to the trauma field, and helped us see the interaction between mind and body in trauma," says Charles Figley, professor at the School of Social Work at Florida State University and Vietnam vet, whose early work on war trauma is often credited with prompting the inclusion of PTSD as a diagnosis in the DSM (see sidebar, page X). "He's one of the most generative and creative minds in the trauma field, and his influence has been pervasive," says psychiatrist Judith Herman, renowned trauma expert at Harvard Medical School.

At the same time, van der Kolk is also one of the trauma field's most controversial figures. Often prickly, rarely shy about offering his own opinions, and unafraid of a good fight, he's scandalized a number of cognitive-behavioral therapists and academic researchers by openly embracing EMDR, demonstrating an interest in such truly outre techniques as Thought Field Therapy, enthusiastically taking up nonstandard somatic therapies, and even sending his patients off to participate in theater groups and martial arts training.Van der Kolk's bold criticism of the orthodoxies of psychotherapy and public advocacy of somatic approaches have, in particular, outraged many. "Advocating unproven body psychotherapies is professionally irresponsible," says Edna Foa, professor of psychology in the psychiatry department at the University of Pennsylvania. "He's marginalized himself as a scientific thinker--he's no longer in the mainstream," adds Richard Bryant, noted trauma researcher and psychology professor at the University of New South Wales in Australia. "Until he provides data in support of his new [somatic] approach, the field isn't obligated to pay any attention to what he's doing," sniffs psychologist Richard McNally, author of the widely cited Remembering Trauma, a critique of recovered-memory theory.

The intensity of response van der Kolk kicks up is an indication of the crusader's fervor underlying his work and his determination to make the field viscerally understand that trauma isn't simply a neutral mental health issue, but a profoundly moral concern. Spicing his talks with earthy, Dutch-accented American slang, van der Kolk regularly reminds his audience in a tone of subdued indignation that trauma forces the reality of human evil into our consciousness, often the evil of presumably good and upright people--our neighbors, our leaders, our families, and ourselves. It's not a perspective people always welcome because, as he writes in his book Traumatic Stress, most of us like to believe "that the world is essentially just, that 'good' people are in charge of their lives, and that bad things only happen to 'bad' people. . . . Victims are the members of society whose problems represent the memory of suffering, rage and pain in a world that longs to forget."

A Diagnosis Non Grata

While trauma is always clinically described as a horrifically abnormal event, for any casual student of the human condition, it's actually a perfectly normal feature of history, one that has emotionally scarred billions of men, women, and children since before the beginning of recorded time. And yet, while philosophers, writers, and ordinary people have always known that terrible events can cause a lifetime of psychological pain, until the latter part of the 20th century, mental health professionals were oddly blind to this fact of life. "Psychiatry itself has periodically suffered from marked amnesias in which well-established knowledge has been abruptly forgotten," writes van der Kolk in Traumatic Stress, "and the psychological impact of overwhelming experiences has been ascribed to constitutional or intrapsychic factors alone." In other words, a failure to "get over" a trauma was often ascribed to personal weakness or an unconscious desire not to recover.

Even the official nosology of the psychiatric profession reflected this peculiar obtuseness. The 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-I ) had included combat-related stress under the diagnosis of "gross stress reaction," but this was dropped from the DSM-II in 1968--the same year that troop strength reached its peak in Vietnam. All that was left of trauma in DSM-II was the pallid diagnosis "adjustment reaction to adult life," under the general heading of "transient situational disturbance." Adjustment reaction was a grab-bag diagnosis, including "fear associated with military combat and manifested by trembling, running and hiding" and "unwanted pregnancy." It wasn't until 1980, after years of lobbying and wrangling, that PTSD was included in DSM-III (see sidebar page 37).

So when van der Kolk first went to the VA in 1978, not only was there no official traumatic stress diagnosis, but the VA assumed that any psychiatric problems occurring more than one year after discharge couldn't be related to military service. Besides denying veterans any compensation for delayed traumatic reactions--probably the overriding consideration in the VA's longstanding lack of interest in the enduring impact of "combat stress"--this rule effectively scotched any research or clinical treatment directly focused on trauma. "When I went to work for the Boston VA," remembers van der Kolk, "there wasn't a single book in the library on war neurosis."

Unable to do research on war trauma because the VA wouldn't fund studies on a diagnosis that didn't exist, van der Kolk and his colleagues did the first study ever on the real nightmares the vets had and, in another first, used the Rorschach inkblot test to reveal the twin pattern of hyperarousal and dissociation that traumatized vets showed. For van der Kolk, this research pointed to the paradoxical conundrum at the heart of trauma. "This is still the issue with traumatized people--they see and feel only their trauma, or they see and feel nothing at all; they're fixated on their traumas or they're somehow psychically absent." In either case, traumatic memories from the past have utterly usurped the present.

By the late-1980s, van der Kolk had had extensive experience working with vets and was becoming a well-known figure among PTSD researchers. He'd been responsible for several important studies, including, besides the Rorschach and nightmare papers, research into psychopharmacology and trauma, and had published the book Post-Traumatic Stress Disorder: Psychological and Biological Sequelae, the first book published specifically about PTSD. But in spite of his impressive re´sume´, he felt deeply discouraged. He'd learned a lot, but he didn't think he was fundamentally helping his patients. Even after months or years of work, his patients still suffered from flashbacks, nightmares, depression, aggressive rage, anxiety. They still either couldn't talk about their trauma at all or when he pushed them to talk about it--as he and many therapists often did, and still do--they began hyperventilating, shaking, yelling, crying, became physically agitated, or just collapsed in a state of helpless fear and dread. "I'd become a reputable PTSD researcher and clinician, but I felt I'd utterly failed my patients," van der Kolk remembers. "I guess they thought I was a good guy, they felt understood by me, but that didn't necessarily help them to get back into their lives."

And what was the treatment that he felt was not really helping his patients to move on? It was standard talk therapy 101--helping them explore their thoughts and feelings--supplemented with group therapy and medications. During individual sessions with clients, he often focused intensely on patients' past traumas, in the interest of getting them to process and integrate their memories. "I very quickly went to people's trauma, and many of my patients actually got worse rather than better," he says. "There was an increase in suicide attempts. Some of my colleagues even told me that they didn't trust me as a therapist."

The Neurobiology of Trauma

The fundamental conundrum of how trauma affects the mind and body that still plays out in treating trauma survivors was already crystallizing in van der Kolk's mind 20 years ago. "When people get close to reexperiencing their trauma, they get so upset that they can no longer speak," he says. "It seemed to me then that we needed to find some way to access their trauma, but help them stay physiologically quiet enough to tolerate it, so they didn't freak out or shut down in treatment. It was pretty obvious that as long as people just sat and moved their tongues around, there wasn't enough real change."

Back in the early 1980s, believing that future progress lay in a better understanding of the biology--particularly the neurobiology--of trauma, van der Kolk had applied for a VA research grant on the subject. Even though PTSD was now "official," his proposal was turned down flat. The opening sentence of the rejection letter still vividly resonates in his mind. "It's never been shown that PTSD is relevant to the mission of the Veterans Administration." Since then, the VA has grown up and become a leading supporter and funder of trauma research, but in the early '80s, it was clearly a diagnosis non grata to the establishment. Both dumbfounded and enraged by the VA's response, van der Kolk says he never read past that first sentence, and decided right then to seek greener pastures and put in his notice.

He moved back to the Massachusetts Mental Health Center, a state hospital and psychiatric teaching institution associated with Harvard Medical School, where he'd received his psychiatric training and, before that, had spent a year as a mental health worker on a research ward for unmedicated schizophrenic patients. Here he discovered how easy it is for the best-intentioned therapist to inadvertently make traumatized patients worse. He was struck how some female patients fell apart during personal contacts with him and other male staff, becoming agitated and assaultive. Why would they so suddenly switch from being pleasant and sensible, to losing their minds when a man would pay attention to them? he wondered. Looking into the histories of the women, most of whom had been diagnosed as borderlines or schizophrenics, he found that they'd all been severely and chronically sexually abused as children and adults.

Van der Kolk began to realize that, for these women, being in a room alone with a man who directed questions at them emotionally hurled them back into their traumas. He noted that their entire bodies responded as if they were being molested again--heart pounding, muscles tensing--they seemed, literally, to take leave of their senses--unable to distinguish now from then. "It seemed that their traumatic memories, like those of Vietnam veterans, prevented them from being able to modulate their autonomic arousal," he observes. "Their physiological housekeeping systems had been messed up by trauma."

It now seemed to him that chronic trauma explained a great deal about how borderline patients acquired their deep impairments, and why they were so hard for therapists to treat. "Borderlines have a terrible reputation because they often are simply impossible," says van der Kolk. "They cling to you and then hate you, and, either way, they won't leave you alone. But if you look at their behavior through their traumatic background, it makes perfect sense. If you've been raped and abused for years as a child and adult, your entire organism and personality has been organized around your trauma. If they have PTSD, the way they act is understandable--they're not just people trying to make your life miserable, but people trying to survive."

Van der Kolk's experience with borderlines reinforced his belief that talk therapy by itself, even in the context of a warm, supportive therapeutic encounter, wasn't enough to reverse the profound physical and emotional changes wrought in his patients by pervasive trauma. But he credits Hurricane Hugo with showing him see just how physical helplessness contributes to the development of serious post-traumatic symptoms, and making him wonder if physical movement might not contribute to healing.

In 1989, directly after Hurricane Hugo had ravaged Puerto Rico, van der Kolk accompanied FEMA officials to lend his expertise to dealing with the traumatic aftermath of the devastating storm. "I arrived in the middle of this devastation, and what I saw were lots and lots of people working with each other, actively putting their lives back together--carrying lumber, rebuilding houses and shops, cleaning up, repairing things."

But the FEMA officials immediately told everybody to cease and desist until assorted bureaucracies could formally assess the damage, establish reimbursement formulas, and organize financial aid and loans. Everything came to a halt. "People were suddenly forced to sit still in the middle of their disaster and do nothing," van der Kolk remembers. "Very quickly, an enormous amount of violence broke out--rioting, looting, assault. All this energy mobilized by the disaster, which had gone into a flurry of rebuilding and recovery activity, now was turned on everybody else. It was one of the first times I saw very vividly how important it is for people to overcome their sense of helplessness after a trauma by actively doing something. Preventing people from moving when something terrible happens, that's one of the things that makes trauma a trauma."

Pondering this striking lesson, van der Kolk wondered if perhaps the most damaging aspect of trauma wasn't necessarily the awfulness of it, but the feeling of powerlessness in the face of it, the experience of being unable to escape or fight or have any impact on what was happening. "The brain is an action organ," he says, "and as it matures, it's increasingly characterized by the formation of patterns and schemas geared to promoting action. People are physically organized to respond to things that happen to them with actions that change the situation." But when people are traumatized, and can't do anything to stop it or reverse it or correct it, "they freeze, explode, or engage in irrelevant actions," he adds. Then, to tame their disorganized, chaotic physiological systems, they start drinking, taking drugs, and engaging in violence--like the looting and assault that took place after Hurricane Hugo. If they can't reestablish their physical efficacy as a biological organism and recreate a sense of safety, they often develop PTSD.

The Monopoly of Talk

Van der Kolk was now sure that, just as the experience of physical helplessness was at the core of trauma, there was something about frustrated action to repair the situation that played a role in developing long-term PTSD. And he began to wonder if helping traumatized people engage in meaningful, physical action would allow them to recover from PTSD. His growing sense that the body, as much as the mind, might hold the key to recovering from trauma ran up against the sacrosanct tradition of the talking cure as the alpha and omega of all psychotherapy. It was about this virtual monopoly of mainstream therapy by institutionalized talk that van der Kolk was becoming increasingly skeptical.

Talk is relevant--even vitally important--he says, for traumatized patients who don't yet really know what's happened to them, who were too young to understand what was happening, who weren't listened to or believed, or who still can't make sense of what happened. His own therapy is still "very talky," he adds. But, van der Kolk continues, "fundamentally, words can't integrate the disorganized sensations and action patterns that form the core imprint of the trauma." Treatment needs to integrate the sensations and actions that have become stuck, so that people can regain a sense of familiarity and efficacy in their "organism."

Van der Kolk is also very tough on the old shibboleth of psychotherapy-as-restorative-relationship. Too often, he insists, trauma patients and therapists both move into a quasi-relationship because, that way, they can both evade the real pain of focusing on and dealing with the physical trauma imprints. "Clients may look for 'relationship' in therapy because they can't stand what they feel in their own bodies--as long as the therapist is with them, they can distract themselves from their inner experience. The 'felt sense' has become a minefield, and clinging to others is one way of avoiding the intolerable sensations within," says van der Kolk. But what patients really need, he believes, is the "therapist's attuned attention to the moods, physical sensations, and physical impulses within. The therapist must be the patient's servant, helping him or her explore, befriend, and trust their inner felt experience." Relationship therapy can seem like a kind of ersatz friendship, but "it doesn't make you better friends with yourself."

To underscore the shocking possibility that neither talk nor relationship may be necessary in trauma treatment, van der Kolk likes to tell the story of his training in Eye Movement Desensitization and Reprocessing (EMDR), an approach held in very low esteem by many of his research colleagues. Although he initially considered EMDR a fad, like est or transcendental meditation, he went for the training after seeing the dramatic effects it had on some of his own trauma patients. "They came back and told me how supportive our therapy relationship had been, but that EMDR had done more for them in a few sessions than therapy with me had done in four years," he recalls. Van der Kolk decided to go see for himself what this weird new thing was all about, and took the training.

He didn't like the training at all: "It felt too packaged, too much like a Billy Graham revival-type thing." He was, however, amazed at what happened to him when he subjected himself to EMDR as part of the training. The Trauma Clinic he'd established at Massachusetts General Hospital in 1991 had recently been closed--ostensibly for budgetary reasons, but most likely, he suspected, because of his high-profile advocacy of clergy-abuse victims, while his then department chair, a Jesuit priest, was serving as the principal advisor to Cardinal Law, who's since resigned after being accused of covering up incidents of pedophilia among more than one hundred priests in the Archdiocese of Boston. The sudden closing of the Trauma Clinic was the focus for his EMDR session. "During the session, I was fascinated by all the different images from my early childhood that made their way very rapidly through my consciousness, and which seemed somehow related to the loss of my clinic. It was like the kind of hynopompic experience you have when you first begin to wake in the morning, with ideas coming and going and being forgotten before you really wake up." Afterward, he felt as if "something had been processed and left behind," and his distress about the clinic's closing had significantly lessened.

His own EMDR practice student during the training was another clinician, who refused to tell van der Kolk anything about what he wanted to work on, except that it was "some very tough stuff between me and my dad when I was little." Overtly hostile and uncommunicative throughout the session, the clinician kept saying that he didn't really want to share what he was upset about. As a result, van der Kolk was totally in the dark about what was going on inside the person he was trying to "help" with the EMDR.

At the end of the session, the man looked relieved of much of his distress.

"How was that?" van der Kolk asked.

"I'd never refer a patient to you," the man barked at him.

Van der Kolk replied, "Oh, why is that?"

The man replied, "I really hated the way you dropped your fingers at the end of each movement!"

"But what about your original problem?" van der Kolk asked.

"Oh, I feel I completely resolved the issue with my dad."

This episode engaged van der Kolk's curiosity about the role of the therapeutic relationship. "This guy didn't trust me. We didn't have a warm relationship. I never knew anything about what was bothering him. Yet he seemed to have processed whatever it was he needed to take care of. It drove home to me the possibility that maybe people can do excellent therapeutic work, even if they don't like and trust you (as happens, of course, in many victims of interpersonal trauma), as long as the therapist knows how to help them "digest" the imprint of the trauma."

Bottom Up, Not Top Down

In 1994, van der Kolk published a paper called "The Body Keeps the Score," in which he reviewed the existing research about the neurobiological underpinnings of traumatic reactions. The paper described how trauma disrupts the stress-hormone system, plays havoc with the entire nervous system, and keeps people from processing and integrating trauma memories into conscious mental frameworks. Because of these complex physiological processes, van der Kolk explained in the paper, traumatic memories, in effect, stay "stuck" in the brain's nether regions--the nonverbal, nonconscious, subcortical regions (amygdala, thalamus, hippocampus, hypothalamus, and brain stem), where they're not accessible to the frontal lobes--the understanding, thinking, reasoning parts of the brain. In short, he demonstrated with four-part scientific harmony that it was our bodies, not our much-vaunted minds, that control how we respond to trauma, what we do and don't consciously remember, and whether we recover from it or live in thrall to it. "We're much less controlled by our conscious, cognitive appraisal than our psychological theories give us credit for being," van der Kolk remarks dryly.

For a densely written article on psychobiology, "The Body Keeps the Score" had a far-reaching impact that brought van der Kolk into much wider circles of therapists than his previous books had done. For this, he credits the article's catchy title. "If you want to write something that gets people's interest, give it a great title. People wanted to know what the hell that article was all about." The paper attracted the interest of Scott Rauch, director of the neuroimaging lab at Massachusetts General, who asked van der Kolk if he'd like to take a look inside the brains of some of his trauma patients--something that would have been unthinkable before the '90s. The neuroimaging team scanned the brains of eight trauma-patient volunteers. The first scan was while they remembered neutral events in their lives, and the second scan was when they were exposed to scripted versions of their traumatic memories.

During the scanning, the images actually showed dissociation happen in the brains of these PTSD patients. When they remembered a traumatic event, the left frontal cortex shut down--particularly Broca's area, the center of speech. But areas of the right hemisphere associated with emotional states and autonomic arousal lit up, particularly the area around the amygdala, which might be called the "smoke detector" center of the brain. According to van der Kolk, what this suggested is that "when people relive their traumatic experiences, the frontal lobes become impaired and, as result, they have trouble thinking and speaking. They no longer are capable of communicating to either themselves or to others precisely what's going on."

Other neuroimaging studies Van der Kolk has collaborated on since also showed that the executive functions of the brain become impaired when traumatized people try to access their trauma. "The imprint of trauma doesn't "sit" in the verbal, understanding, part of the brain, but in much deeper regions--amygdala, hippocampus, hypothalamus, brain stem--which are only marginally affected by thinking and cognition. These studies showed that people process their trauma from the bottom up--body to mind--not top down." But if trauma is situated in these subcortical areas, "then to do effective therapy, we need to do things that change the way people regulate these core functions, which probably can't be done by words and language alone."

So what could trauma therapists do to help people "regulate their core functions"? Perhaps because of its title, van der Kolk's article caught the immediate and excited attention of many body psychotherapists, who'd worked with trauma patients for years, but had generally been dismissed--if noticed at all--by the psychiatric establishment as New Age flakes. To them, "The Body Keeps the Score" was something like an unexpected benediction from on high. "For the first time, a traditional, mainstream psychiatrist and neurobiology researcher was legitimizing the importance of understanding the effects of psychological disturbance on the body," says Babette Rothschild, a private practitioner in Los Angeles and author of The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. "It was very exciting to have him confirm what many practitioners had believed for a long time--that there's something called somatic memory."

If the body people were entranced with van der Kolk, the feeling was mutual. As he looked out into the audience before delivering an address to them at this time, he remembers thinking, "How well put together these people all look compared to a typical audience of psychotherapists." But while they appreciated his presence and what it stood for--his recognition that understanding the body was key to understanding the mind--he seemed to think they had more to teach him than he had to teach them. "I gave my talk, and a bunch of the people there shook their heads and said, 'this poor fellow--he knows a little bit about the body, but he really doesn't understand it.' Several took pity on me and offered to teach me what I needed to learn."

The body therapists made him see how much of the work of healing from trauma is, he says, "really about rearranging your relationship to your physical self. If you really want to help a traumatized person, you have to work with core physiological states and, then, the mind will start changing." He adds, "if clinicians can help people not become so aroused that they shut down physiologically, they'll be able to process the trauma themselves. Therapists must help people regulate their affective states. That's what we do. We do it so a person can find the strength to face her own inner horrors and begin to move and regain a life for herself."

One body therapist whose work especially impressed van der Kolk was Peter Levine, the developer of an approach to trauma treatment called Somatic Experiencing. Trauma, argues Levine, is "'locked' in the body, and it's in the body that it must be accessed and healed." PTSD, he argues, is "fundamentally a highly activated, incomplete, biological response to threat, frozen in time." All animals, including humans, are physically programmed by evolution to flee, fight, or freeze in the face of grave threats to life and limb. But in humans, when these natural responses to danger are thwarted and people are helpless to prevent their own rape, or beating, or car accident, the unfinished defensive actions become blocked as undischarged energy in their nervous systems. They remain physiologically frozen in an "unfinished" state of high biological readiness to react to the traumatic event, even long after the event has passed. The undischarged energy of the blocked response to the trauma eventually metastasizes into the full-fledged panoply of PTSD symptoms. Levine believes that psychological trauma is very much about action interruptus, which the traumatized human organism still needs to complete.

Levine believes that trauma victims, having been totally helpless and unable to move--physically and psychologically--must regain in therapy that lost capacity to move, to fight back, to live fully in their bodies as much as in their minds. Instead of curling up into scared little balls when threatened, these patients need to learn in the very cells of their bodies that they can stand up and kick butt.

Just how to help numbed and terrified trauma clients acquire a little more of the Rambo spirit is demonstrated in another video van der Kolk likes to show at workshops. It features a body therapist named Pat Ogden, originator of a treatment method called Sensorimotor Psychotherapy. In it, the client--a young woman sexually abused as a child--says very faintly early in the session, "I'm not feeling my body" and "I'm just about gone," indicating that the memory of the abuse causes her to shut herself down--go numb, blank, and frozen-in order not to feeling anything. "At this point," comments van der Kolk, "she's basically not there. The moment you're not feeling your body, you're gone, because the body really is the engine of aliveness, of thought. As long as people don't feel their bodies, we're wasting our time and theirs trying to do talking psychotherapy." With great emphasis, he adds, "Becoming comfortable in their bodies is, for our patients, the number-one, paramount issue, and if we can't help them do that, then we can't help them at all."

In the video, Ogden tracks the woman's growing physical discomfort in the early stages of the session, helping her to focus on her feelings, rather than flee them. Says van der Kolk, "Asking her, 'Where do you feel that? How does that feel? What happens in your body when you say this?' helps her stay grounded in her body and in touch with a core part of herself; it allows her to keep her wits about her."

Later in the session, when she's standing, the woman says she feels "mushy" in her midsection, defenseless--"like, if you do anything to me I don't want, I wouldn't have the right to stop you." Gradually, without getting into the content of her trauma at all, Ogden helps the woman "fight back"--first by letting her fulfill an urge she has to push by having her push hard against her (Ogden's) shoulder. The woman looks more alive, stronger. When Ogden asks her what's happened, her hands come together in fists and this woman, who earlier said she didn't even have the right to stop someone from hurting her, now begins to release some pent-up fury: "I want to say to you that if you fuck with me, I'll kill you!" she almost hisses at an invisible attacker. Ogden encourages her to engage in a kind of mock combat--both of her hands pushing both of Ogden's hands, while Ogden braces herself on the floor. It's, in its way, a real struggle, with both woman really getting into it, pushing and grunting, and ending with both out of breath.

The effects are remarkable. The client, who's been almost palpably rigid and shrunken into herself, now is laughing, at ease, confident, even exultant. "I feel totally energized and strong," she says breathlessly. "That was really good!" A week later, she returns--a different woman--alive, open-faced, smiling. "I feel great," she says, telling Ogden that she's bought some new clothes and gone to a party. "Every day, I see a brighter face in the mirror." As for the trauma, she half shrugs and says, "What was done was done."

Van der Kolk emphasizes that at no point during this session does Ogden ask the woman to describe what happend to her. "Her problem isn't that she hasn't told the story, but that her body continues to collapse in the face of reminders of her trauma. Pat helps her stay embodied, so that she doesn't lose control of herself.

"Once you can do what you couldn't do during the trauma," adds van der Kolk, "once you can take the action you need to protect yourself, and once you're able to recenter and refocus yourself on a deep, organismic basis, you'll move on. The trauma is no longer interesting."

A Huge Debate

While some of the mainstream trauma field's leaders are intrigued by the potential in this treatment, many prominent figures are dismissive, when not positively horrified. In fact, the only issue that's generated as much heat in the trauma community has been the recovered-memory debate. Van der Kolk now finds himself in the thick of a battle that, once again, pits people of passionate convictions, high-minded purpose, and not a little professional ambition against each other.

This particular clash over the place of body psychotherapy in trauma treatment exploded at the 2000 World Congress meeting of the International Society for Traumatic Stress Studies in Melbourne, Australia. Van der Kolk himself inadvertently lit the fuse when he was asked to chair a plenary session on body psychotherapy, which featured the work and videos of several somatic therapists. One video (which van der Kolk hadn't seen) showed a practitioner sitting astride a rape victim. Although van der Kolk later repudiated this particular work, saying it exhibited serious boundary violations, the film caused an uproar. "It had a remarkable fallout," says Australian psychology professor and trauma specialist Richard Bryant. "Nearly all the major players in the trauma field were appalled by the fact that he'd used a leading trauma meeting to demonstrate a therapy like this, which was both ethically marginal and had no empirical support whatsoever. A huge debate emerged about the role of evidence in science versus the belief of many therapists that if they 'know' something works, they don't have to wait for the science to prove them right."

The "huge debate" continues to churn on. While this particular skirmish involves somatic therapy, the overall conflict is an old one, which basically reflects the division between two subcultures in the profession--practitioners and scientists. This is certainly not a "pure" division (clinicians do research; researchers do clinical work), but the world views of each differ substantially. Clinicians are immersed in the messy reality of daily clinical practice with multiply-diagnosed patients, and are often glad to try out innovations on the say-so of colleagues and on their own personal experiences that almost none would care to subject to a controlled, double-blind study. To researchers, "innovative" is often just another term for "outlandish." From their perspective, the only safe and dependable treatments are those that have been empirically proven in carefully controlled studies with homogeneous populations, that are easily put in the form of a "treatment protocol."

These differences lead to "enormous tension" between practitioners and scientists, says Bryant, a tension he believes therapists tend to use to their own advantage when they accuse scientists, as they regularly do, of being more interested in their dry paradigms than in real-life patients. "Therapists often put forward the view that the process of validating new treatments is too difficult and takes too long, in the meantime depriving suffering patients of treatment they know from experience works, just because scientists want them to do randomized trials. But, we [researchers] would argue the opposite--that because we're treating people who are in such pain, we have an ethical responsibility to make sure we aren't making them worse."

Edna Foa, one of the foremost authorities on prolonged-exposure therapy--in which traumatized patients repeatedly recount their trauma until it loses its disturbing power--is also not enchanted by van der Kolk's expedition into somatic therapy. Indeed, she suggests that the whole clinical practice of psychotherapy needs to be renovated along more scientific lines. "I think we've come to the point in the scientific research of therapy that clinicians shouldn't be allowed to practice and disseminate treatments without solid evidence that they work. Doctors can lose their licenses if they use unproven treatments. Why shouldn't we be the same way? Why allow practitioners to go wild with unvalidated therapies that may not help and can even make people worse?" Van der Kolk counters that scientific funding organizations virtually never support research in unproven treatments, thus promoting an Orwellian cycle of only advancing the exploration and practice of what is already known and closing the door on true exploration. In essence, such strictures would not only eliminate the practical insights and experience of therapists who actually see the real-life complexity of human suffering, but would put the kibosh on any original and potentially useful ideas emerging from clinical practice.

Living both in the laboratory and in the clinical office, van der Kolk has firsthand experience with the different paradigms that rule these worlds: Laboratory researchers pose a particular question they want answered, choose the subjects and methodology that will provide the best test of that question, and ruthlessly screen out any confounding variables. But "confounding variables" are the stuff of ordinary therapy. "As a clinician, you always have to listen to what your patients are bringing in, listen to what they're telling you that doesn't necessarily fit DSM categories," van der Kolk says. "It's the raw data of daily clinical practice and the variations in clinical experience that generate new research protocols."

More than just about any other field, the town-gown split between scientists and practitioners in psychotherapy reflects sharp differences in fundamental ways of taking in the world. "Skepticism is the core of scientific enquiry," says trauma expert Alexander McFarlane of the University of Adelaide. "Science is based on statistical comparisons between groups--it's not a science of the individual subject. And it's supposed to be critical--scientists make their money out of criticizing ideas. Therapy, on the other hand, happens in the realm of the individual stories people tell, and the variety of ways they do it." The therapeutic endeavor is built on a framework of reasonable trust and belief in what the patient says, not criticism. "You can't treat patients if you don't believe in what you're treating," says McFarlane. In a moment of candor not calculated to endear him to his researcher colleagues, van der Kolk says simply, "It's an issue of temperament: Therapists seem to enjoy living with the uncertainty, unpredictability, and complexity that comes with the intimacy of the relationship, whereas most laboratory scientists are most committed to establishing 'facts,' which, by virtue of the dictates of the scientific method, can only encompass a small slice of the total complexity of human beings."

But van der Kolk is nothing less than an equal-opportunity provocateur. He seems determined to make clinicians fundamentally reconsider their usual responses to the suffering souls who visit their offices, down to the furnishings they choose. With his characteristic wryness, he insists that "As long as people sit on their tochas and simply move their tongues around, they may not be able to make enough of a difference to affect internal sensations and motor actions. People need to learn to regulate their physical states in order to get their minds to work. Once they shift their physiological patterns, their thinking can change."

It's been an implicit premise of psychological science and clinical practice both, as it is of our entire culture, that our singular human identity resides in our disembodied minds. The West's infatuation with Cartesian dualism has made our bodies somehow strange to us, a self-alienation reinforced by clinical psychology. It's hard even to conceive of the lofty mind--our own, anyway--as an indisputably physical, material organ, a wrinkled, ovoid mass of blood and tissue. PTSD--or any deeply painful emotional state--is experienced as a foreign intrusion that smothers our "true self," our mind's self. Most of psychotherapy is geared to getting this mind-self back, and most of it is conducted as a mental exchange between two people sitting quietly in chairs. Even psychopharmacology seems intended more to quell the rebellious body--quiet and soothe it, get it out of the way and under wraps--than acknowledge and welcome its living presence in the therapy room.

For all the ferment he's helped create, van der Kolk admits that he doesn't have any easy answers about how to unravel the tangled web of trauma, much less reconcile our culturally enshrined mind-body split. During a presentation last year, he confessed his discomfort to several hundred therapists. "I always wonder how I can continue to do workshops like this and ask you to sit on your rear ends all day listening to me talk, knowing that people really only learn when they move and act," he says. "I feel increasingly bothered by the real contradiction between what I practice and what I preach." With his penchant for stirring things up and raising questions that can't be ignored, it's a safe bet that as long as van der Kolk feels uncomfortable with therapy's conventional wisdom, the rest of us will, too.

Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker .


The End of Innocence

Reconsidering Our Concepts of Victimhood

Dusty Miller

Whether delivered by hand grenade or by hurricane, by fist, machete, or burning plane, traumatic experiences are universal across cultures, and so are attempts to heal them. How well those attempts succeed depends in part on the stories a culture tells itself about victimizers and victimhood--about recovery, wholeness, and resilience. This is particularly true of intimate family violence, which broke into the light in the late 20th century, casting ripples that continue to this day.

As a systems therapist, incest survivor, and recovering alcoholic, I've lived through several stages of our culture's attempt to come to terms with child sexual abuse--as a victim in the silent 1950s; as a therapy client in the oblivious 1960s and 1970s; and as a psychotherapist in the 1980s and 1990s, when once-dismissed accounts of abuse filled my therapy practice (and my television screen) only to be partly discredited within the decade during another swing of the cultural pendulum.

We clinicians are still feeling our way toward a middle path, one that avoids the extremes of disempowering pity and "buck-up" denial. Our clients (and if we're survivors, we ourselves) still struggle to negotiate what sociologist Ervin Goffman called "spoiled identity": the isolating experience of being cast outside the circle of "normal" life, along with gays, paraplegics, and madwomen. Helping a client move from subjugation by the worst thing that ever happened to me to a nuanced and effective life has turned out to be more complex--and oddly enough, more commonplace--than I imagined when I first sought help.

One in a Million

The simplest version of my own story begins with my father. After he came home from World War II, he led at least three separate lives: one in Manhattan with his German mistress and her mother, who followed him to the States; one with my mother and me in Northampton, Massachusetts; and one in my bedroom at night, with my mother seemingly oblivious and asleep at the other end of our house.

Photographs of me at 3, before that secret life began, show a cheerful little girl, eyes full of delight, almost always smiling at the camera, smiling at the man taking the pictures--her father. In my kindergarten picture, taken two years later, my body expresses what none of us would put into words for 20 years. Around the kindergarten table the children sit, posture-perfect, hands folded in front, eyes gazing alertly at the photographer, all of the faces smiling--except one. Thin and awkward, my arms and legs sprawled weirdly over the little chair, my mouth hanging open and my eyes staring vacantly off into space, I'm the only one not looking at the camera.

The year was 1950, a time so different from the present as to be almost another country--a postwar, post-Holocaust world, cocooned in a vast cultural silence about victimization and the aftereffects of victimization. In this world, bleached of any reference to trauma, alcoholism, or child sexual abuse, there was no such thing as Megan's Law, Battered Child Syndrome, the Betty Ford Center, or Post-Traumatic Stress Disorder.

According to a leading psychiatric text, incest was something that happened only once in a million families. No child I knew ever told me she'd been repeatedly struck in the face (as I had) by a father who at other times was playful, loving, and kind. Until I was 17, I didn't try to tell anybody--not even my beloved godmother--that my father forced me to perform sexually. Nor before I was 24 did anyone believe me.

In 1962, as a frightened freshman at Cornell University, I made my way to the college counseling center. I was 17 and an excellent student, but I was already drinking heavily, sleeping around, and generally confused by my sexuality. In my initial interview, I wasn't explicit about my father's incestuous abuse. But I talked about my unhealthy closeness to him, my fear and loneliness, and my feelings of being "different" from others my age.

I began counseling with the head of the center. He asked me endless questions about my relationship with my mother . Although I kept trying to talk about my father, this man said it was because of my "overclose" mother-daughter attachment that I was experiencing the plague of bisexual attractions and recommended that I spend the summer with my father in his one-bedroom apartment in Manhattan. I fled from my would-be helper and waited seven years to try to speak again.

Thoreau once said that it takes two to tell the truth: one to speak and one to listen. The first person to listen to me was Florika, a bright young Romanian immigrant whose father had not only sexually abused her but had begun force-feeding her amphetamines at 13, when she faltered as a virtuoso child violinist. I met her when I was 24, living in New Haven, Connecticut, after graduating from Cornell. I was drinking a lot at the time, working in a women's carpentry collective, practicing karate, learning to run the printing press at a radical newspaper, and playing drums in the New Haven Women's Liberation Rock Band, where Florika was the bass player. Many were the nights we roamed New Haven together, spray-painting buildings with graffiti urging women to smash the patriarchy.

We were alone in the dark in Florika's apartment one night, high on marijuana, when I experienced a state of wordless, paralyzing, bodily fear that I'd now call a flashback. Wrapping me tightly in a blanket the way she'd learned in a mental hospital, Florika told me soothingly that I'd be alright. Finally, she crooned that she "understood" me.

"What do you understand?" I asked.

"That you're one of us," she whispered.

I don't remember exactly what I said next, but I'll never forget the relief that followed my first stumbling words of disclosure and our mutual recognition. For the first time, I heard that I wasn't the only one. In that era of denial, I don't think I yet realized that incest had ever happened to anyone except Florika and me.

Within 24 hours, Florika had also introduced me to the daily use of amphetamines--something that made me feel powerfully in control even though I'd never been more out of control. The pseudocloseness of shared addiction felt familiar, like the secrecy, stimulation, and shame I'd lived so many nights in my father's house.

My pattern of what we now call "trauma reenactment" went undetected for years by mental health professionals: our profession played a cultural role analogous to the Non-Protecting Bystander in the incestuous family system--like my mother sleeping at the other end of the house. Psychiatrists and psychologists repeatedly beat the bushes for any explanation rather than the obvious ones: that I was telling the truth about my sexual abuse; that I was desperately trying to soothe a neurobiology disregulated by trauma; and that my addictions were creating major physical, psychological, and practical problems of their own.

Counterbalancing Experiences

If this narrow story of trauma, rage, misdiagnosis, therapeutic mistreatment, and spoiled identity was all there were to tell, I'd be dead by now--as dead as Florika, who took a fatal overdose of heroin in her late twenties while working as a Hollywood studio musician. But my life, like most lives, included commonplace and counterbalancing experiences that had nothing to do with abuse: the emotional support of my godmother and many teachers; a wordless enjoyment of the natural world; and successful involvements in school, radical politics, work, and athletics.

During my college summers in the '60s, for instance, I was part of the movement to register African American voters in the Deep South, where I met people whose sources of resilience were very different from my own. I particularly remember Jereldine Johnson, a powerfully built African American woman who lived with her 13 children (plus me for one summer) in a cabin in rural Tennessee. Scorching sun; red clay in skin, hair, nostrils; smoke of the wood stove, even when it was 100 degrees out; crying babies--all were part of Jereldine's daily life.

In prayer meetings and rallies in small rural churches in the cotton fields, Jereldine and her neighbors faced poverty, violence, and racism together--with songs, testimonies, political action, and energetic joy. Everyone participated. Everyone, no matter how uneducated or beaten down, was assumed to have something to offer. In contrast to the isolated inner struggle of the abuse survivor, traumatic experiences among the African Americans I met in the South were confronted communally and held in a spiritual perspective, leading to something other than bitterness and despair. It was years before I could put into practice what Jereldine had shown me, and I returned home alone at the summer's end, still closely guarding the secret of my sexual victimization--except when I was drunk (which was often).

So it went until an early winter day in 1978, a year after my father's death, when I found myself in a car on an interstate in Connecticut, being driven back to my job (as a dorm counselor near my childhood home in Northampton, Massachusetts) by someone I hardly knew. After I opened the car door and tried to jump onto the freeway--it seemed like a good idea at the time--the terrified driver delivered me struggling and shouting to the emergency room of a hospital off the nearest exit.

Three days drunk, covered with blood from self-inflicted cuts, my hair disheveled, dressed in jeans and an old army shirt of my dad's, even my gender was unrecognizable. I was wrestled into submission by six emergency room workers, injected with a paralyzing amount of Thorazine, and transported by ambulance to a locked ward for violent women at the Connecticut state hospital in Waterbury. I was 34.

I sobered up in a gloomy, disinfectant-smelling darkness. Was I in a barracks, a dorm, or a concentration camp? I'd stayed briefly in private psychiatric hospitals before, but never had I been forcibly locked in with other violent, despairing women. Life had finally thrown in my face what a half-dozen therapists had overlooked. For a decade, my episodically competent days had been fueled by amphetamines, caffeine, rage, and prescribed antipsychotic drugs like Stelazine; in the evenings, I'd mellowed out with tranquilizers, gin, and sex with near-strangers. This regimen of prescribed and self-prescribed drugging had worsened my flashbacks until they mimicked transient psychotic states.

I don't know what diagnoses I'd been given by my well-intentioned New Haven psychologist, Dr. M., who'd minimized my alcoholism and repeatedly told me that my memories of incest were fantasies representing my disguised yearning for my father. But I suspect my bulging file contained references to borderline personality disorder or depression with psychotic features. Like thousands of other traumatically abused and misdiagnosed women, I was well on my way to developing the "spoiled identity" of a chronic mental patient. Dr. M. had led me to believe that I'd spend the rest of my life in and out of psychiatric units like the one I then found myself in at Waterbury.

Only my middle-class connections, I suspect, saved me from involuntary commitment. Two days after my arrival, three well-dressed, college-educated friends appeared in the middle of an ice storm and talked their way into meeting with the psychiatrist on call. "She needs to be in detox," said the psychiatrist, and released me to them.

It was the beginning of the end of my addictions.

Two months later, in another locked psych unit after another violent, drunken altercation, a psychologist suggested I move to the alcohol treatment unit one floor below. I agreed and for six rocky weeks, I self-consciously sat through 12-step meetings, heard about a Higher Power, and got used to the idea that I was powerless over alcohol and that my life had become unmanageable.

Once I stopped abusing drugs and alcohol, my flashbacks and dissociated states lessened markedly. With my friends' encouragement, I weaned myself from the overpowering antipsychotic medications that had kept me groggy and debilitated. I'd given up the spoiled identity of the mental patient in favor of the more accurate--and therefore more helpful--label of the recovering addict and alcoholic. But in 12-step meetings, I often felt awkward and out of place, and there were still parts of my story that I couldn't tell.

The Politics of Truth

Clean and sober, I returned to graduate school and shot like a rocket from chronic PTSD and rampant addiction to what seemed like the other end of the rainbow. Within six years, I was "Dr. Miller," a clinical psychologist doing postdoctoral work in family and narrative therapy at the University of Calgary Medical School in Alberta. On one memorable day, I visited a Canadian mental hospital as a consultant and expert on domestic violence and addiction. I'll never forget a social worker's giving me an enormous key, which opened all the wards, including a locked ward similar to the one I'd been committed to in Connecticut. Holding that key and remembering the movie King of Hearts , I was tempted to open every door. I was also irrationally terrified that my identity as a former mental patient would somehow be exposed.

As a family systems therapist, I loved drawing connections between a family's surface pain and hidden issues of addiction, patriarchal social assumptions, and domestic violence. I loved the "difficult" families, especially the mistrustful, mislabeled, and misunderstood mothers. I loved being mentored by iconoclastic family therapists who did battle with The System, personified by well-intentioned but oblivious social workers, psychologists, and psychiatrists like those who'd mislabeled and mistreated me.

Then one day in 1985, I sat behind a one-way mirror supervising a graduate student working with a father and his young daughter. Someone in the therapy room--I can't now remember who--said the word "incest," and it resonated through the microphone and into my observation room. A student next to me whispered a question, but I couldn't hear her words. Tears fell onto my hands as I twisted them in my lap.

When I confided in a senior family therapist, he told me not to get too involved and to just do my job. It sounded like the message I'd been given as a child: don't rock the boat, only remember the good times, and don't air family business in public.

But times had changed. If power consists in part in determining whose stories will be told and whose believed, the balance of power was shifting. Stories like mine were being whispered to a new generation of women therapists, spoken out loud in new 12-step meetings for adult children of alcoholics, and aired among feminists involved in the movement to stop domestic violence. The floodgates had opened. Control of the politics of truth had moved from the experts to the experienced.

After nearly a century in which the mental health field had dismissed reports like mine as fantasies, we victims lost patience with being spoken about and began to speak for ourselves. If our culture wanted to play Non-Protecting Bystander, we'd strip away the collective ignorance that had served as its shield. Like gay people and people of color before us, we defiantly embraced and began to dismantle the spoiled identity we'd been assigned. Oprah Winfrey, Maya Angelou, former U.S. Senator Paula Hawkins, and former Miss America Marilyn Van Derbur all said on television that they'd been sexually abused as children. By becoming vocal, we challenged the family and cultural role we'd been assigned: to suffer in silence, save everyone else from discomfort, and internalize the damage.

In the face of the carefree old public narrative--that incest was either imagined or consensual, and in any case, only occurred in one in a million families--we faced what lay in plain sight: that child sexual and physical abuse were real, damaging, and prevalent; and so were rape and other forms of family violence. If childhood and family trauma could be stopped and effectively treated, we figured, whole categories of the DSM --borderline personality disorder, dissociative disorders, substance abuse, cutting, sex addiction, other behavioral addictions, PTSD, and even some forms of anxiety and depression--might practically disappear. The elephant that had crashed unrecognized outside the windows of the consulting room for 80 years was finally seen and named.

We of this new generation of feminist clinicians saw childhood trauma for what it was. What we didn't know--and didn't know we didn't know--was how to treat the multiple layers of disruption it had caused. We recognized the critical importance of telling the story, but not that telling too much, too fast, to a relative stranger could retraumatize us and our clients. Stuck in a Manichean universe, which divided humanity into evil perpetrators and innocent victims, we had no nuanced language for the complex spiritual wounds of intimate violence: the conflicted familial bonds of love and pain; the sense of being isolated and unsafe in the universe; the distrust of the body, love, or pleasure; and the questioning of God's intentions after profound human betrayal. We didn't know that an individualistic and secular talking cure could only take us and our clients half the way home.

By the mid-1980s, we clinicians were experimenting with hypnotherapy, cognitive-behavioral work, and psychodynamic approaches that sometimes fostered inaccurate recall, retraumatization, family cut offs, and regression. Exposure therapy (developed for combat vets), for example, had been used effectively to desensitize adult women who'd suffered a single incident of rape. But when incest survivors repeated their stories over and over, they relived their traumas physiologically, along with the complex relational wounding of betrayal by a close family member. The biologically based rage, terror, and helplessness that followed were then often turned against the self in the form of renewed cutting, self-destruction, and addiction.

I remember, for instance, an incest survivor in Northampton who was coping well and working in a responsible position at a local title insurance company. After entering therapy, she became grossly obese, stopped working, and, to my knowledge, has never worked again.

I'd reentered therapy myself in the mid-1980s and, for the first time, I was assembling a coherent life narrative with a clinician who believed me. But if this was the validation I'd sought, why did I feel worse after nearly every session? Helpless and enraged after reliving detail after detail of how my father had hurt me and my mother had abandoned me, I'd walk out of her office and end up in an expensive shop in Northampton, flipping out my MasterCard for beautiful clothes I couldn't afford.

I stopped exercising, gained weight, and became increasingly isolated. I could barely work. My glands were swollen, my joints ached, I slept erratically, and I was acutely lonely. So it went until I quit therapy--because my therapist continued to insist that I confront my widowed, 80-year-old mother with her failure to protect me.

I wasn't alone in my misgivings. In the early 1990s, I was frequently asked to consult with bewildered therapists, whose clients had entered therapy doing more or less okay and had then fallen apart. I particularly remember Frieda, a talented sculptor who'd been in therapy for seven years. She'd stopped working on her art, became a child instead of a partner to her husband, and was drinking too much and neglecting her children. In consultation, I asked why she was persisting with therapy that apparently wasn't doing any good. I suggested--much to her therapist's shock and dismay--that Frieda take a break from individual therapy, try a group focused on building present-time, real-life competence, return to sculpting, and go to Alcoholics Anonymous.

Frieda's therapy had been modeled on a psychodynamic approach influenced by British researcher John Bowlby, the expert on mother-infant attachment. The idea was to compensate for early betrayal and "insecure attachment" by providing clients with a dynamic, reparative, and trustworthy therapeutic relationship.

In practice, this often meant making excuses for destructive behavior and implying that nothing better could be expected of someone so horribly damaged. The focus was on the wounded child to the exclusion of the competent adult. To make matters worse, many therapists eventually became exhausted by the role of ministering angel and turned punitive with their clients.

This therapeutic quicksand was responsible for slogans, buttons, and bumper stickers like "It's got to get worse before it gets better" and "It's never too late to have a happy childhood." In Northampton, where I live, adult women walked around with teddy bears in their backpacks--and some, I hate to say, still do. Many became disconnected from any community but the community of survivors, and any identity beyond the spoiled identity of victimhood. Their lives consisted mostly of living alone, writing in journals about what had happened to them, and making the rounds of group therapy, individual sessions, support groups, and inpatient units.

Some channeled their rage into confronting or cutting off from their parents, but few looked out the window into a larger social world. No effective equivalent of Mothers Against Drunk Driving emerged to lobby for the next generation of kids. Social attention was diverted instead to a phantasmagorical distraction: the notion--never, to my satisfaction, confirmed--that secretive, satanic cults had subjected thousands of American children to ritual abuse. In Northampton, this hit home when a new psychiatrist took over the women's wing of a nearby psychiatric hospital. Until managed care put an end to it, patients referred there for brief stays emerged, months later, bearing diagnoses of multiple personality disorder and living in terror of the cult members who, they said, had devastated their childhoods.

That's why, when the False Memory Syndrome Foundation (FSMF) burst on the scene in 1992 and began challenging professional licenses and picketing therapists for "splitting up families," I felt ambivalent. On the one hand, they represented such a backlash. On the other hand, as I quietly said behind closed doors, they had a point. We were walking into dense fog where it was hard to tell what was real and what wasn't. Given the way I hadn't been believed myself for so many decades, I wanted the story told by victims about their victimizers to be always simple and always true. It wasn't turning out that way. Yet it was almost taboo among us to admit that much of what we were doing wasn't working. Anyone who criticized therapeutic practice risked being identified with the FMSF, whose members were presumed to all be Abusers and Non-Protecting Bystanders. A new elephant had entered the consulting room, and we were in denial all over again.

Nurturing the Competent Adult

In this state of unease and not-knowing, I reached beyond the incest recovery movement. In 1995, I drove to Burlington, Vermont, for a weekend workshop in "Just Therapy," a New Zealand approach connected to both the Narrative Therapy movement and indigenous movements for social justice. Led by a white man, a Maori man, and a Samoan woman, all from New Zealand, the group opened every session with chanting and prayer, challenging us bemused, secular Americans to do the same.

That day, I awoke to the spiritual thinness of the therapeutic work we were doing. Within the incest recovery movement, victims had been assigned a debilitated and isolated purity, while abusers and nonprotecting parents were monsters without humanity or compensating strengths. In this black-and-white universe--with good and evil people neatly divided--our clients remained as trapped in spoiled identity as their perpetrators, cut off from humanity as a whole, from their own failings and strengths, and from the healing power of acceptance.

I thought variously of Gandhi's independence movement, of Alcoholics Anonymous, and of the Civil Rights movement, all of which had flourished rather than imploded. What had been their secret? Despite their enormous differences, all had transformed participants--and the culture at large--in a way I can only describe as spiritual. All had acted in the present moment--cognizant of, but not enslaved by, the past. All had faith in something bigger than themselves, and none demonized their purported enemies. Could the trauma survivors' movement do the same?

At around this time, I came across journal articles by the pioneering research clinicians Bessel van der Kolk of Boston University and Marsha Linehan of the University of Washington. Both turned attention from the psyche to the body of the trauma victim and hypothesized that self-harmful behavior like cutting could be an attempt to soothe chronic neurobiological disregulation. If this were true, our clients couldn't think, talk, confront, cathart, or "re-story" their way to wholeness. Their nervous systems were continually telling them that the past was the present. Rather than a prolonged version of the Primal Scream, they needed new ways to learn to reregulate their disturbed neurophysiologies.

At this point--please bear with me here--I took up tennis. I was in my late forties and out of shape, and I just wanted to get more play, joy, and exercise into my life. My tennis teacher, Deedie Steele, became such a model of encouraging and demanding realism that if I were still supervising clinical graduate students, I'd require them to watch her teach tennis.

Deedie thought anyone could become a competent tennis player, and her teaching reflected both kindly encouragement and a precise analysis of everything I needed to do to improve. Standing across the net from me on the public court in Northampton, she watched how I placed and moved my feet, knees, elbows, and wrists as carefully as if she were preparing me for Wimbledon. She showed me in minute, persistent detail how to make necessary changes. Good therapists, I thought one sunny day as I ran sweating around the court returning her serves and trying to pay attention to my right wrist, are like Deedie: they believe that each client can function as an effective adult, and they help them gain the skills necessary to make this happen.

In the classroom, in supervisions, and in my therapy office, I widened the lens and began thinking in similar terms, analyzing precisely the outer (relational) skills and inner (self-calming) skills that trauma survivors needed to function better. Then I taught these skills, whether they were considered "therapy" or not. I began asking questions that were once outside the therapist's domain: How much do you exercise? What do you eat? Do you have a sense of a Higher Power or a Protective Presence in your life? How do you play and express yourself creatively? Do you meditate? Are you getting enough sleep?

In my own life, things were moving, too. I entered a long-term relationship with someone who helped me learn to play and have fun. We renovated a house together in Northampton with the help of our son-in-law, a contractor, and I became part of a family that included grown children and grandkids.

I also returned to 12-step meetings--and there, too, things had changed. Women participate more actively in the recovery movement now, and I felt freer to share my story. The time I spent in those church basement rooms opened a door to a deeper spiritual yearning. After years of dabbling in Buddhist books, I began meditating regularly and discovered, in Pema Chodren and Thich Nhat Hanh, the notion of impermanence. This basic Buddhist tenet--that the "self" isn't fixed and that all circumstances and states of mind pass was the perfect antidote to the sense of doomed identity that had brought me to my knees in that mental hospital in Connecticut. I became more solid--and yet, oddly enough, more open to friends and strangers. I was living a fuller life than many people who'd never been abused.

Leaving a church basement one night, I found myself rethinking the whole question of victimhood, healing, and wholeness. As much as my clients needed to understand the links between their victimization and self-destructiveness, I thought, they needed even more to take an ordinary place within the web of life.

In 1995, my graduate students at Antioch New England university suggested we incorporate what I was trying with individual clients into group therapy. Our first three-month group was held in the offices of a domestic violence program in Greenfield, Massachusetts. This notoriously poor, predominantly white area of northwestern Massachusetts is a landscape of played-out farms, abandoned brick factories, and tattered, triple-decker apartments lining the side streets of decaying, 19th-century mill towns. Unemployment is high, and so are heroin addiction, crack use, and domestic violence.

Our first eight participants were women who'd repeatedly called the domestic violence center's hotline--most of them grandmothers, foster mothers, and single mothers with staggering histories of childhood abuse, alcoholism, cutting, drugging, enmeshment in battering relationships, and visits to local psychiatric inpatient units and emergency rooms.

We opened the first session by teaching the women simply to breathe with awareness. Then we talked about the links between their childhood histories, their addictions, and the way they had internalized all three roles: Victim, Abuser, and Bystander. Each week, we asked how trauma had affected them, but we also asked about the roots of their resilience--their successful coping strategies and the people they remembered who'd been there for them, even if not consistently.

Over time, we taught them to turn to other members of the group for support rather than to the group leaders. They painted and drew. In brief guided meditations, we helped them connect to something bigger than themselves. That opened the door to developing a felt sense of Protective Presence, evoked from memories of protective adults, beloved pets, nature, and compassionate religious teachers like Jesus and the Buddha. They learned to reliably evoke this presence to remind themselves that even though they'd been victimized, they'd also been whole people all along.

In the last three weeks of the three-month group, we focused on how they intended to give back to the larger community. Some returned to Alcoholics Anonymous or Narcotics Anonymous. Others went back to school, college, or work. Others chose to volunteer in the storefront drop-in centers I'd helped organize with other therapists, community activists, a small order of radical Catholic nuns, and a visionary federal project dedicated to supporting innovative work with trauma survivors. Self-destructive behaviors diminished and, perhaps more important, participants created an identity for themselves that included, but wasn't limited to, their traumatic past.

Since then, I've trained more than 200 women with histories of trauma, most of them poor, with limited education. I call this program ATRIUM (Addiction and Trauma Recovery Integration Model) after the entry chamber of the heart. The metaphor is meant to suggest that the groups are just a starting point. Their graduates now lead similar groups in local prisons, jail diversion projects, AIDS programs, and the three drop-in centers for survivors. Many of these women--among them many welfare-dependent single mothers and grandmothers--have turned out to be more effective group leaders than some of the highly educated professionals that I've trained. They're helping create what may be the therapy of the 21st century: a blend of peer support, psychoeducation, interpersonal skills training, meditation, creative expression, spirituality, and community action.

Time Is a River

I'm now close to 60--a middle-class, middle-aged professional living on Prospect Street in Northampton, Massachusetts--the same street I grew up on. I still occasionally see women in town with teddy bears in their backpacks and buttons saying "It's never too late to have a happy childhood." I want to tell them that their button is wrong: it is too late. Time is a river that runs in only one direction. Trauma survivors--be they Vietnam veterans, Cambodians, Holocaust survivors, sexually victimized women, or firefighters who escaped from the World Trade Center--never become people to whom trauma didn't happen. But the ripples that flow outward from every traumatic event don't have to sink us, define us, or assign us a single identity. "Victim," I want to tell them, describes a specific moment in time, not permanent self-definition. This is a comforting aspect of the impermanence that transforms every emotional state.

As a culture, we're only just waking from sleep. It's long been easier to blame people covertly for their reactions to childhood abuse than to face what happened to them. We pay staggering public health bills for the addicted and traumatized, but we balk at spending on preventing that trauma in the first place. Protective workers charged with investigating crimes against children, for example, make less than half what we pay the police officers who investigate adult crimes.

There are a few hopeful signs that this may change. In the wake of the priest scandals and the collective public wounding of the September 2001 attacks, words like victim and trauma have enlarged their meanings beyond the mostly female holders of this particular spoiled identity. The psychic damage suffered by the firemen and construction workers of Ground Zero made it clear that not only Vietnam veterans and sexual-abuse survivors suffer from PTSD. Nobody's yet suggested that the "heroes" of 9/11 are part of a culture of complaint. As Jack Rosenthal put it last fall in the New York Times Sunday Magazine, "Before 9/11, trauma often referred to the horrible physical injuries seen on E.R. Now the psychiatric use of the term may just as likely be referring to the time bombs that 9/11 lodged in the minds of thousands."

Meanwhile, I'm continuing to play tennis. Thanks to expert coaching and hard work, our aging, ragtag team, The Courtesans, has progressed from dead last to a respectable standing in our local league. When I travel to Washington, D.C., these days to meet with the federal agencies that fund our grass-roots projects in Franklin County, I sometimes pass the Mall, where, during huge women's rights rallies, I played in the New Haven Women's Liberation Rock Band with Florika. I think back 30 years to that desperate, unconscious, distrustful, and enraged young woman, three days drunk and covered with self-inflicted cuts, who was shot full of Thorazine and bundled off to a state hospital in Connecticut. She'd be both contemptuous and amazed to see who she's become: a physically healthy professional woman who works inside the system without ever quite joining it. And although I still hold in my heart that wild young woman and understand how she came to be, the river of life has flowed a long way since then, and she's now only part of me.

Dusty Miller, Ed.D., is director of the Atrium Consultation and Training Institute in Northampton, Massachusetts. She's the author of Women Who Hurt Themselves; Your Surviving Spirit: A Workbook of Spiritual Resources for Coping with Trauma; and numerous other publications on trauma and addiction. She's also the codirector of the Willing Spirit Retreat Center in Cape Cod, Massachusetts. Address: 229 Prospect Street, Northampton, MA 01060. E-mails to the author may be sent to


Barrett, Mary Jo. "Healing from Trauma." In Spiritual Resources in Family Therapy, edited by Froma Walsh, 193-209. New York: Guilford, 1999.

Chodron, Pema. Awakening Loving-Kindness. Boston: Shambhala Publications, 1996.

Herman, Judith Lewis. Trauma and Recovery: The Aftermath of Violence from Domestic Abuse to Political Terror. New York: Basic Books, 1992.

Jordan, Judith V., et al. Women's Growth in Connection: Writings from the Stone Center. New York: Guilford Press, 1991.

Linehan, Marsha. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press, 1993.

Miller, Dusty. "Incest: The Heart of Darkness." In Secrets in Families and Family Therapy, edited by Evan Imber-Black. New York: W. W. Norton, 1993.

----. Women Who Hurt Themselves: A Book of Hope and Understanding. New York: Basic Books, 1994.

----. "Challenging Self-Harm Through Transformation of the Trauma Story." In Sexual Addiction and Compulsivity, 3, no. 3 (1994): 213-27.

----. Your Surviving Spirit: A Spiritual Workbook for Coping with Trauma. Oakland: New Harbinger Publications, 2003.

Miller, Dusty, and Laurie Guidry. Addictions and Trauma Recovery: Healing the Body, Mind and Spirit. New York: W. W. Norton, 2001.

Najavits, Lisa, R. D. Weiss, S. R. Shaw, and L. R. Muenz. "Seeking Safety: Outcome of a New Cognitive-Behavioral Psychotherapy for Women with Posttraumatic Stress Disorder and Substance Dependence." Journal of Traumatic Stress, 11, no. 3 (1998): 437-56.

van der Kolk, Bessel, Alexander McFarlane, and Lars Weiseth. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press, 1996.

The Evolution of Modern Sex Therapy

by Katy Butler

Twenty years after the sexual revolution, in the most sexually explicit culture in the world, a surprisingly large number of people continue to have difficulties with the sexual basics. The Social Organization of Sexuality, a statistically balanced 1994 survey of the sexual habits of 3,432 Americans, found that 24 percent of the women questioned had been unable to have an orgasm for at least several months of the previous year. Another 18.8 percent of the women (24 percent of those over 55) reported trouble lubricating; 14 percent had had physical pain during intercourse; and 11 percent were anxious about their sexual performance. Equally high proportions of men reported interlocking difficulties: 28 percent said they climaxed too quickly, 17 percent had performance anxiety and 10.4 percent (20 percent of those over 50) said they'd had trouble maintaining an erection.

Before the 1950s, people with these sorts of problems were given pejorative labels like "impotent" and "frigid." Psychoanalytic therapy had little to offer them beyond symbolic explorations of their upbringings and "Oedipal" conflicts. Things got slightly better in the 1950s, when Joseph Wolpe and other behaviorists taught people to reduce their fear by breathing deeply and relaxing while imagining sexual situations that had made them tense. This was of some help, but things only really changed in the 1970s, after gynecologist William Masters and his research associate Virginia Johnson began studying the physiology of human sexual response in the laboratory.

Modern sex therapy--a repertoire of precise physical techniques that teach the body new responses and habits, lower anxiety and increase focus on the here-and-now--builds on Masters and Johnson's work. Therapy consists mainly of counseling and "homework" in which new experiences are tried and new skills practiced. If clients are too tense or reluctant to try something new, systems approaches, couples therapy, drugs and psychodynamic therapy may be tried as well.

Modern sex therapy often begins with instruction in "sensate focus." The pressure to have an orgasm, keep a firm erection or prolong intercourse is taken away. Instead, individuals or partners are told to set aside time to caress themselves or each other in a relaxed environment, without trying to achieve any sexual goal. Once anxiety is lowered, sex therapy often proceeds successfully, especially in treating the following common problems:

Vaginismus. Vaginismus is the spastic tightening of the vaginal muscles and can make intercourse impossibly painful. It can be so severe that not even a Q-tip can be inserted in the vagina, and some women with vaginismus have never, or rarely, completed sexual intercourse in the course of years of marriage. Often the result of physically painful experiences like childbirth, painful intercourse, rape or molestation, it is a learned fear response. Therapy involves teaching the woman to relax and breathe while gently inserting the first of a graduated series of lubricated rods, starting with one as small as is necessary for comfort. In ensuing weeks, the woman uses incrementally thicker rods and then inserts her partner's finger and finally his penis into her vagina. Nothing is forced, and insertion is always under the control of the woman.

Premature ejaculation in men. Treatment involves lowering anxiety and teaching the man to become aware of his arousal during lovemaking, until he recognizes the sensations that precede his "point of no return." Then he practices what sex therapist Barbara Keesling, author of Sexual Healing, calls "peaking"--pausing before the point of no return and relaxing, breathing and stopping movement until his arousal subsides. After a few minutes' rest, the man returns to movement, stimulation and arousal. The "peak and pause" routine is repeated five or six times per homework session. The exercise can be done by a man masturbating alone, while his partner is giving him oral sex or during intercourse. Men can squeeze their pubococcygeal or PC muscles during the pause to dampen arousal, or the man's partner can squeeze on the coronal ridge just below the head of the penis.

Erectile difficulties in men. A common problem among older men, erectile failure is often caused by an interaction of physical and psychological factors. Smoking, diabetes, blood pressure drugs, alcoholism, neurological injury and normal aging can all worsen erectile problems. Treatment has been revolutionized since the introduction of Viagra, which not only helps men with primarily physical problems, but can also jump-start those suffering primarily from anxiety.

Men who awaken with erections or have them while masturbating can probably blame anxiety if they have trouble during intercourse: muscular tightness and breath-holding can send blood out of the penis, causing it to wilt. Sex therapy requires slowly disarming anxiety and performance pressure, and learning to enjoy sex with and without an erection. Therapy often begins with declaring intercourse off-limits and encouraging the couple to enjoy each other orally and manually, without demanding that the penis perform.

In the next "stop-start" phase, the man's partner stimulates him to the point of erection, stops until his penis becomes totally soft and then stimulates him again, repeating the process up to three times if the erection returns. Other exercises include "stuffing," which allows the man to become familiar with the sensation of being in the vagina without having to perform sexually. The female partner gently folds his flaccid penis into her vagina, using her fingers as a splint while lying in a scissors position, at right angles to the man, with one of his thighs between her legs. The couple then lies together for 15 to 30 minutes without moving. In subsequent sessions, as anxiety lessens, the man practices moving slowly while breathing evenly and staying relaxed.

Orgasmic difficulties in women. Therapy with "pre-orgasmic" women was pioneered by psychologists Lonnie Barbach of San Francisco, author of For Yourself: The Fulfillment of Female Sexuality, and Joseph LoPiccolo, a coauthor, with Julia Heiman, of Becoming Orgasmic. It has extraordinarily high success rates with women once written off as frigid. In group and individual programs lasting 6 to 10 weeks, women are given basic information about female sexual response and are encouraged to spend one hour a day on self-pleasure "homework," familiarizing themselves with their own anatomies and sexual responses, examining their vulvas with a mirror and speculum, massaging themselves, perhaps reading Nancy Friday's collections of sexual fantasies and masturbating. Most of the women soon learn to give themselves orgasms, and then gradually transfer their new skills to lovemaking. First they masturbate to orgasm in front of their partners, then learn to come while touching themselves during intercourse, and then teach their partners to pleasure them to orgasm using their fingers or penis.

Most women successfully transfer their new responsiveness to partnered sex. The exceptions tend to be women who have learned to reach orgasm by squeezing their thighs tightly together--a position that makes it virtually impossible for them to have an orgasm with a penis inside them. In LoPiccolo's clinic at the University of Missouri in Columbia, such women relearn a more fluid orgasmic response by deconstructing their masturbation rituals step-by-step and gradually learning to have orgasms without clenching their thighs. They may begin by simply uncrossing their ankles while masturbating and then slowly change their patterns until they can have orgasms with their legs apart.

If a woman can reach orgasm with digital stimulation from her partner, LoPiccolo considers that therapeutic goals have been met. Women respond orgasmically to a wide variety of stimuli--some to dreams and fantasies; others to the rubbing of an earlobe or breast; others to digital caressing of the clitoris or G-spot; and still others to intercourse. All are considered normal human variations. At an American Association of Marriage and Family Therapy conference last year, LoPiccolo said that when couples come to him saying they'd like the woman to have an orgasm during intercourse, he doesn't consider this a therapy goal so much as a growth goal, like learning to dance. "If you want to learn the tango," he said by way of analogy, "You get tango lessons, not therapy."
Tantra at Home

Modern Tantric techniques to improve anyone's sex life:

Heighten Awareness of All the Senses William Masters and Virginia Johnson introduced to the West a technique called "sensate focus," in which the receiving partner focused on his or her own sensations while being slowly and nonsexually caressed.

Tantric versions are more playful and aesthetic: Tantric teacher Margo Anand of Mill Valley, California, for instance, recommends that the receiving partner sit blindfolded on the bed, while the nurturing partner wafts a variety of smells, such as peppermint, licorice, gardenia, or even Chanel No. 5, under his nose. Next he is treated to sounds--bells, gongs, even crackling paper. Then he is fed distinctive-tasting foods--almonds, grapes dipped in liqueur, whipped cream, fruit or bittersweet chocolate. Finally, the nurturing partner strokes the receiving partner's body with pleasant textures--silk scarves, fur mittens or feathers. The ritual closes gently and formally. "With utmost gentleness, as if you had never touched him before, let your hand rest on his heart," writes Anand. "Allow your hands to radiate warmth, tenderness, and love."

Create Intimacy Through Gentle Contact: Modern Tantrism focuses strongly on the subtle physical harmony between partners. In Tantra: the Art of Conscious Loving, yoga teachers Charles and Caroline Muir of the Source School of Tantra in Maui, Hawaii, recommend spoon meditation:

Lovers lie together spoon-fashion on their left sides and gently synchronize their breathing. The outer person, the nurturer, rests his right hand on the heart of his partner. Placing his left hand on her forehead, he visualizes sending love and energy from his heart down his arm and into her heart on his out-breath. On the in-breath, he draws energy back from her forehead and into his body in an endless circle.

The Muirs also recommend that partners do yogic breathing in unison: inhaling, holding the breath for a few seconds, exhaling and holding the breath out for a few more seconds. While breathing out, one partner visualizes accepting energy while the other visualizes projecting it. Couples can also inhale and exhale in counterpoint, visualizing "shooting out" energy on the out-breath through heart, head or groin and receiving it on the in-breath.

Focus on Connection Rather Than Orgasm: Much of conventional sex therapy has focused on orgasm. Many previously unsatisfied women were liberated in the process, but it also turned intercourse into a big project, made orgasm the be-all and end-all of being together sexually, and defined any other sexual interaction as "the failure to achieve orgasm." Tantrism extols the joys of brief sexual connections without orgasm. In The Tao of Sexology, for example, Taoist teacher Stephen Chang recommends that couples practice the "Morning and Evening Prayer" for at least 2 to 10 minutes, twice a day. Every morning and evening, partners are to lie together in the missionary position, lips touching, with arms and legs wrapped around each others' bodies and the man inside the woman. The couple breathes together in a peaceful, relaxed state, with the man moving only enough to maintain his erection. "The couple enjoys and shares the feelings derived from such closeness or stillness for as long as they desire," writes Chang, who notes that orgasm sometimes follows without any movement. "Man and woman melt together, laying aside their egos to exchange energies to heal each other."

Enhance Sexual Pleasure: Ancient and modern Tantric and Taoist sex manuals are full of sophisticated physical techniques designed to enhance the pleasure of both partners, stimulate orgasm in the woman and delay orgasm in the man. Chang, for example, recommends a Taoist practice called "Sets of Nine." The man slowly penetrates the first inch or so of his lover's vagina with the head of his penis only. He repeats this shallow stroke slowly nine times, followed by one slow stroke deep into the vagina. The next "set" consists of eight shallow strokes and two deep strokes, followed by seven shallow strokes and three deep strokes and so on until a final set of one shallow stroke and nine deep strokes. The "sets" help men prolong intercourse by balancing intense and less intense forms of stimulation and arouse women by stimulating the G-spot and numerous nerve endings in the neck of the vagina.

Separate Orgasm From Ejaculation: In its most signal departure from Western sex therapy, modern and ancient Tantrism recommend that men, especially older men, frequently enjoy what it calls a "valley orgasm"--orgasm without ejaculation. Chang recommends that as the man senses himself approaching the "point of no return," both partners stop all movement while the man clenches his pubococcygeal or PC muscle (the urination-stopping muscle known to many women from the Kegel exercises they were taught to strengthen uterine and bladder muscles after giving birth). The man also slows and deepens his breathing, looks into his partner's eyes, connects with her heart and channels energy upward from his groin toward his heart and the crown of the head. Orgasm without ejaculation often follows. Ejaculation can also be reserved, without stopping the experience of orgasm, by pressing on what Chang calls "The Million Dollar Point," in a small hollow between anus and scrotum.

Honor Sex, But Keep It in Perspective: "When sex is good," Charles Muir said at a recent workshop, "It's 10 percent of the relationship. When it's bad, it's 90 percent."

Networker associate editor Katy Butler, a former reporter for The San Francisco Chronicle, has contributed to The Los Angeles Times, The New Yorker, The New York Times Book Review and The Washington Post. For more information on Charles Muir, write to P.O. Box 69, Paia, HI 96779. Correspondence to Katy Butler may be sent to the Networker .


Pathways to Sexual Intimacy

Revealing Our Many Selves in the Bedroom

by Richard Schwartz

Mark and Stacey, an attractive couple in their early thirties, have only been married two years and they're already knotted in conflict. In our first session, Mark, an intense, athletically built man, gets to the point, "I hate it that we're such a stereotype, but it's the typical scenario of me wanting more sex than she does. We're down to once every two weeks--if I'm lucky--and it's driving me crazy. I have a strong sex drive, so if it were up to me, we'd do it every day, the way we used to when we were dating. Now, not only do I not get my sexual needs met, but I feel rejected because most of the time I get shot down when I initiate."

Stacey, slim, darkhaired, sits rigidly in her chair. "I know we don't have sex as much as Mark likes," she says, with an edge in her voice, "but for me to want to make love, I have to feel emotionally connected to him and, to be honest, most of the time, I just don't. He seems so obsessed about this issue. I constantly feel pressure to satisfy him. It's like raw sex is the only thing he wants from me. It's gotten to the point where any time he touches me I freeze up--I'm afraid to respond even affectionately because if I do, he thinks it's an invitation to sex."

"Yeah, in some ways that's the hardest part of it for me," Mark interrupts, "the way she sees me now. She looks at me like I'm one of those guys on The Sopranos. I like sex, but I'm no drooling animal. I can be romantic and I do try to help her feel close, but whatever I do does no good," he says despondently. "No matter how sensitive I try to be, it's like she has this view of me as a sex-crazed gorilla."

I ask each of them to describe what typically happens when they do have sex. Stacey says, "After some time goes by when we haven't had sex, Mark gets more and more sulky, and I begin to feel I'm like a bad, unloving wife. So I hug him or pat his shoulder or maybe just smile at him or something and, oh boy! That's all it takes--he's off to the races. I feel I can't say no again, and so we'll get in bed and start kissing. I try to be as warm as I can get myself to be; I don't want to just lie there like a dead fish. And, usually, at a certain point, I can work myself up so that I'm into it, sort of. Afterwards, I feel relieved because I know he feels happier and not so angry at me and, also, he'll back off and I won't have to do it for a while."

Mark seems not to have heard the many negative qualifiers in Stacey's description of their sex life. "That's what I don't get," he exclaims with exasperation. "In the middle of it, she comes alive and seems to like what I'm doing, but the next day she's uninterested again. If you like it, why not want more? Also, I don't enjoy the beginnings that much because I want to feel wanted by her, not like I have to kick start her engine every time. I'm not one of these guys who just wants to satisfy himself. I'm good at foreplay and I've learned what she likes."

Mark and Stacey are caught in a classic struggle, and most couples therapists have responded with a now-classic technique: get him to back off by issuing a moratorium on sex and assigning exercises that allow them to show affection to each other without any sexual expectation. Trained as a problem-solving, strategic therapist, I used to give that directive to couples and often found that it had the desired effect. It probably would've worked with Mark and Stacey, too. As he contained himself so she felt less under seige and more cared for, eventually they could've found a frequency that felt okay to each, checked off this particular glitch on their list of relationship issues, and left therapy reasonably satisfied.

I once felt an outcome like that meant I'd done my job. Not anymore. Through the years, I've come to see that this kind of technical fix, however immediately useful, is unequal to the inner complexity of people and their potential to know each other intimately.

Know Your Selves

No other area of a couple's life holds as much promise for achieving intimacy as sex. Indeed, the promise of intimacy may be as important as lust for drawing human beings toward sex in the first place. My goal now is to help partners reach the kind of soul-deep connectedness in their sexual encounters that can transform their lives and their relationship with each other.

The Latin adjective intimus means "inmost, deepest." So real intimacy means, first of all, that both partners listen deep inside--i.e., get to know their inner worlds of emotion, desire, and vulnerability--and then reveal what they've learned to each other in an atmosphere of loving acceptance. The couples I've helped reach that level of resonance report tremendous rewards for themselves and their relationships. However, as rewarding as that state is, it's also quite rare--both because of the risks involved in being that vulnerable and because knowing yourself isn't a simple task.

When people listen deeply inside, they encounter a host of feelings, fantasies, thoughts, impulses, and sensations that comprise that background noise of our everyday experience of being in the world. When they remain focused on and ask questions of one of those inner experiences, they find that it's more than merely a transient thought or emotion. Within each of us is a complex family of subpersonalities, which is why we can have so many contradictory and confusing needs simultaneously, especially around sex. American poet Walt Whitman got it right in "Song of Myself": "Do I contradict myself? Very well then I contradict myself, (I am large, I contain multitudes.)" So do we all contain multitudes.

Thus, the Oracle of Delphi's admonition to "know thyself" should really have been to "know your selves." I call these subpersonalities "parts" because, when I first started doing this kind of work, that's how my clients referred to them. "Part of me wants to stay married and faithful, but another part wants to be free to get laid every night of the week with a different woman," a client might say. "I know I'm successful at my job, but there's a part of me that says it's only a matter of time until everybody else finds out how stupid and incompetent I really am," another would report. While people like parts of themselves that make them feel powerful, competent, and in control, they tend to dislike and even despise what they feel are their less attractive, more troublesome, parts. In one session, Stacey said spontaneously "I hate the part of me that's so scared to have sex with Mark." But hating and trying to get rid of parts that we don't like doesn't work. We only feel more polarized inside, and the despised part gets stronger.

Getting to know ourselves in all our multiplicity isn't an easy stroll through a familiar neighborhood. When our inner parts meet our partner's parts, the complexity is compounded, which is why couples therapy can be so difficult. Despite the fact that, like Mark and Stacey, most partners want me to get the other to change, I try to help each listen inside to discover why they respond to their mates in such extreme, and often damaging, ways.

I've found that, if I establish a safe, accepting atmosphere in our sessions, clients can have inner discussions with their parts. In a trancelike state of internal focus, they can dialogue with their parts about what motivates them to react in irrational or self-defeating ways. In listening to their parts' stories, their behaviors or beliefs become comprehensible.

As clients learn to separate from their extreme emotions and thoughts (their parts) in this way, I find that they spontaneously tap into a calm, centered state that I call their Self. When this happens in a session, it feels as if the very molecules in the atmosphere have radically shifted. My clients' faces and voices grow softer and more tranquil; they become more open and tender, able to explore their parts without anger, defensiveness, or dislike. When accessing this state of Self, clients are tapping into something deeper than all these conflicting inner warriors, something that spiritual traditions call "soul."

Now imagine what it can mean for a relationship when each partner connects to such a Self. If intimacy means being able to truly know and reveal all our parts to a beloved other, then the presence of Self makes doing so possible. When they make a Self-to-Self connection, people sense at a very deep level that they aren't alone and that even their most shameful facets are loved. When, during sex, each partner can dive beneath the surface where their contending parts are creating stormy waves and into the calm depths of Self-to-Self connectedness, their bodies and souls meet and sense a oneness that's delicious and profoundly satisfying. For me, then, intimacy has two components: the knowing and revealing of one's secret parts and also the sense of awe and belonging that comes with Self-to-Self connectedness.


The first step toward that kind of intimacy involves helping each partner get to know the parts that are triggered by their problems. Because Mark and Stacey were polarized around their sexual relationship, I thought they'd feel safer doing this exploration in private. I suggested that I meet with each of them separately for a session or two. To help people find their parts, I usually begin by asking them what they think or feel about the problem they bring me. When I saw Stacey individually, for example, I asked her what she said to herself when Mark approached her for sex. "Oh no, here we go again!" she replied contemptuously. "I feel angry and helpless and just yuck! But then, I tell myself, 'God, I suppose I've got to do it or he'll make me pay.'"

I then asked her to focus on the disdainful voice. She said she sensed it in the back of her head. As she focused there, I suggested she ask it why it felt such revulsion for Mark and for sex? Putting her hands up as if to push the entire subject away, she said the voice was really disgusted by the whole thing--sweaty, naked bodies, ugly, hairy genitals, revolting fluids, and ridiculous animal noises. Stacey's face was scrunched up in a look of loathing as she spoke, when suddenly she stopped cold and put her hands over her eyes."Oh my God, it's my mother!" she cried out. "It's my mother's voice in me!"

As we explored this revelation, Stacey recalled that her mother had conveyed her own deep revulsion with all things having to do with the body and sexuality. Some schools of therapy consider a voice like that a "parental introject" or a "schema" of learned cognitions (i.e., the internalized attitudes of Stacey's mother), and would encourage Stacey to ignore or argue with it. While there's no doubt that this part absorbed aspects of Stacey's mother, I find that such parts intend to protect rather than torment. These aversive, controlling voices belong to a category of parts I call the Managers, which act to protect people from hurt and trauma suffered in the past--usually when they were very young and unable to defend themselves emotionally or even physically. There are all kinds of Managers. Some are inner critics who drive people to perform perfectly so they'll never reexperience old feelings of failure and inadequacy. Other managers, like Stacey's, are early-warning systems that operate to prevent the person from even getting near an experience that might cause harm. Sex is perhaps the area of life most prone to the meddling of overzealous managers.

Managers like Stacey's bring new meaning to the phrase "safe sex." They have to be in control of the action. They see spontaneous expression as dangerous. They don't want anyone to know about, much less witness, certain parts of you. They also don't want you to be rejected or exploited, so they keep your heart closed to others. Managers monitor the passion, affection, play, and spontaneity you express in sex. If you begin to get carried away, they might interrupt the action with distracting thoughts, suddenly erase sensation or inject pain, or make you tense and uncooperative. Managers are the ultimate control freaks.

The Return of the Exiles

If you think of Stacey's voice as an introject or a cluster of thoughts, it makes sense to try to get her to challenge or eliminate it. If, in contrast, you view it as an inner personality, you get curious about why it's in the role of puritanical mother. Rather than try to shut down this "manager-mother," I wanted to know why she had this role in Stacey's inner drama. I've found that when we approach our Managers with respect, instead of resentment and dislike, they often have good reasons for what they do. I asked Stacey to sit quietly, breathe evenly, and go inside. "Ask the mother part what it's afraid will happen if it doesn't keep you so repulsed by sex," I said.

After a moment, Stacey had a vivid image of herself as a 6-year-old girl in the bathroom. Her father was helping her undress to take a bath, and as she watched the scene play out, she could see something wrong about it. Her father was looking at her in a funny way, once she was naked, his voice sounded different, and he trembled slightly. She sensed again the fear and confusion she'd felt then--the feeling that something bad was happening, and that it had something to do with her being naked.

The 6-year-old was one of Stacey's Exiles. Exiles are often childlike parts of ourselves that carry the memories and sensations from times when we were hurt, terrified, abandoned, or shamed. Because we want to forget those experiences, we exile these parts, and our Managers do their best to keep them from ever being triggered. Whenever Mark became amorous, it began to scare Stacey's little girl, so her manager-mother went into action, damping down any sexual feelings. Unfortunately, by keeping the Exile deep underground, Stacey not only missed unpleasant memories and sensations, she also missed the most sensitive, innocent, and open aspects of herself. If Exiles carry our most rending pain, they also can give us our capacity for joy, love, passion, creativity, imagination, playfulness, and sheer zest for life. If we shut away the Exiles, we also shut away much of what gives sex, and life in general, pleasure and adventure and meaning.

Mark, too, had parts that influenced the patterns between him and Stacey. When I saw him alone, I asked him to relax and focus on the feeling of frustration he felt whenever Stacey "shot him down." He closed his eyes and said he noticed a voice saying that he needed and deserved lots of sex. I told him to ask the voice about itself. Mark smiled and said that that voice called itself "The Stud," and it looked like a very buff, very macho, very tan version of himself. Mark said The Stud bombarded him with images of himself having sex in numerous hot and ingenious ways with his wife and other women, who panted and moaned in lusty abandon. Mark said he liked The Stud and that it had a powerful influence on him. He basically agreed with The Stud that his life should be more like those images. Many men have parts like Mark's stud, but not many are so open about it so early in therapy.

"Ask The Stud," I said, "what it's afraid would happen if you don't get to have sex all the time." He soon became quiet. After a long silence during which his face betrayed intense emotion, Mark said he'd felt waves of shame as he watched an image of himself as a 13-year-old in the boys' locker room. Talking in a bare whisper, he said that, at that age, he'd had small protuberances at his nipples. The other boys had ridiculed him mercilessly, calling him "Tits," asking him when he was going to buy a bra, and telling him he was really a girl. At such a vulnerable age, this kind of abuse was deeply traumatic to a young boy's developing sense of his own manhood. It was then that The Stud stepped into its role and the devastated 13-year-old was exiled. Never again, vowed The Stud, would he let anybody doubt Mark's masculinity, and it pushed him to seduce as many girls as he could.

Since he'd married Stacey, The Stud constantly pressured him to have affairs, especially after Stacey started rejecting him. So far, he'd resisted--he loved Stacey and wanted their marriage to succeed--but he was afraid that, if their sex life didn't improve, he'd succumb.

Firefighters to the Rescue

Mark's stud is characteristic of a third category of parts that I call the firefighters.

Like the Managers, the Firefighters want to protect the Exiles, but where Managers are cautious and often very rational in their attempts to protect Exiles, Firefighters leap into action after the Exile's feelings have been triggered. Firefighters are emergency responders who come out, hoses on full blast, when we feel so bad we have to drown the flames of emotion before they destroy us. These Firefighter parts manifest as urges to binge on food, alcohol, drugs, sex, work, or anything else that offers quick relief from pain.

Firefighter sex is one way to stave off intolerable feelings. Only while having or fantasizing about sex can people like Mark feel they have value, strength, or personal agency. Furthermore, a sexual Firefighter's obsession with power, dominance, and high-voltage sensation, can make us oblivious to the human being we're having sex with. Indeed, Stacey complained that she felt that Mark wasn't really there with her during sex; he didn't seem to care who was there, as long as a compliant body shared his bed. As is true for most Firefighter activity, the irony is that this part's efforts to help the exiled 13-year-old didn't work: ultimately they backfired. Stacey repeatedly rejected Mark for his sexual boorishness, only making Mark's exiled teen more ashamed and his stud more desperate.

When we uncover the dance of parts within and between members of a couple, we see many vicious cycles. The aggressiveness of Mark's stud triggered Stacey's Manager, which further triggered his stud, and so on, with disastrous results for their sex life. An Indian proverb says when the water buffalo battle in the marsh, it's the frogs who suffer. As Mark and Stacey's protective parts became increasingly extreme, the Exiles in each of them were increasingly wounded. My experience is that until each partner can care for and heal their own Exiles, these battles will continue. So I asked Mark how he felt about his young teen, and Stacey about her 6-year-old girl. Predictably, Mark was ashamed of the boy and didn't want to remember what he'd felt like. "That was all a long time ago," he said with a dismissive wave of his hand, "and I can't see any point in talking about that now." Similarly, Stacey was irrationally critical of the little girl. "She must've done something to make my father change like that," she said stubbornly.

It's very common for people to fear or dislike their Exiles initially. So I ask a client to find the rejecting or fearful voice that dislikes the Exile and politely ask it to just step back or relax for a bit. Sometimes it takes several requests for it to step back, but when it happens, the client's feelings toward the Exiles change dramatically from disdain and anger to curiosity or compassion, from fear to a sense of peace and confidence. When I ask clients what this calm, compassionate part is, they often reply with  something like, "This isn't a part like those other voices. This feels more like who I really am, like my real self." It seems that as people separate from their parts, their Self spontaneously emerges.

Once a client shows more qualities of Self, I ask him or her to enter the scene that an Exile is stuck in. "Can you go into that locker room and be there in the way that boy needed someone to be there at the time?" I asked Mark. Even after 20 years of doing this kind of work, I'm still awed by the way people unerringly know just what to do to heal these wounded inner parts. Mark said that as he approached the 13-year-old, the boy looked up with fear and embarrassment, thinking that this strong, athletic man would also make fun of him. Instead, as Mark played the scene, he sat down on the bench a few feet from the boy. He gently told the boy that there was nothing wrong with him or his body, that the appearance of his breasts was due to hormonal changes and they'd soon look perfectly normal. Other boys were also insecure about their bodies, Mark pointed out. "And anyway, I love you," he said to the boy. At this, the boy dropped his guard and burst into tears. Mark put his arm around the boy and took him out of the locker room, to a safe and pleasant place in the present--Mark visualized taking the boy canoeing on a nearby lake that he and Stacey often visited.

Meanwhile, Stacey went through a similar process. She helped the little girl out of the tub, carefully folded her in a fluffy, warm towel, and, embracing the girl, told her that she'd done nothing wrong. Whatever happened was her father's problem, not hers. Stacey, too, brought the girl into a safe and comfortable setting--to the living room couch--where she folded her arms around the little girl as she read her a story, while the sun streamed through the window.

After people compassionately witness their past in this way and retrieve the Exiles that are frozen there, they feel far less vulnerable. Consequently, the parts that guarded those Exiles are freed from their protective roles. The inner, reactive voices--explosive anger, self-hatred, anxious vigilance, compulsive behavior--transform into valuable helpers. A chronically suspicious, distrustful inner voice, for example, becomes an accurate intuition, helping the person sense who's safe to open up to, but no longer automatically closing off to everyone or keeping him in a fog of paranoia. A carping inner critic becomes a supportive voice urging the person to keep trying rather than constantly beating her down. After rescuing his 13-year-old, Mark focused back on The Stud, who was relaxed and smaller, less musclebound. Similarly, when Stacey returned to her manager-mother, the part was willing to reconsider the beliefs it had taken on from her mother, now that it didn't need to keep the little girl safe. These are the beginning steps in the process of transforming inner parts.

The Exiles of both Stacey and Mark carried feelings of worthlessness and self-loathing, and believed that they were fundamentally flawed and unlovable. Stacey's little girl craved the tender affection and protection that a father is supposed to provide--and, in fact, that's what she wanted from sex with Mark. She was drawn to him in the first place because of his strength, competence, and apparent self-confidence--his take-charge personality seemed to promise perpetual safety. Stacey's Exiles would only let her enjoy sex that was cozy, warm, adoring, and not terribly erotic; they were frightened by insensitivity, crudeness, or, often, even unashamed lust.

Mark's Exiles, meanwhile, couldn't at first believe that a woman as pretty and vivacious as Stacey would find him--a weak, "effeminate," 13-year-old--attractive. Because of the Exiles' own fears and anxieties about his manhood, he only let another person have access to him through sex--but sex was also the way he reassured himself that he was really a man. As a result, men like Mark become highly attached to and possessive of their current lover while constantly looking around for another. Since Mark and Stacey had Exiles that were extremely needy and full of impossible expectations of the other, and Managers and Firefighters that strongly provoked the other's protectors, their sex life was doomed from the start.

Healing Together

After Mark and Stacey made peace with their inner exiles in private sessions and, consequently, were each less vulnerable and reactive to the other, I brought them together for a joint session. I told Mark and Stacey, "No wonder you feel so hopeless. You never had a chance for real intimacy. As you heal these parts we've found, you'll finally have a chance."

In the joint session, my role is to help them remain Self-led as they speak to each other. When I notice that either of them has been hijacked by a part, I encourage them to focus inside briefly and then come back and speak for their parts rather than from them. When a partner speaks from the Self about its parts, the other partner is less likely to be triggered and more likely to hear the message.

Mark and Stacey nervously shared with each other what they'd learned in individual sessions. It was extraordinarily touching--as it often is when embattled couples begin to thaw out--to see Stacey tell Mark with unfeigned emotion how sad she felt for that young boy who had been so cruelly humiliated. "I can understand now why you feel so driven, and why my rejection hurts you so much," she said, looking him deeply in the eyes. Mark said he'd never known about the old incident with her father, and now it made complete sense that she'd cringe when he pursued her. He knew what it felt like to be hounded. The quality of the conversation between the two of them was soft and hesitant, but direct.

Stacey asked Mark if he was willing to be patient around sex while she continued to work with her own inner parts--several other Managers had surfaced in therapy. Mark said that he'd really try to let her be in control of that arena, which would be easier now that he knew himself and his stud better. Both sighed as they began to understand that this was only the beginning of a long process. This was different from any conversation they'd ever had. They'd felt closer and more real to each other than any other time during their marriage.

Self-To-Self Connection

Once couples get a taste of what real Self-to-Self connection feels like, they're eager to keep going, particularly when they see the barriers to their own freedom fall away. Over the course of a year, working with their parts, sometimes individually, more often in front of each other, Mark and Stacey reported continuing changes in their sexual and nonsexual lives together. Each was becoming a different person with the other; in fact, they were becoming a lot of different people with each other in ways that increasingly energized, touched, and delighted them both.

As the polarization between parts diminishes within a person, so it diminishes between partners. Stacey was no longer afraid of Mark's stud. In fact, she was surprised to discover a formerly hidden "hot babe" part of herself that could sometimes meet or even exceed the energy of Mark's stud. Mark said that whereas all his previous sexual experience had been dominated by his stud's frenzied aggressiveness, now he'd come to also enjoy the softer, slower kind of sex that Stacey preferred. His stud was less agitated and more sensual. It no longer hijacked him and took him away into fantasy worlds, so he was more responsive to Stacey's moods.

What most surprised this couple was discovering how moving and powerful sex was when they allowed their more vulnerable parts to be present--those parts that they'd previously barricaded behind various protectors. No longer terrified, wounded victims, the Exiles began to exhibit their capacity for openness, innocence, sensitivity, and childlike pleasure. "You know," Mark said, "sometimes when Stacey and I are together, I feel like that embarrassed 13-year-old kid I used to be. I even let myself act as if I'm more like I'm 8 or 10, or even younger--all bouncy and eager the way I was then." To his wonder, when he let himself feel young, vulnerable, and a little awkward, rather than cleaving to the old image of a technically perfect sexual operator--Stacey responded with loving warmth and laughter, kissing and stroking him as if he were her beloved child. While feeling highly charged sexually, he also felt, for the first time in his life, utterly cherished and nurtured.

It took longer for Stacey to let herself feel that vulnerable--her distrust was very intense. Eventually, however, she could let the little girl out in a nonsexual context during sessions, becoming playful in a funny, slightly silly, way. Later, the little girl began to spontaneously show up in their bed. As the little girl took part in sex, Stacey said she felt the same kind of total love and acceptance from Mark that he'd reported from her when his boy was present. They both found humor and playfulness moving seamlessly from their nonsexual to sexual lives and back again. They teased each other during the day, which often became a prelude to sex.

One of the enormous advantages of this kind of free-flowing give-and-take of parts between a couple is the variety and richness it brings to their lives. Stacey remarked one day toward the end of therapy that what she loved most about their new sexuality was the unpredictability of it. For the first time in her life, she was no longer trying to control every aspect of their sexual encounters and, instead, could let any part of herself spontaneously emerge in her body during their lovemaking. The appearance of a part in her often elicited a new part in Mark, so sex, which had been a predictable deployment of stereotyped parts, became an improvised and often astonishing dance in which neither one knew in advance who would show up. This meant for Stacey that she'd suddenly find herself moving in ways she'd never moved before and saying words she'd never said, and all the different parts seemed to find great joy in finally expressing themselves as openly and physically as they wanted. She constantly expected to berate herself for acting so brazenly, but the torrent of criticism from her Managers seemed to have dried up. She still occasionally felt embarrassed the morning after, but that didn't last long, since Mark seemed so happy about it all.

Mark and Stacey were also experiencing more and more Self-to-Self intimacy, although they'd have been puzzled by what I meant, if I'd told them this. I don't talk very much about the Self with clients; before they've done much work with their parts, it might sound incomprehensible to them. Afterward, they know and experience Self-to-Self connection without having to name it. Clients still in thrall to their parts, manifesting in extreme and polarized form, or couples who mostly see only angry, resentful, dependent, jealous, self-pitying parts in each other, may not know there's anything like a Self within them. But the simple process of learning to help a part "step back" before they talk to each other allows the couple to experience a few minutes of agenda-free, open-hearted curiosity about the other. Fleeting as they are, such moments inevitably create an almost palpable sense of connection that wasn't there before and can carry them through ensuing "parts wars."

Enough of these moments and a couple begins to know that, whatever stormy melodrama roils the waters of their relationship, it cannot interrupt a deeper, more enduring current flowing between them. When your partners hold Self-to-Self connection, parts can come and go spontaneously within both, without eliciting the old fears, angers and misunderstandings, because each of them senses the calm, abiding presence of an essential "I" in the storm. That connection forms a loving backdrop to a couple's sexual experience that makes it safe and wonderful for any part to come out. It's the safety of the Self-to-Self connection that allows the delicious surrender to the sexual process.

Once a couple has tasted Self-to-Self intimacy, they know that whatever tempests they find themselves in aren't the essential reality of their connection. No matter what the parts are saying during these inevitably rough times, the couple knows that sooner or later they'll again speak to each other in their true voices. And when that happens, each loses a sense of lonely separateness, and, at some level, experiences a state of union and oneness. They sense that both of them are part of the deep ocean, not the isolated waves. Both are home.


Richard Schwartz, Ph.D., is the director of the Center for Self Leadership (website: He is the originator of the Internal Family Systems Model and author or coauthor of five books, including Internal Family Systems Therapy . Address: 217 North Lombard Street, Oak Park, IL 60302; e-mail address: Letters to the Editor about this article may be sent to


Satori in the Bedroom

Tantra and the Dilemma of Western Sexuality

by Katy Butler

Freud once said that four people--two mothers, two fathers--lie in bed with every couple making love. If only that were all. Hugh Hefner is under the covers with us, and Carl Djerassi, who invented the birth control pill, and Alex Comfort, who wrote The Joy of Sex. Shere Hite is there taking notes, and a doctor from the Centers for Disease Control, and Pope John Paul II and Kenneth Starr. Cindy Crawford's perfect body may float in space above us, or Long Dong Silver's, daring us to turn on the light and look at how we don't measure up.

When a man sleeps with a woman, he sleeps with her past as well, including her memories of pregnancy, date rape, abandonment or shame. When a woman sleeps with a man, she sleeps with the young boy caught reading his father's Playboy magazines and the teenager in the back seat, expected to know everything without being shown. Each of us in the industrialized West carries into the bedroom not only personal memories, but collective ones: we are layered with exhortations, like sedimentary rock. Sex, the Victorians told our great-grandmothers, is dirty: Save it for the one you love. The mature female orgasm, said Freud, is the vaginal orgasm: That comes only to women who resolve their penis envy. Women's sexuality, said the marriage manuals of the 1950s, is problematic, like the delicate wiring of an old MG: Husbands must be master mechanics. Vaginal orgasm is a myth, said the feminist theorists of the 1980s. Find the clitoris. Now.

Sleeping around will ruin your reputation, we were told in the fifties: Why buy the cow when you can get the milk through the fence? Sleeping around will free you, we were told in the sixties: Smash monogamy. Men and women are pretty much alike, we were told in the seventies. Men are from Mars, women are from Venus, we are told today.

Many of us enter the bedroom now as if we have been told we are about to play a high-stakes game. There is no rule book, or else it's been hidden. Everyone else, we think, knows how to play. We charge down the field. We pass the ball. A whistle blows. The rules have changed. The teams are being shuffled. We'll be playing with a shuttlecock now instead of a ball, and the goalposts have been moved to the other end of the field. We start running and the crowd roars, but we're not sure what we did right. Now we are on the bottom of a pile of bodies. We are given five different rule books and told to choose one that suits us. (We have no idea what book the other team is playing from.) Bleeding from the shin, we strap on our battered equipment again and once more run down the field.

We lie down with all of this, and more, when we lie down in bed with each other. We sleep with the war between men and women fueled by patriarchy and differences in physiology, and with the uneasy cease-fire in the erogenous zone that followed the feminist and sexual revolutions. We sleep with the legacy of the 1970s, when you could find, on many a middle-class nightstand, the dry, clinical bestsellers of William Masters and Virginia Johnson, the pioneers of behavioral sex therapy. The bright lights of their science were supposed to banish our fears and superstitions, like crucifixes held before a vampire. Yet the fear of pleasure, and of being discovered having pleasure, still runs beneath our bedroom floors like an underground river.

For most of us, our first sexual act was also an act of secret rebellion against our parents. The memory of this defiant split lives on in our cells in the disembodied, suppressed yet obsessed way our culture approaches sex today. Few of our fathers talked to their sons about how to enhance a woman's pleasure or prolong their own; few of our mothers ever told their daughters about the delights or even the location of the clitoris. We found out anyway, and paid the price.

In the dark recesses of our mental closets lies a negative cultural dowry--the muumuus that missionaries gave the naked Polynesians; the penitentes' cat-o'-nine-tails; the chastity belt; and the confessional--all the trappings of the Augustinian Catholic tradition that declared sex a dirty distraction on the path to God and the source of original sin. ("As the caterpiller chooses the fairest leaves to lay her eggs on," wrote the poet William Blake two centuries ago, "so the priest lays his curse on the fairest joys.") All of this we bring into the bedroom.

When we sleep with each other, we sleep with images we've absorbed and, without knowing it, those our lovers have absorbed as well. Like fast food, images of other people's orgasms, stripped of context and connection, are now available 24 hours a day and consumed alone and on the cheap. They demand of us a bravado we rarely feel. They lurk eternally on the Internet and in the phone-sex banks, at the corner video store and in the Congressional Record . Our bedrooms are colonized by them. When a woman lies down in bed with a man, a light show of images plays over her body without her knowing it: red-satin garter belts, perhaps, or beaver shots or Marilyn Chambers or Monica Lewinsky or the Penthouse Pet of the Month. When a man lies down with a woman, images of imaginary men play over his face without his knowing it--the hero of Tristan and Iseult, perhaps, or a Tammy Wynette song or a romance novel. No wonder we feel split within ourselves and from each other. We expect sexualized romantic love to carry a greater psychological burden than does any other culture on earth while we simultaneously denigrate the sexual. And so we reverberate between sexual obsession and sexual shame.

Last September, we found on our doorsteps newspapers full of the details of the president's intimacies with Monica Lewinsky--the thong underwear, the cigar, the joke sunglasses, the rejected girl crying in the rain. It didn't matter what the details were or the context in which they occurred. All that mattered was the telling of them. Opening the paper, some of us imagined how our own intimacies would read some morning, printed in black and white and dumped on our neighbors' doorsteps.

What we read in the papers that day reflected the impoverished language we bring to sex. In 1931, the English novelist Virginia Woolf wrote in The Waves, "I need a little language such as lovers speak, words of one syllable." But we can speak of lovemaking everywhere except the bedroom. For the delicate skin that touches our lover's most tender places, we have no words except the pornographic, the childlike and the scientific. We speak of vaginas, labiae, clitorises, cunts, hair pies and "down there." We call it a prick, a dick, a sledgehammer, a penis, a pee pee or Mr. Happy. Our worst insults are sexual: cunt, slut, whore, dickhead, pussy-whipped, cocksucker.

And so we lie in bed with each other, reaching for pleasure, tenderness and connection, with both too much and too little to guide us: Hustler on the newsstand, Dr. Ruth or Dr. Laura on the radio and Debbie Does Dallas on the VCR. "You do not have to be good," wrote the poet Mary Oliver. "You do not have to walk on your knees for a hundred miles through the desert, repenting. You only have to let the soft animal of your body love what it loves." But that's a big only. No wonder we are sure that someone, somewhere, is having better sex than we are. No wonder someone, somewhere is pretending to have better sex than we are. No wonder we fear we will never get it right.

Yet sometimes we do get it right--or it gets us right. Many of us have experienced something in bed that the languages of pornography, sex therapy, feminism and the double standard could not contain. It might have been the afternoon we washed our partner from head to toe in the shower, kneeling under the spray to scrub even the soles of her feet, until washing became a ritual of tenderness and awareness. It might have been a dawn when we woke from a dream experiencing what the radical psychoanalyst Wilhelm Reich called a "full-body orgasm," in which we were the wave and also a body drifting at the water's edge, pulsating to our fingertips as the wave broke on the shore. It might have been a night a man looked into our eyes and stroked our nipples for hours until we gave in to our own responses rather than following what we imagined to be his timetable. Or a night a woman looked into our eyes while we were coming and we felt safe, seen and known.

In these moments, lovemaking is sensed as healing, wholesome and holy. Our focus broadens out beyond orgasm. Our small selves are no longer in command, and we give ourselves over, little boats on a deep river. The fear of not performing well disappears, the ghosts are banished from the bedroom and the present moment absorbs us. The West's self-created divisions--between sacred and profane, heart and pelvis, male and female, victim and predator, body and soul--are temporarily healed. We understand what Walt Whitman meant when he wrote, "If anything is sacred, the human body is sacred," and what the 16th-century Anglican marriage ceremony meant when it included among its vows, "With my body, I thee worship." Our bedroom is no longer hostage to the porn palace, the sex lab or the unfinished war between men and women. For a moment, the bedroom becomes a ritual space where we enter trance and forget time.

For most of us, such moments are rare and random, despite the mixed sexual blessings of the past three decades. The sexual revolution rightly told us that sex could be a domain of pleasure and self-expression. But its prescription--quantity over quality--did not free us. The feminist revolution challenged the practice of sex as a ritual of loving female submission and encouraged women to speak of their sexual desires and sexual violations. It lit up ancient chasms between the genders, but did not bridge them.

Modern sex therapy helped thousands with simple, effective behavioral techniques, usually focused narrowly on achieving erection, intercourse or orgasm. Yet few of us have much of a clue about continuing to create the more profound joys of sexuality--especially after the first six months to two years of a relationship, when hormones subside and desire fades. We may move from arousal to contentment or indifference or contempt. We may not know how to contend with softer, slower erections and other changes related to aging. A surprising number of stable couples stop making love much, or altogether. The ghosts return to the bedroom. We may lie down in resignation in the bed we've made together, or walk once more out the door.

Or not. Some of us will embark instead on a quest for a fuller experience of intimate sexuality. We will use whatever tools we can, depending on who we are and the decade in which we set out. We may enter Reichian therapy, wrap ourselves in Saran wrap, read Nancy Friday, follow The Rules, or repeat phrases from Men Are From Mars, Women Are From Venus, but we will not give up. We want to banish the bedroom's ghosts or at least replace them with more benign presences. Risking the humiliation our culture visits on those who speak of their own sex lives rather than other people's, we will try to decolonize the bedroom. We sense that this quest requires not "more of the same"--not more sexual perfectionism or ever-more-exotic partners or positions--but a broader context, a change at the metalevel. If we embark on this quest today, we may buy a book, watch a video or go to a weekend workshop on Tantrism, which is now the West's most popular form of adult sex education.

Presaged by the popularity in the 1960s of the Kama Sutra of Vatsyayana, a 3rd-century Indian sex manual, Tantra has become a postmodern hybrid. On the most prosaic level, it is nothing more than a pastiche of positive sexual attitudes and techniques drawn from Western humanistic psychology, Chinese Taoist sexology and classical Indian Tantrism--a wild sexual and religious tradition that influenced both Buddhism and Hinduism and flourished in India about 500 A.D.

This esoteric system used breath, visualization and other yogas to arouse, channel and transform energy throughout the body. Its meditations often took the form of visualizing gods and goddesses in sexual union. In India, adherents of the tiny sect of "left-handed" Tantra took things a step further: in secret rituals, they broke all the rules of their caste-bound society, consuming taboo foods, such as alcohol and meat, sounding yogic bijas or sacred syllables and coupling with one partner after another. In contrast to monastic traditions that suppressed sexuality and avoided women, Tantrikas welcomed the energies of aggression and sexuality and transformed them. Men did not ejaculate, and the goal was to move arousal up the spine to the brain in an explosion of enlightenment and bliss. Sex was not a dirty detour from the path to God, it was the path

Today, Tantra's esoteric practices are being pressed into the service of goals that are tamer, more domestic and less religious: uniting sexuality and intimacy, and enhancing sexual pleasure for long-term couples. It's not the techniques that count so much as Tantra's enlargement of the context in which sex is held--as pleasurable, inclusive, healing, and holy. This widening of the lens was apparent as soon as modern Tantrism first registered on the American cultural radar in 1989, when a 450-page book called The Art of Sexual Ecstasy: The Path of Sacred Sexuality for Western Lovers tried to sweep the clutter of negative sexual images out of the Western bedroom. Written by Margo Anand, a writer and sex workshop leader who had studied psychology at the Sorbonne and meditation in India, it was like no sex manual the West had ever seen. She spent eight pages alone describing how to prepare a bedroom for lovemaking. Think of the bedroom as a "sacred space," Anand wrote. Vacuum the bedroom and take out the newspapers and coffee cups. Bring in plants, flowers and candles. Drape a scarf over the bedside lamp to create soft lighting. Walk three times around the room with your partner, misting the air with a plant sprayer of scented water while saying "As I purify this space, I purify my heart." This, Anand implied, was as much a part of sex as kissing.

The suggestions might seem impossibly precious. But ceremonially cleaning the bedroom and bringing in flowers and soft lights contained a metamessage: You do not have to go somewhere else or become a sliver of yourself to have sex. You don't have to "do the nasty" while hiding in the dark from your disapproving parents. When you bring flowers into the bedroom, you bring in more of yourself as well, and that can make you realize how much you had previously left outside the bedroom door. And if the bedroom is already inhabited by ghosts, why not bring in flowers as well?

In the place of pornographic slang and Latin words, Anand suggested Taoist phrases that were free of negative Western sexual connotations. Try saying "jade stalk"or "wand of light" for penis, she suggested; for vagina, substitute "cinnabar cave" or "valley of bliss." Or call them "yonis" and "lingams," after the Sanskrit words used to describe the stone sculptures of sexual organs that are still bedecked with flowers and worshiped in rural temples in India. "Behold the Shiva Lingam, beautiful as molten gold, firm as the Himalaya Mountain," she quoted the "Linga Purana," a Hindu ode to the penis of the god Shiva, Lord of the Dance. "Tender as a folded leaf, life-giving like the solar orb; behold the charm of his sparkling jewels!" It was heady stuff for a culture where "testosterone poisoning" is a running joke and the only goddess worshiped is a virgin mother. And it cleared the decks for something new.

Anand and other teachers of modern Tantra suggested that sex could involve all of us, including the warring inner parts we think we've transcended but have merely avoided: the lustful and soulful; the wounded and voracious; the slutpuppy in her Victoria's Secret lingerie and the good girl in her flannel nightie; the sensitive postfeminist man and the crude teenage boy.

Last October, at a five-day, $795-a-person workshop for couples at the Esalen Institute, yoga and Tantra teacher Charles Muir wove these warring inner and outer sexual worlds together. On the first night, he spoke about his own sexual upbringing to 23 couples sitting before him in a circle. His listeners ranged in age from 22 to 73. Among them were two Latin American academics, four lawyers, a black woman doctor, two construction managers, two women who worked in television, several massage therapists from the Esalen staff and an Irish farmer. Some sat as entwined with their partners as trailing vines, while others betrayed, in their gestures and body language, uneasiness with each other and an inequality of love or desire.

Muir, who is now separated from his wife and coteacher, Caroline (she wanted sexual fidelity; he didn't), runs the Source School of Tantra in Maui, Hawaii, and leads frequent workshops around the country. He was wearing a silk shirt and an amethyst pendant. He was slim, in his early fifties, with brown hair, protuberant eyes and spatulate fingers that gave him the look of an elongated frog. His language was closer to New York street than Hindu temple.

He had come of age in the Bronx, he said, during "The Great Fuck Drought of the Fifties." Everything he knew about sex, he said, he had learned from Johnny Patanella, the leader of his childhood street gang: Get it up, get it in, and get it off. Fuck 'em hard and fuck 'em deep. Muir said that before he discovered Tantra, he was a yogi on the mat and a "sleazebucket" in bed. He said that men give nicknames to their penises because they want to be on a first-name basis with the one who makes all their important decisions.

There were shocked laughs, a snigger. The men thought they were long past this. The women didn't want to think their men had ever thought this way.

But there was a method to his crudeness. Once Muir bonded with the part of the men that had eternally remained the teenage boy, he gently, without emasculating them, brought them into the sexual realm of context, emotion, feeling and intimacy traditionally defined as female. "In lovemaking, women lead with their hearts," he went on more softly. "Men lead with their second chakra [their groins]. We hurt each other."

Tantra, Muir said, could help them make love stay. "The average couple makes love 2.3 times a week for the first two years," he said. "After two years, the average couple makes love once a week--and making love can be a well of energy and healing.

"Chemistry is temporary. You're going to learn to base love not on chemistry--which lasts six months or two years, if you're lucky--but on alchemy. When the chemistry is no longer there, alchemy says you take what is there and you change it. Become a master alchemist."

Easier said than done, given some of the histories that the couples revealed in private conversations. One couple came to Esalen to put the "pizzazz" back in their marriage; later they acknowledged they'd hardly made love in the nine years since the birth of their son.

Paula, a Mexican American academic in her fifties who was there with Carlos, the professor with whom she lived, had not had an orgasm in the year since her hysterectomy. She had been raised a Catholic and was date raped in college. She still couldn't shake off a notion her mother had given her--that only bad girls are good at giving men sexual pleasure; at night, she still put on her pajamas behind the bathroom door. Carlos was in his forties; he had been divorced twice and had been raped and tortured a decade earlier in a South American prison.

Russ Solomon, a retired San Diego real estate developer, had raised four children with his wife, Liz, during 40 years of marriage. They looked as comfortable together as old shoes and clearly liked and respected each other. But sex, they said, had been disappointing on their wedding night when they'd both been virgins and disappointing ever since. "All I knew," Russ told me one day, "was that I was to get my penis in her vagina, and that was it." He had lain back, expecting Liz to arouse and satisfy him.

She said nothing that night, and nothing for many nights to come. She had no language then, no woman had language then for what she felt or wanted. "When you were born in 1937," she says, "it wasn't your place to show him."

Since then, they had rarely taken more than 15 minutes to make love. She spoke frequently, in front of Russ, of "40 years of shit and disappointment in the bedroom." Russ didn't treat her like a woman, didn't measure up. "I would love a flower on the pillow or a note," she said one day. "But Russ cuts articles out of the newspaper that he thinks I would be interested in. And I am. But it's not the intimacy I long for."

Couples like these could have taken their "sexual dysfunctions" and marital issues into the private confines of a sex therapist's office. But they were seeking something that Western sex therapy, for all its strengths, does not provide. Sex therapy's pioneers, Masters and Johnson, had brought thermometers, charts and transparent vaginal probes mounted with tiny video cameras to the study of sex. Sexual problems, they argued, weren't usually rooted in intractable intrapsychic or interpersonal conflict; they could often be solved by learning new behaviors. They, and those who followed them, taught women to masturbate to orgasm and men to squeeze their penises just below the coronal ridge, before they reached the "point of no return," to resolve premature ejaculation. Their techniques often worked with amazing ease, and they drained sex of some of its shaming power by making things seem as brisk, practical and scientific as a good recipe for apple pie.

But they also drained sex of magic. If their governing metaphor was the bedroom-as-medical-lab and sexual practice as an antiseptic medical-behavioral prescription, Muir's guiding metaphor at Esalen was the bedroom as temple and sexual practice as worship. And if sex therapy was predicated on healing people so that they could have sex with each other, Muir suggested that sexual pleasure itself could be healing.

In the course of the week, Muir gasped, held his breath, bugged out his eyes to demonstrate how men could use yogic breathing, pauses in lovemaking and finger pressure on their perineums to delay or forgo ejaculation. He and his coteacher, yoga practitioner Diane Greenberg, showed women how to take a man's "soft-on" and "use it like a paintbrush" to stimulate their clitorises and outer lips, or stuff it softly into the vagina. And he extolled the sensual pleasures of the half-erect penis. Referring to the Kama Sutra , he talked of varying strokes, pressure and speed. "If we go straight down the fairway--deep deep deep--we'll only be stimulating one area, guys," he said one afternoon, stroking a Plexiglas wand inside an anatomically correct, purple-velvet and pink-silk "yoni puppet" from San Francisco's House of Chicks. "Try shallow, shallow, shallow, deep! The more variety, the more information floods the brain, and the more you wake up."

A sex therapist, or in a more enlightened society, a sex educator, could have said the identical words, but the context--playful, normalized and semi-public--would not have been the same. A miniature culture, as transient and self-contained as a dewdrop, was being formed. For a handful of days, as the couples strolled the Esalen grounds above the Pacific, moving from cabin to hot tub to class, nobody was too busy or too tired to have sex. Nobody read anything about Kenneth Starr, or looked at the Sports Illustrated swimsuit issue or downloaded pornography from the Internet. Every night, in their TV-free, phone-free cabins, they looked at and touched each other's flesh-and-blood bodies rather than electronic images and paper dreams.

In class, Muir held out to them the possibility that sex could be more than a source of pleasure: it could be a source of intimate bonding as well. He taught them how to lie together spoon-fashion and breathe in unison. Sex, he said, could be more even than emotional intimacy: it could be an interplay of invisible energies that coursed through each lover's body and radiated beyond it. Every day, he led participants in yogic breathing and stretching, and then asked them whether they could feel an "energy hand" the size of an oven mitt growing beyond their flesh-and-blood hands. He had them fluff and clean their "auras" by sweeping their hands in circles a few inches from the body.

He acted not only as sex educator and yoga teacher, but priest. He taught them to chant one-syllable Sanskrit mantras designed to activate each of the body's seven chakras or energy centers that are believed to ascend the body's core. And he formed them into slow Tantric circle dances in which the men and women stared into the eyes of partner after partner while visualizing sending love and healing to virtual strangers.

If the West has defined male sexuality as the norm and female sexuality as the problem, Tantra glorifies the female: a woman's orgasms are said to increase her capacity to act as a channel for the flow of shakti, the universal female energy that powers the universe. And by deemphasizing the moment of ejaculation and emphasizing energy and context, the workshop provided the women with more of what they often complain is missing from standard-issue sex--love, sensuous touching and intimacy.

Under Muir's tutelage, lovemaking was not, as some feminists put it, a recapitulation of the power inequalities of rape, but a worship of the female and a reenactment of the drama of Shiva and Shakti, the Hindu god and goddess whose lovemaking created the universe. Partners were to see in themselves the flow of divine fundamental energies; the act of love as reproducing the first stages of the creation of the world.

Women, Muir declared, could and should have multiple orgasms, while men were depleted by ejaculation and should sometimes try the "valley orgasm"--orgasm without ejaculation. And he transcended the no-win squabble Freud started over the virtues of clitoral versus vaginal orgasms by teaching effective techniques for vaginal stimulation of the G-spot; he declared that women, too, could ejaculate when sufficiently stimulated.

This is a tall order for a culture in which 24 percent of women surveyed say that they, like Paula, have not had an orgasm during the previous year. A complex history lies behind this statistic. If the sexual lives of many men begin with repeated sexual rejection and shame, the sexual lives of many women begin in choicelessness: breasts stroked in a laundry room by a best friend's father; the struggle lost in a back seat; the unwanted kiss from uncle, teacher, boss or neighbor. When women sleep with men they sleep as well with their fear or memory of the peeper, the flasher, the child molester, the rapist, the Don Juan, the womanizer, the sexual predator, the horrible first husband and the just plain jerk. Women, too, have a double standard: we divide men not into virgins and whores, but into predators and marriage material. In a reverse of the fairy tale, we fear that while we lie in bed, our lovers will metamorphose from Beauty to the Beast.

Such memories and fears, Muir suggested, are embedded not only in the brain, but in the cells of the body. His cure was a sexual ceremony to be held in the privacy of each couple's bedroom on the third night of the workshop. In a men-only meeting beforehand, he showed videotapes and coached each man on how to do for his lover what no therapist or body worker could do--massage her "Sacred Spot," the G-spot inside her vagina.

The G-spot, Muir said, is a little known and widely misunderstood area of sexual sensitivity--a raised, furrowed area of tissue about the size of a quarter, an inch and a half inside the front wall of the vagina, against the pubic bone. When stroked, it can become erect, firm and responsive and can trigger vaginal orgasms and ejaculation of a clear liquid. But it is also the dark closet in which old sexual pain is stored. "Sacred Spot" massage, he said, might release ecstatic sexual pleasure. It might also release old memories: the women might complain of numbness or bruising, or explode in fear, sobbing or rage. "This is Tantra kindergarten," he said, coaching the men to simply be loving and to be there, no matter what. "You get an A just for showing up."

After supper, before the ceremony began, the men fanned out to their cabins all over Esalen to take on the traditionally female task of "preparing the space" for the ceremony. While Liz and the other women relaxed and giggled in the Esalen hot tubs, Russ cleaned their cabin, combed his white hair and took a shower. In another cabin, one of the construction managers lit incense and paced his room. On the other side of the garden, one of the lawyers scattered rose petals on the sheets. Carlos, the Latin American academic, arranged a vase full of flowers he had cut from the Esalen garden, cued up a CD on his laptop, lit candles, put on a formal Mexican shirt called a guayabera , turned back the sheets and waited for Paula.

When the couples shared their experiences in the group the next day, it was almost as though the sexes had exchanged roles. "Carlos massaged me so gently so tenderly," Paula said. "The other times he had massaged me it was like, let's hurry up and get this over with." After an hour or so, she said, Carlos had turned her over and asked permission to stroke her "sacred spot" with his finger. Not long afterward, she had her first orgasm in a year. "I just had a whole strand of pearls full of climaxes," she said. "It kept going on and on, the pleasure."

One woman--whose husband had left her for another woman 14 months earlier--was floored by the tide of anger and fear the exercise released. It was, she said, "like a bad acid trip." Other women came close to bragging about having multiple orgasms and ejaculations (one woman had 22 over an hour and a half), while their men were quiet, tearful and open. The men had taken on the traditionally feminine role of focusing wholeheartedly on the pleasure of another, and it had changed them. The construction manager cried, describing how he'd waited nervously for his girlfriend, terrified that he wouldn't measure up. Another man told the group that whenever he'd made love before, his consciousness had zigzagged back and forth, first checking in on his own erection and then checking in on his partner. "Last night, my presence was so totally focused on Andrea that I didn't have to worry about myself at all," he said. "When she came, I was wailing with her like I was having the biggest orgasm of my life, and I was totally limp."

Here, in a context where differences between men and women were not only acknowledged but glorified and mythologized, and where men's performance fears were out in the open, women were getting what they wanted.

The next evening came the turnabout. After supper, Muir took off his amethyst crystal pendant, blue silk shirt and oatmeal jeans. He lay on pillows on the floor in his boxer shorts, holding a clear black plastic wand from a magic store at his groin like a surrogate penis. One man pushed his girlfriend to the front of the crowd. "I don't want you to miss any of this," he said.

Diane Greenberg knelt between Muir's legs and showed the women an unbelievable range of ways to pleasure a man's penis. She was competent and sure. She twirled her fingers around the wand like a feathery screw. She squeezed it at both at the top and the bottom, explaining that this way the blood wouldn't be forced out. She slapped it and tapped it and pretended to use it like a microphone. She clasped her fingers and encircled the wand, running her thumbs in circles up and down the frenulum as though winding a bobbin.

She was leading the women into the dangerous territory of the slut goddess. If some women's sexual lives begin in choicelessness, others begin with an inner war: lying on a blanket on a hill on a warm night, grabbing at the hands that give such pleasure and pulling them away, worrying what the owner of these hands will call her to his friends the next day-- slut, pig, whore. There are years of this, and then the rings are exchanged, the rice is thrown, the church doors open and the woman is expected to become as sexy and free as the bad girl she struggled for years not to be. Fear of taking on the slut archetype can persist through years of financial independence and supposed liberation, narrowing the range of pleasure a woman dares to give a man in the bedroom. By way of antidote, Muir and Greenberg spoke of Uma, a Hindu female divinity who "wears her sexuality on the outside." They lauded Hindu temple dancers and sacred prostitutes, and urged the women to try on this aspect of the powerful divine feminine. They encouraged the couples to let loose with noise--Esalen had heard lots of it, they said, and if couples got too self-conscious, they could shout or wail into a pillow.

Then Greenberg coached the women on the coming evening's ceremony. This time, the women would "honor" the men, first massaging their bodies and their penises. ("First get him hard, ladies," Muir interjected. "Then he'll agree to anything.") Next, Greenberg said, the women were to insert one finger into their man's anus and stroke and stimulate the exquisitely sensitive "sweet little hollow" at the base of the prostate. This, she cautioned, was a delicate business. "Rather than me entering him, I'll have him sit on my finger," she explained.

Then Greenberg turned to the men. "You're going to be penetrated, guys" she said, "as we are penetrated."

As Greenberg pulled the women into new territory, Muir took the men into the unknown as well. "Every man has gone through a war of his own that has robbed him of his yin [female aspect]," he said. "Each young boy is taught that men don't cry, don't feel. The job of reclaiming your yin is sweet. You won't wake up the same guy in the morning. Tonight, you get to be the illogical one. You get to have feelings tonight. Ladies, I want you to show up big. He may test you, he may be irrational. He may become terrified.

"You give and you're strong and you fix things." he said, turning to the men. "You're gigantic. How much can you let yourself be small and feel? Allow yourself to be penetrable and vulnerable? Five million homosexuals can't be wrong. There must be something up there that's good."

When Carlos and Paula described their night's experience in the group the next morning, Carlos was in tears--deep, strong tears. During the ceremony, he had reexperienced being raped and tortured in a South American prison and had not "left his body," as he had when having flashbacks before. He had also experienced something beyond the personal as though a great wind were blowing through him and breathing his body for him. And Paula had faced something she'd once held at arms' length. "Being raised Mexican Catholic, women who do that are sluts," she said, referring to the way she'd stroked Carlos' penis and penetrated his anus. "I gave myself permission not just to touch it with my eyes closed, but to look at it and be there in all my glory, and I felt pure."

On the last day of the workshop, Muir urged the couples to try a "10-day test drive"--to connect somehow sexually, physically and emotionally for at least 10 minutes every day. By the time the couples were packing their bags, few of the men displayed the sexual bravado they'd come in with--the bravado this culture trains them for. One man, a lawyer, had told the group the first night that he'd come to the workshop because he wanted to experience a 30-minute orgasm. He left muttering about "Tantra kindergarten."

His desires had become simpler and more ambitious: to only connect with his wife of 22 years. One busy day he left work, met his wife at their son's soccer game and drove with her to the far end of the field, where they kissed and held each other for 10 minutes in the car.

Some couples--like the pair who told me brightly that they wanted to put the "pizzazz" back in their marriage--left with little. Others took away all the bells and whistles you'd expect from a sex workshop: sobbing, wailing, energy releases, multiple orgasms, female ejaculations. Others left with something perhaps more precious: the understanding that good sex--wholesome, healing and holy--is an accumulation of small mercies, beginning with whatever mercy you need right now. Like being able to take off all your clothes in front of your lover, and touch his penis in all your glory and feel pure.

They went home--to San Diego and Cleveland and Denver, to the impeachment hearings and football games and a larger culture reverberating, more publicly than usual, between sexual obsession and sexual shame. Ghosts inevitably reentered their bedrooms. Old marital squabbles reared their ugly heads again. But sometimes old disappointments were held in a new way.

If anyone had come to understand the meaning of small mercies, it was Liz and Russ. On the night that Russ had pleasured her, Liz had come to their cabin door and found him still in the shower. Something about that melted her heart. "I brought to last night 40 years of lack of trust and feeling I'm not seen as a woman," she had said in the group next day. "I've stayed in the relationship oftentimes with doubt."

"I was so touched Russ was washing his body for me, that he would even be late to do this," she said. "All the resentment and fear was gone. I felt like a woman. It was enough."

"He put on a Japanese robe," she told the group, turning to her husband. "You looked very manly in it. I wore a white silk Dior nightgown and felt like a bride. When we slipped it off, I loved the look of my body. If we had only done this on our honeymoon, what a difference it would have made."

"She could have said, 'This is your obligation,'" said Russ. "But she dismissed all that. We didn't shout and cover our faces with pillows, but it's nice to know that it's possible. We take away the hopes and stories we've been told. I pray that we will remember."

"It was enough." said Liz. "Russ was willing, after 40 years of marriage, to try something. That was enough."

When they returned home, they followed Muir's suggestions for the "10-day test drive." Every day, she and Russ lay down with each other in the morning and the evening, and snuggled and held each other. "It's been wonderful," Liz told me. "There's been no anxiety, no repulsion. It's not about making love. It's about breathing together, holding hands, the eye contact, touching the heart, the forehead. We are doing our homework. But I'm not sure we're doing it right."

In her last sentence, I heard the reverberations of our culture's sexual perfectionism. She and Russ had returned to a society with bigger work to do than any person or couple can do alone. Yet they had grasped the essence of classical Tantra as practiced in India nearly two thousand years ago, and that essence is not purely sexual. At its base, it involves welcoming and transforming all energetic and powerful states, even negative and difficult ones, by holding them in a different context.

That context involves knowing that Saint Augustine and all his intellectual and spiritual heirs, including our parents and Larry Flynt and Kenneth Starr, were wrong: Sex is neither a nasty secret pleasure nor a sin, but a part of the pattern of the universe. To put it one way, the desire to make love, connect, procreate and survive has been programmed, along with pleasure, into our genes and dreams. To put it another: Sex is sacred--intricate and dangerous and pleasurable and utterly ungraspable.

Networker associate editor Katy Butler, a former reporter for The San Francisco Chronicle, has contributed to The Los Angeles Times, The New Yorker, The New York Times Book Review and The Washington Post. For more information on Charles Muir, write to P.O. Box 69, Paia, HI 96779. Correspondence to Katy Butler may be sent to the Networker .


Passionate Marriage

Helping Couples Decode the Language of Their Sexuality

by David Schnarch

Betty, a designer in a high-powered advertising firm, and Donald, a college professor bucking for tenure, had been married for 15 years. They spent the first 10 minutes in my office invoking the standard litany of our times as an explanation for their lousy sex life they were both just too busy. Not that this focus precluded blaming each other for their difficulties.

"Betty gets home from work so late that we barely see each other anymore, let alone have sex," said Donald resentfully. "We're collaborators in child raising and mortgage paying, but we're hardly lovers anymore. I've taken over a lot of the household chores, but she often doesn't get home until 9 p.m. and most nights, she says she's just 'too tired' for sex."

Betty sighed in exasperation. "Sometimes I think Donald wants me to leap from the front door to the bedroom and take care of him," she said. "But I'm being swallowed up by a sea of obligations my boss, the kids, the house, the dog, Donald, everybody wants a big chunk of me. Right now, I feel there's nothing left of me for me, let alone for him. He just doesn't get it that I need more time for myself before I'm interested in sex."

I asked them to be specific about how the stress from their very demanding lives revealed itself in bed exactly what happened, and in what order, when they had sex. Several moments of awkward silence and a number of false starts ensued before another, much more intimate, level of their marital landscape revealed itself.

Betty looked hard at Donald, then at me. "The fact of the matter is, he doesn't even know how to kiss me!" she said grimly.

"How would you know? It's been so long since you let me kiss you!" hissed Donald.

When I asked them to describe their foreplay, Betty looked embarrassed and Donald sounded frustrated. "During sex, she turns her face to the side and I end up kissing her cheek. She won't kiss me on the mouth. I think she just wants to get sex over with as fast as possible. Not that we have much sex." Betty shook her head in distaste. "He always just rams his tongue halfway down my throat I feel like I can't breathe. Besides, why would I want to kiss him when I can't even talk to him! We don't communicate at all."

Over the years, I've worked with many couples who complain bitterly that the other kisses or touches, fondles, caresses, strokes the "wrong" way. I used to take these complaints at face value, trying to help the couple solve their problems through various forms of marital bargaining and forbearance listen empathically, give a little to get a little, do something for me and I'll do something for you teach them the finer points of sexual technique and send them home with detailed prescriptions (which they usually didn't follow) until I realized that their sexual dissatisfactions did not stem from ignorance, ineptitude or a "failure to communicate." On the contrary, "communicating" is exactly what Donald and Betty were already doing very well, only neither much liked the "message" the other was sending. The way this couple kissed each other, indeed their "vocabulary" of foreplay, constituted a very rich and purposeful dialogue, replete with symbolic meanings. Through this finely nuanced, but unmistakable language, both partners expressed their feelings about themselves and each other and negotiated what the entire sexual encounter would be like the degree and quality of eroticism, connection and intimacy, or their virtual absence.

Donald and Betty had tried marital therapy before, but their therapist had taken the usual approach of dealing with each complaint individually job demands, parenting responsibilities, housework division and sexual difficulties as if they were all separate but equal situational problems. Typically, the clinician had tried to help Donald and Betty resolve their difficulties through a skill-building course on compromise, setting priorities, time management and "mirroring" each other for mutual validation, acceptance and, of course, better communication. The net result of all this work was that they felt even worse than before, even more incompetent, inadequate and neurotic, when sex didn't improve.

Knowing that Betty and Donald were most certainly communicating something via their gridlocked sexual styles, I asked them, "Even if you are not talking, what do you think you might actually be 'saying' to each other when you kiss?" After a minute, Donald said resentfully, "She's telling me I'm inadequate, that I'm not a good lover, I can't make her happy and she doesn't want me anyway." Betty defensively countered, "He's saying he wants me to do everything exactly his way and if I don't just cave in, he'll go ahead and do what he likes, whether /like it or not!" I asked her why she was willing to have intercourse at all if she didn't even want to kiss him. "Because he is such a sullen pain in the ass if I don't have sex," Betty replied without hesitation. "Besides, I like having orgasms."

Donald and Betty perfectly illustrated the almost universal, but widely unrecognized, reality that sex does not merely constitute a "part" of a relationship, but literally and metaphorically embodies the depth and quality of the couple's entire emotional connection. We think of fore-play as a way couples establish connection, but more often it's a means of establishing (^connection. Betty was a living rebuttal of the common gender stereotype that all women always want more foreplay; she cut it short so they could get sex done with as quickly as possible and Donald understood. Donald returned the compliment by "telling" Betty he knew she didn't like him much, but he was going to get something out of her anyway with or without her presence, so to speak.

Clearly, foreplay for this couple was not simply a mechanical technique for arousal, amenable to the engineering, skill-building approach still dictated by popular sex manuals. Nor were they likely to improve sex just by being more "open" with each other, "asking for what they wanted" another popular remedy in self-help guides and among marital therapists as if they weren't already "telling" each other what each did and did not want, and what each was or was not willing to give. Instead of trying to spackle over these normal and typical "dysfunctional" sexual patterns with a heavy coat of how-to lessons, I have learned that it makes much more sense to help the couple analyze their behavior, to look for the meaning of what they were already doing before they focused on changing the mechanics.

Rather than "work on their relationship" as if it were some sort of hobby or home-building project, Betty and Donald, like every other couple I have seen, needed to understand that what they did in bed was a remarkably salient and authentic expression of themselves and their feeling for each other. The nuances of their kissing style may have seemed trivial compared to the screaming fights they had about money or the long days of injured silence, but in fact it was an open window into their deepest human experience who they were as people, what they really felt about each other, how much intimacy they were willing to risk with each other and how much growing up they still had to do.

As in any elaborate and nuanced language, the small details of sex carry a wealth of meaning, so while Donald and Betty were surprised that I focused on a "little thing" like kissing, rather than the main event frequency of intercourse, for example they were startled to find how truly revealing it was, about their personal histories as well as their marriage. I told Betty I thought she had probably come from an intrusive and dominating family that never dealt openly or successfully with anxiety and conflict. "So now, you have a hard time using your mouth to tell Donald not to be so overbearing, rather than turning it away to keep him from getting inside it. You've become very good at taking evasive action to avoid being overwhelmed," I said. "You're right about my family," Betty said softly, "we kids didn't have any privacy or freedom in my family, and we were never allowed to complain openly about anything just do what we were told, and keep our mouths shut."

On the other hand, I said, I imagined Donald had never felt worthwhile in his family's eyes. He had spent a lot of time trying to please his parents without knowing what he was supposed to do, but he got so little response that he never learned how to read other people's cues he just forged blindly ahead, trying to force his way into people's good graces and prove himself without waiting to see how he was coming across. "Come back here and give me a chance to prove myself!" his behavior screamed. "Are you so used to being out of contact with the people you love that you can successfully ignore how out of sync you are with them?" I asked. To Donald's credit, he didn't dodge the question, though he seemed dazed by the speed with which we'd zoomed in on such a core issue.

Nevertheless, Donald and Betty discovered that their discomfort in describing, in exact detail, what was done by whom, when, how and where, was outweighed by their fascination at what they were finding out about themselves far more than was remotely possible from a seminar on sex skills. Betty, for example, had suggested that once kissing had stopped and intercourse had started, her sexual life was just fine after all, she had orgasms and she "liked" them. But when I asked her to describe her experience of rear-entry intercourse a common practice with this couple she did not make it sound like a richly sensual, erotic or even particular-pleasant

encounter. During the act, she positioned herself on elbows and knees, her torso held tense and rigidly parallel to the mattress while she protectively braced her body for a painful battering. Instead of moving into each thrust from Donald, she kept moving away from him, as if trying to escape. He, on the other hand, clasped her hips and kept trying to pull her to him, but never got a feeling of solid physical or emotional connection.

In spite of the fact that both were able to reach orgasm widely considered the only significant measurement of successful sex- Betty and Donald's minute-by-minute description of what they did made it obvious that a lot more was happening than a technically proficient sex act. I told Betty I was glad she had told me these details, which all suggested that she thought it was pretty hopeless trying to work out conflicts with people she loved. "I suspect you've gotten used to swallowing your disappointment and sadness without telling anybody, and just getting along by yourself as best you can," I said. "It sounds very lonely." At that point, much to Donald's shock, Betty burst into tears. I said to Donald that he still seemed resigned to chase after people he loved to get them to love and accept him. "I guess you just don't believe they could possibly love you without being pressured into it. In fact, I think both of you use sex to confirm the negative beliefs you already have about yourselves."

For several seconds Donald looked at his lap, while Betty quietly cried in the next chair. "I suppose we must be pretty screwed up, huh?" Betty snuffled. "Nope," I said. "Much of what's going on between you is not only understandable, it's predictable, normal and even healthy although it doesn't look or feel that way right now." They were describing the inevitable struggle involved in seeking individual growth and self-development within the context of marriage.

Betty said she used to enjoy sex until she became overinvolved with her job, but I suggested that the case was more likely the reverse that the demands of her job gave her a needed emotional distance from Donald. Her conscious desire to "escape" from Donald stemmed from emotional fusion with him she found herself invaded by his worries, his anxieties, his insecurities

and his needs as if she had contracted a virus from him. 'You may feel that you don't have enough inside you to satisfy his needs and still remain a separate, whole person yourself," I said. 'Your work is a way of keeping some 'self for yourself, to prevent being absorbed by him. That's the same reason you turn your head away when he tries to kiss you."

I suggested that Donald's problem was a complementary version of the same thing: in order to forestall the conviction that he had no worthwhile self at all, he felt he had to pressure Betty, or anybody he loved, to demonstrate they loved him over and over. Donald, of course, did not see that he was as important to Betty as she-was to him, but their mutual need for each other was really a function of two fragile and insecure selves shoring each other up.

Like most of us, neither Betty nor Donald was very mature when they married; neither had really learned the grownup ability to soothe their own emotional anxieties or find their own internal equilibrium during the inevitable conflicts and contretemps of marriage. And, like most couples after a few years of marriage, they made up for their own insecurities by demanding that the other provide constant, unconditional acceptance, empathy, reciprocity and validation to help them each sustain a desired self-image. "I'm okay if, but only if, you think I'm okay," they said, in effect, to each other, and worked doubly hard both to please and be pleased, hide and adapt, shuffle and dance, smile and agree. The more time passes, the more frightened either partner is of letting the other know who he or she really is.

This joint back-patting compact works for a while to keep each partner feeling secure, taut eventually the game becomes too exhausting to play. Gradually, partners become less inclined to please each other, more resentful of the cost of continually selling themselves out for ersatz peace and tranquility, less willing to put out or give in. To the extent that neither partner has really grown up and is willing to confront his or her own contribution to this growing impasse, however, both would prefer to fight with or avoid the other. It's less frightening to blame our mates than to face ourselves. The ensuing "symptoms" low sexual desire, sexual boredom, control battles, heavy silences often take on the coloring of a deathly struggle for selfhood, fought on the implicit assumption that there is only room for one whole self in the marriage. "It's going to be my way or no way, my self or no self!" partners say in effect, in bed and out leading to a kind of classic standoff.

Far from being signs of a deeply "pathological" marital breakdown, however, as Donald and Betty were convinced, this stalemate is a normal and inevitable process of growth built into every marriage, as well as a golden opportunity. Like grains of sand inexorably funneling toward the "narrows" of an hourglass, marriage predictably forces couples into a vortex of emotional struggle, where each dares to hold onto himself or herself in the context of each other, in order to grow tip. At the narrowest, most constricting part of the funnel where alienation, stagnation, infidelity, separation and divorce typically occur couples can begin not only to find their individual selves, but in the process acquire a far greater capacity for love, passion and intimacy with each other than they ever thought possible.

At this excruciating point in a marriage, every couple has four options: each partner can try to control the other (Donald's initial ploy, which did not succeed), accommodate even more (Betty had done so to the limits of her tolerance), withdraw physically or emotionally (Betty's job helped her to do this) or learn to soothe his or her own anxiety and not get hijacked by the anxiety of the other. In other words, they could work on growing up, using their marriage as a kind of differentiation fitness center par excellence.

Differentiation is a lifelong process by which we become more uniquely ourselves by maintaining ourselves in relationship with those we love. It allows us to have our cake and eat it too, to experience fully our biologically based drives for both emotional connection and individual self 1 direction. The more differentiated we are the stronger our sense of self-definition and the better we can hold ourselves together during conflicts with our partners the more intimacy we can tolerate with someone we love without fear of losing our sense of who we are as separate beings. This uniquely human balancing act is summed up in the striking paradox of our species, that we are famously willing both to die for others, and to die rather than be controlled by others.

Of all the many schools of hard experience life has to offer, perhaps none but marriage is so perfectly calibrated to help us differentiate if we can steel ourselves to take advantage of its rigorous lessons, and not be prematurely defeated by what feels at first like abject failure. Furthermore, a couple's sexual struggle what I call the sexual crucible is the most powerful route both to individual maturity and the capacity for intimate relationship, because it evokes people's deepest vulnerabilities and fears, and also taps into their potential for profound love, passion, even spiritual transcendence.

In the typically constricted sexuality of the mid-marriage blues, Betty and Donald's sexual repertoire consisted of "leftovers" whatever was left over after eliminating every practice that made one or the other nervous or uncomfortable. The less differentiated a couple, the less they can tolerate the anxiety of possibly "offending" one another, the more anxiety they experience during sex and the more inhibited, rigid and inflexible their sexual style becomes: people have sex only up to the limits of their sexual and emotional development. Unsurprisingly, Donald and Betty's sexual routine had become as predictable, repetitious, unadventurous and boring as a weekly hamburger at McDonald's. This is why the standard advice to improve sex by negotiating and compromising is doomed to failure most normally anxious couples have already long since negotiated and compromised themselves out of any excitement, variety or sexual passion, anyway.

And yet, it would have been pointless and counterproductive to march Donald and Betty through a variety of new sexual techniques. Using sex as a vehicle for personal and relational growth is not the same as just doing something new that raises anxieties. Rather, it depends on maintaining a high level of personal connection with someone known and loved during sex allowing ourselves to really see and be seen by our partners, feel and be felt, know and be known by them. Most couples have spent years trying not to truly reveal themselves to each other in order to maintain the illusion of complete togetherness, thus effectively smothering any true emotional connection, with predictably disastrous effects on sex.

Donald and Betty were so obsessed with sexual behavior, so caught up in their anxieties about who was doing or failing to do what to whom in bed, that they were not really emotionally or even physically aware of each other when they touched. Like people "air kissing" on social occasions, they were going through the motions while keeping a kind of emotional cordon sanitaire between them. Their sex was more like the parallel play of young children than an adult interaction except that they each watched the other's "play" with resentment and hurt feelings. Betty complained that Donald touched her too roughly "He's crude and selfish!" she said, "and just uses me to please himself." Her complaint undercut Donald's sense of self, and he defensively accused her of being a demanding bitch, never satisfied and fundamentally unpleasable thereby undermining her sense of self.

In order to help them each find a self and each other, I had to redirect their gaze away from their obsession with mutually disappointing sexual behavior, and encourage them to "follow the connection" rediscover or establish some vital physical and emotional link as a first building block to greater intimacy. To consciously "follow the connection," however, requires the full presence and consent of both partners, each purposely slowing down and giving full attention to the other, feeling and experiencing the other's reality. For example, I suggested that Betty and Donald, who couldn't come up with even one way in which they made some sort of vital contact, might simply caress each other's hands and faces while attending to what they were doing and feeling.

The next session, Donald reported that he now understood why Betty felt he was too "rough"; he said the experience made him realize that he usually touched her with about as much care and sensitivity as if he was scouring a frying pan! But slowing down to really become conscious of what he was doing made him experience a sudden jolt of emotional connection with Betty. This awareness was an unnerving sensation for someone who had spent his life performing for other people (including his wife rather than actually being with them.

Betty, too, was shaken by the jarring reality of their connection. She hadn't liked being touched roughly, but the concentration and attention in Donald's hands as he really felt and got to know her body was deeply disturbing; she found herself suddenly and unexpectedly sobbing with grief and deprivation for the warmth and love she'd missed as a child, and that she had both craved and feared in her marriage. Donald managed to keep his own anxiety in check during Betty's unexpected reaction, holding her hand while she cried her eyes out and gradually calmed down on her own. Later that night, they had the best sex they had experienced in a very long time.

Buoyed by this first success, more hopeful about their future together, they both wanted to know how they could enhance this new and still tentative sense of connection. I suggested they try something called "hugging till relaxed," a powerful method for increasing intimacy that harnesses the language and dynamics of sex without requiring either nudity or sexual contact. Hugging, one of the most ordinary, least threatening gestures of affection and closeness, is also one of the most telling. When they hugged, Betty complained that Donald always leaned on her making her stagger backward while Donald accused Betty of pulling away from him, letting go "too soon," and leaving him "hugging air."

I suggested that Betty and Donald each stand firmly on their own two feet, loosely put their arms around each other, focus on their own individual experience and concentrate on quieting themselves down while in the embrace neither clutching nor pulling away from or leaning on each other. I never tell clients how long to hug, but few initially can take more than four or five seconds before they experience a kind of emotional "jolt" when the connection threatens to become too intimate for comfort. Once both partners can learn to soothe themselves and maintain their individual equilibrium, shifting their own positions when necessary for comfort, they get a brief, physical experience of intimate connection without fusion, a sense of stability and security without overdependency.

While practicing hugging until relaxed with Donald, Betty found that as she learned to quiet her own anxiety, she could allow herself to be held longer by Donald without feeling claustrophobic. Just relaxing in the hug also made her realize that she normally carried chronic anxiety like a kind of body armor. As Betty calmed down and began to melt peacefully into the hug, not pulling away from fear that Donald would, literally, invade her space, he noticed his own impulse to break it off before she wanted to. After they had spent several weeks working on hugging till relaxed, they began to feel more centered within themselves when they did it; each no longer anxiously watched for the least little twitch in the other, or wondered what the other was thinking, or worried about doing it "wrong." When they each could settle down in the hug, they discovered that together they eventually would enter a space of great peace and tranquility, deeply connected and in touch with each other but secure in their self.

Soon, they could experience some of the same kind of deep peace during sex, which not only eliminated much of the anxiety, resentment and disappointment they had felt before, but vastly increased the eroticism of the encounter. Now that they knew what they were looking for, they could tell when it was absent. It was as if each had let slip away a hard, tough carapace, and allowed something tender and vulnerable to emerge. Later, in my office, while Betty gently stroked his arm, Donald teared up as he told me about the new sense of quiet but electric connection he felt with her. "I just had no idea what we were missing; she seemed so precious to me that it almost hurt to touch her," he said, his voice thick with emotion.

This leap in personal development didn't simply occur through behavioral desensitization. Sometimes, Betty and Donald got more anxious as their unresolved issues surfaced in their physical embrace. At times, when Betty dared to shift to a more comfortable position, Donald felt she was squirming to avoid him. It was my job to help them see how this reflected the same emotional dynamics present in other aspects of their marriage. Betty was attempting to "hold onto herself while remaining close to someone she loved, and likewise, Donald was refusing to chase after a loved one to get himself accepted. Insight alone didn't help much; a lot of self-soothing was required. Ultimately, they stopped taking each other's experience and reaction as a reflection on themselves and recognized that two separate realities existed even during their most profound physical union.

Building on their new stockpiles of courage earned in these experiments with each other, I suggested that Donald and Betty consider eyes-open sex, the thought of which leaves many couples aghast. Indeed, Donald's first response to the suggestion was that if he and Betty tried opening their eyes during sex, they wouldn't need birth control because the very thought made him so anxious he could feel his testicles retreating up into his windpipe! But eyes-open sex is a powerful way of revealing the chasm between sensation-focused sex and real intimacy. Most couples close their eyes in order to better tune out their partners so that they can concentrate on their physical feelings; it is a shocking revelation that to reach orgasm supposedly the most intimate human act most people cannot tolerate too much intimacy with their partners, so they block the emotional connection and concentrate on body parts.

Eyes-open sex is not simply a matter of two pairs of eyeballs staring at each other (indeed, people can hide behind a blank stare), but a way to intensify the mutual awareness and connection begun during foreplay; to really "see" and "be seen" is an extension of feeling and being felt when touching one another. But if allowing oneself to be known by touch is threatening, actually being seen can be positively terrifying. Bravely pursuing eyes-open sex in spite of these misgivings helps couples not only learn to tolerate more intimacy, it increases differentiation it requires a degree of inner calm and independent selfhood to let somebody see what's inside your head without freaking out. "It scares me," said Betty, speaking many people's experience. "I don't like my body much, and I don't like a lot else about myself, and I don't really expect him to, either."

But the experience was also exhilarating. As Donald and Betty progressed from shy, little, peekaboo glimpses into each other's faces to long, warm gazes and soft smiles, each found their encounters more deeply moving. Betty slowly realized that whereas before she had wanted to escape from Donald, now she yearned to see all of him, and for him to see all of her. "I felt so vulnerable, as if he could see all my inadequacies, but the way he looked at me and smiled made all that unimportant." Donald gradually relinquished the self-image of a needy loser; he no longer needed to pursue Betty for reassurance and found, to his delight, that she wanted him a breathtaking experience. "Her eyes are so big and deep, I feel I could dive into them," he said in wonder.

Both began to experience an increasing sense of self-acceptance and personal security. "We're having better sex now than we've ever had in our lives," Betty reported, "And I thought we were getting to be too old and far too married for exciting sex." Donald agreed. Betty and Donald, like society at large, were confusing genital prime the peak years of physical reproductive maturity with sexual prime the specifically human capacity for adult eroticism and emotional connection. "Are you better in bed or worse now than you were as an adolescent?" I asked them. "Most people definitely get better as they get older, at least potentially. No 17-year-old boy is sufficiently mature to be capable of profound intimacy he's too preoccupied with proving his manhood; and a young woman is too worried about being 'used' or too hung up about romance and reputation to really experience her own eroticism. Most 50-year-olds, on the other hand, have a much better developed sense of who they are, and more inner resources to bring to sex. You could say that cellulite and sexual potential are highly correlated."

"So that's why I have such incredible erotic talents!" said Betty.

As far as issues of gender equality are concerned, both men and women become more similar as they age and approach their sexual potential. Men are not as frightened of letting their partners take the lead in making love to them, and they develop far greater capacity and appreciation for emotional connection and tenderness than they had as young men. Women, on the other hand, become more comfortable with their own sexuality, more likely to enjoy sex for its own sake and less inclined to apologize for their eroticism or hide behind the ingenue's mask of modesty. As they age, women feel less obligated to protect their mate's sexual self-esteem at the cost of their own sexual pleasure.

Once a couple's sexual potential has been tapped, partners are no longer afraid to let their fantasies run free with each other. Donald, for example, let Betty know that he dreamed of her tying him up and "ravishing" him sexually so one day, she bought four long, silk scarves and that night, wearing three-inch high heels and a little black lace, she trussed him to the bed and gave him what he asked for, astounding him and surprising herself with her own dramatic flair. Betty had always secretly cherished a fantasy of being a dangerous, sexually powerful femme fatale, but Donald's clingy neediness had dampened her enthusiasm for trying out the dream also she had been afraid it would make him even more demanding. But now, knowing he was capable of being himself regardless of what she did or did not do, Betty felt much more comfortable expressing her own sense of erotic play.

The Sexual Crucible Approach encourages people to make use of the opportunity offered by marriage to become more married and better married, by becoming more grown-up and better at staking out their own selfhood. But the lessons learned by Betty and Donald, or any couple, extend far beyond sex. The same emotional development that makes for more mature and passionate sexuality also helps couples negotiate the other potential shoals of marriage money issues, childrearing questions, career decisions because differentiation is not confined to sex. In every trouble spot, each partner has the same four options: dominate, submit, withdraw or differentiate. Differentiation does not guarantee that spouses can always have things their own individual way and an unfailingly harmonious marriage besides. Marriage is full of hard, unpleasant choices, including the choice between safety, security and sexual boredom, on the one hand, and challenge, anxiety and sexual passion, on the other.

But spouses who have learned to stand on their own two feet within marriage are not as likely to force their own choices on the other or give in or give up entirely just to keep their anxiety in check and shore up their own frail sense of self. Learning to soothe ourselves in the middle of a fight with a spouse over, say, the choice of schools for our child or a decision to move, not only helps keep the discussion more rational, but makes us more capable of mutuality, of hearing our partner, of putting his or her agenda on a par with our own. The fight stops being, for example, a struggle between your personal needs and your spouse's personal needs, often regarded by each as my "good idea" and her/his "selfishness," but which is really often my fragile, undeveloped self versus his/her equally fragile, undeveloped self. Instead, we can begin to see that the struggle is inside each of us individually, between wanting what we want for ourselves personally, and wanting for our beloved partner what he or she wants for himself or herself. Becoming more differentiated is possibly the most loving thing you can do in your lifetime for those you love as well as yourself. Someone once said that if you're going to "give yourself to your partner like a bouquet of flowers, you should at least first arrange the gift!

There is no way this process can be foreshortened into a technical quick-fix, no matter how infatuated our culture is with speed, efficiency and cost containment. Courage, commitment, a willingness to forgo obvious "solutions," tolerating the anxiety of living without a clear, prewritten script, as well as the patience to take the time to grow up are all necessary conditions, not only for a good marriage, but for a good life. At the same time, reducing all marital problems to the fallout from our miserable childhoods or to gender differences not only badly underestimates our own ability to develop far beyond the limitations of our circumstances, but misjudges the inherent power of emotionally committed relationships to bring us (drag us, actually, often kicking and screaming) more deeply and fully into our own being. Marriage is a magnificent system, not only for humanizing us, maturing us and teaching us how to love, but also perhaps for bringing us closer to what is divine in our natures.

David Schnarch, Ph.D., is the founder of the Sexual Crucible Approach and director of the Marriage and Family Health Center in Evergreen, Colorado. His books include Passionate Marriage: Sex, Love, and Intimacy in Emotionally Committed Relationship and Constructing the Sexual Crucible: An Integration of Sexual and Marital Therapy. Address: 2922 Evergreen Parkway, Suite 310, Evergreen, CO 80439. Website: www.passionatemarriage. com


Bad Couples Therapy

Betting Past the Myth of Therapist Neutrality

by William Doherty

I want to propose a new competition for therapists: awards for the worst experiences doing couples therapy. My own entry would be in the category of a worst experience as a new couples therapist in the first session. It was 26 years ago, but as they say, it feels like yesterday. As a graduate student, I'd done individual counseling before, and had worked with parents and kids, but had never worked with a couple. Thirty minutes into the first session, when I was lost in the midst of a meandering series of questions, the husband leaned forward and said, "I don't think you know what you are doing." Alas, he was right. Naked came the new couples therapist.

Since then, as we say in Lake Wobegon, I like to think I've become an above-average couples therapist, but that might not be much of a distinction. A dirty little secret in the therapy field is that couples therapy may be the hardest form of therapy, and most therapists aren't good at it. Of course, this wouldn't be a public health problem if most therapists stayed away from couples work, but they don't. Surveys indicate that about 80 percent of therapists in private practice do couples therapy. Where they got their training is a mystery, because most therapists practicing today never took a course in couples therapy and never did their internships under supervision from someone who'd mastered the art. From a consumer's point of view, going in for couples therapy is like having your broken leg set by a doctor who skipped orthopedics in medical school.

What's my evidence for these assertions? Most therapists today trained as psychologists, social workers, professional counselors, or psychiatrists. None of these professions requires a course in marital therapy. At best, some programs offer an elective in "family therapy," which usually focuses on parent-child work. Only the professional specialty of marriage and family therapy, which constitutes about 12 percent of psychotherapy practitioners in the United States, requires coursework in couples therapy, but even there you can get a license after working only with parents and kids. After coursework, few internship settings in any field give systematic training in couples therapy, which isn't ordinarily a reimbursable service.

The result is that most therapists learn couples therapy after they get licensed--through workshops and by trial and error. Most specialize in individual therapy, and work with couples on the side. Most have never had anyone observe or critique their couples work. So it's not surprising that the only form of therapy that received low ratings in a famous national survey of therapy clients, published in 1996 by Consumer Reports, was couples therapy. The state of the art in couples therapy isn't very artful.

Why is couples therapy a uniquely difficult form of practice? For starters, there's an ever-present risk of winning one spouse's allegiance at the expense of the other spouse's. All your wonderful joining skills from individual therapy can backfire within seconds with a couple. A brilliant therapeutic observation can blow up in your face when one spouse thinks you're genius and the other thinks you're clueless--or worse, allied with the enemy. After all, one spouse who agrees with you too vociferously can dramatically undercut your effectiveness.

Couples sessions can be scenes of rapid escalation uncommon in individual therapy, and even in family therapy. Lose control over the process for 15 seconds and you can have spouses screaming at each other and wondering why they're paying you to watch them mix it up. In individual therapy, you can always say, "Tell me more about that," and take a few minutes to figure out what to do next. In couples therapy, the emotional intensity of the couple's dynamics doesn't give you this luxury.

Even more unnerving is the fact that couples therapy often begins with the threat that the couple will split up. Often, one spouse is coming just to drop off his or her partner at a therapist's doorstep before exiting. Others are so demoralized that they need an intense infusion of hope before agreeing to a second session. Therapists who prefer to take their time doing their favorite lengthy assessment instead of intervening immediately may lose couples who arrive in crisis and need a rapid response to stop the bleeding. A laid-back or timid therapist can doom a marriage that requires quick CPR. If couples therapy were a sport, it would resemble wrestling, not baseball--because it can be over in a flash if you don't have your wits about you.

As in any sport or art form, there are beginners' mistakes and advanced practitioners' mistakes. Inexperienced and untrained couples therapists don't manage sessions well. They struggle with the techniques of couples therapy, and clients often sense that these therapists aren't skillful. More advanced therapists can manage sessions well with challenging couples, but they make subtler mistakes, of which neither they nor their clients may be aware. I'll start with beginners' mistakes and then describe how couples therapy can go south, even in the hands of experienced therapists.

Beginners' Mistakes

Mistake No. 1--Lack of Structure: The most common mistake made by inexperienced couples therapists is providing too little structure for the sessions. These therapists let spouses interrupt each other and talk over each other. They watch and observe as spouses speak for each other and read each other's minds, making attacks and counterattacks. Sessions generate a lot of energetic conversation, but little learning or change. The partners simply reproduce their familiar patterns in the office. The therapist may end the session with something blandly reassuring like, "Well, we've gotten a number of the issues on the table," but the couple leaves demoralized.

Screenwriters are onto this fundamental clinical mistake. In the movie The Ref, Kevin Spacey and Judy Davis are a warring couple in a therapist's office. At one point, they turn to the therapist, almost pleading for him to intervene in their bickering. He says reflexively, "What I can say is that communication is good." Later, he adds, "I'm not here to give advice or to take sides," whereupon Davis shoots back, "Then what good are you anyway?" When the therapist loses control completely and begs the couple to lower their voices, they shout back, "Fuck you!" in unison--the first time they've agreed on anything in the session.

Sometimes a therapist who doesn't create a clear structure for the sessions will conclude that some clients aren't good candidates for couples therapy because they're too reactive in each other's presence. The upshot is a referral, splitting up the partners for individual therapy, which might further erode the marriage. I once saw a tape of an inexperienced couples therapist who announced that the sessions didn't seem "safe enough" for the angry spouses. (There was no evidence of physical violence or emotional cruelty in the relationship.) The real issue wasn't the couple's ability to handle the joint sessions--it was the therapist's ability. She was the one who didn't feel safe.

I remember when I first realized that I had to ratchet up my structuring skills. I was working with a couple in which the husband was Israeli and the wife American. David was opinionated and assertive, but loving and committed. The challenge I faced in the early sessions was his tendency to interrupt his wife, Sarah. I tried to keep him at bay with my standard armamentarium of diplomatically crafted "I-statements." "David," I'd say, "I'm concerned about your interrupting Maria, which means she can't finish her thought. I'd like to reinforce the ground rule that neither of you interrupts the other. Is that something you're willing to commit to?" He'd agree, be cooperative for a while, and then start interrupting again when she got his goat. Finally, I fell back on my working-class Philadelphia roots, bluntly instructing him, "David, stop interrupting your wife. Let her finish." He looked as though he was taking in my message for the first time. "Okay," he replied meekly. Thereafter, when he'd start to interrupt, I'd keep looking at Sarah while waving my arm in his direction, shooing his comments away. He cut it out, the therapy progressed, and I realized I'd reclaimed a piece of my Philly street past that I could use when the occasion required.

Mistake No. 2--No Plan for Change
: After lack of structure, the most common complaint I hear is that many therapists don't recommend changes in the couple's day-to-day relationship. Some therapists act as if insight alone is enough to help couples change intractable patterns of thinking and acting. But we all know that certain dynamics within a relationship have a life of their own. I start emotional, you start rational, I get angrier, and you get more controlled. Then I mention your mother and you blow up, which pleases me immensely. Just pointing out this dynamic isn't enough to change it. All empirically supported forms of couples therapy require active interventions aimed at teaching couples new ways to interact. Most involve homework assignments. Of course, just making interventions isn't enough if they're too global or generic. If my wife and I are fighting continually over her mother, saying to us, "Remember to paraphrase and use your other communication skills" won't take us very far. Good therapy addresses the way couples actually do their own particular dance, both during the session and back at home.

Mistake No. 3--Giving Up: The third common mistake of inexperienced therapists is giving up on the relationship because the therapist feels overwhelmed with the couple's problems. I've heard enough stories about therapists who abandoned ship too soon to be confident that this is a common mistake. In one case, the therapist did an assessment during the first session, and in the second session pronounced that the couple was incompatible and weren't candidates for couples therapy--without ever trying to help them. In another case, a woman whose husband was becoming emotionally abusive as his Parkinson's disease progressed told me that, at the end of the first session, the therapist had said, "Your husband will never change, so you have to accept what he's doing or get out." Translation: "I don't have a clue about Parkinson's disease or how to help an elderly couple with serious marital problems, so I'm pronouncing yours a hopeless case." This also kept the therapist's average length of treatment in favorable territory with his managed-care employer.

Some therapists survive the early sessions but get frustrated later and actively advise couples to separate. When deciding that the couple isn't amenable to treatment, they don't seem to factor in their own skill level. They may further reduce their own sense of responsibility by making a delayed diagnosis that one of the spouses has a personality disorder. This often means nothing more than "I can't work with this person." Giving up this way is akin to a primary care physician's pronouncing a patient incurable without referring the patient to a specialist in his or her life-threatening condition. I once worked with a young family physician who had a rule that no one should be allowed to die without a consultation from a specialist in what is killing them. I would argue the same for couples: treatment failures, especially those that lead to divorce, shouldn't be accepted without a consultation or referral to a competent, experienced therapist who specializes in working with couples.

Experienced Therapists' Mistakes

Mistake No. 1--Thinking All Couples Are Equal: Advanced practitioners' mistakes are more about strategy than technique, more about missing the context than specific relational dynamics, and more about unacknowledged values than lack of knowledge. I'll focus on two areas of poor couples therapy by experienced therapists: working with remarried couples and working with couples deciding whether to work on their marriage or divorce.

Remarried couples with stepchildren are a minefield, even for experienced therapists, because the partners almost always come with parenting issues, not just couples problems, and because many therapists miss the nuances of stepfamily dynamics. Therapists who specialize in adult relational work but aren't skilled at parent-child therapy will fail with these families. Experienced therapists who treat remarried couples like first-marrieds usually manage the individual sessions well, but use the wrong overall strategy.

I remember my own awakening on therapy with remarried couples almost as clearly as I remember my first session of couples therapy. It was in the spring of 1985, and I'd been trying to get Dave and Diane to reduce conflict in their two-year-old marriage by being equal parents with Kevin, Diane's challenging, 14-year-old son from a previous marriage. It was a familiar coparenting problem. Dave thought that Diane was too soft on the boy, and Diane thought Dave was too strict. They'd sometimes  reach a "compromise," but Diane wouldn't follow through on it. I'd helped many couples with this kind of bread-and-butter problem in family therapy, but I was stuck here. I can feel the chair I was sitting on when I said to myself something like, Bill, why are you insisting that this woman share parenting authority equally with this man? He didn't raise Kevin, Kevin doesn't see him as a father, and Dave doesn't have the same investment as Diane does. She can't treat Dave as an equal here, so stop beating up on her for not succeeding.

I realized that I was misapplying a norm about coresponsibility in biological coparenting to a family structure where it didn't apply in the same way. I then told the couple that I could understand why Diane couldn't give Dave equal say in disciplining her son--the fact was that Diane was the parent. With so many years invested in her son and Dave's relationship with Kevin so new, she couldn't share authority 50-50. I introduced a metaphor that I would come to use often with stepfamilies: in the parenting domain with her child, Diane was the "first violinist" and Dave "second violinist." Diane immediately was relieved, and Dave immediately was alarmed. There was a lot of work ahead, but they did achieve a workable coparenting relationship based on Diane's leadership with her son. Shortly thereafter, I read Betty Carter's work on stepfamilies in which she argued for treating the spouses as having different roles with the children, and then I came across new research by Mavis Hetherington making the same point. Stepfamilies are a different species, and couples in these families have to be treated with different approaches. Many experienced couples therapists still don't know this--or even if they do know it, still lack a viable treatment model.

Beyond coparenting leadership issues, couples in stepfamilies swim in a sea of divided loyalties, which even experienced therapists sometimes miss. I once consulted on a case of a recently married couple in which the wife had three children and the husband none. One thorny issue was that the husband felt left out of the wife's emotional world because they had little time alone together. The wife agreed, and she told the therapist how torn she felt about this. She loved her husband and wanted the marriage to work, but her three school-age children required nearly all of her time after work and in the evenings. She helped them with their homework every night, and they had the kind of extracurricular activity schedules that render contemporary parents part-time chauffeurs and full-time activity directors on the family cruise ship. Weekends were spent doing errands and driving the kids to their traveling soccer games.

In one of the early sessions, the therapist, who was highly experienced in couples work, empathized with the wife's feeling caught between the needs of her husband and those of her children, and supported the wife's decision to prioritize the children. The therapist explained that these years of raising school-age children are ones in which the children's time demands are huge, and the marital relationship inevitably has to take a back seat. She said that, as a wife and mother, she herself knew about these demands, which ease when children get older. In other words, the therapist normalized the marital gap in terms of the family life cycle, recognizing especially the unique strain on a wife who couldn't meet everyone's needs. The wife burst into tears at feeling so deeply understood and accepted. The therapist then turned to the husband and gently asked him for his feelings and thoughts as he'd followed the conversation and seen his wife's pain and tears. The husband, a "good guy," who didn't like conflict, owned that he'd been selfish and pledged to back off on his demands for more time with his wife, promising he'd be more understanding in the future.

The session ended with a warm glow. The couple agreed to continue working on other issues that had brought them to therapy. The therapist was pleased at how she'd been able to combine her clinical skills and her own experience as a wife and mother to help this couple. A few days later, the husband called to end the therapy, saying tersely that they'd decided to continue to work on things by themselves.

The therapist was stunned and consulted with me. I helped her see that she'd missed that there were two distinct family developmental stages at work in this case. Yes, the parent-child development stage was one of intense time demands (leaving aside for the moment the overscheduling supported by the wider culture), but the marital-developmental stage had its own pacing needs: a puppy marriage needs time for play and nurturing. To put aside their new marriage for years on end is dangerous. Of course, it's dangerous even in long-term relationships, but at least there may be a strong foundation and memories of good years. The husband was appropriately worried about the viability of a neglected new marriage. What struck me was how even a skilled, experienced couples therapist had misunderstood the special needs of a remarried couple.

Mistake No. 2--Not Standing by Marriage: If beginners give up on couple relationships because of lack of skill, experienced therapists sometimes give up on couples because of the values they hold about commitment in a troubled marriage. I've heard experienced therapists announce proudly, "I'm not here to save marriages; I'm here to help people." This split between people and their permanent, committed, intimate relationships (which is how I'm defining marriage ) has a superficial appeal. No one wants to save a marriage at the cost of great damage to a spouse or the children. But the statement reflects a troubling--and usually unacknowledged--tendency to value a client's current happiness over everything else.

One highly regarded therapist in my local community describes his approach to working with couples in this way: "I tell them that the point is to have a good life together. If they think they can have a good life together, then let's give it a try. But if they conclude that they can't have a good life together, then I tell them maybe they should move on." Again, at one level, this sounds like practical advice, but as a philosophy of working with marital commitment, it's lame. How does it differ from counseling someone about a job decision? If you think that your frustrating accounting job can eventually work out for you, then try to improve the situation; if not, move on. Most of us didn't stand up in front of our family, our friends (and maybe our God) and declare our undying loyalty and commitment to Arthur Andersen LLP, but we did so with our spouse.

In this way, the ethic of market capitalism can invade the consulting room without anyone's seeing it. Do what works for you as an autonomous individual as long as it meets your needs, and be prepared to cut your losses if the futures market in your marriage looks grim. There are legitimate reasons to divorce, but given the hopes and dreams that nearly everyone brings to a marriage, divorce is a wrenching, often tragic, event. I see divorce more like amputation than like cosmetic surgery. That's a different value orientation than that of one prominent family therapist who sees his job as helping people decide on their best option. "The good marriage or the good divorce," he told a journalist, "it matters not."

A lesbian therapist told me of how her own therapist wouldn't permit her to bring the children's needs into the therapy conversation when she was contemplating whether to stay with her partner. "This isn't about the kids," the therapist insisted. "It's about what you need and want." When the client objected that she had to weigh the kids' needs in her decision, and wanted to talk about it, the therapist balked, insisting that the client was avoiding dealing with her real issues. Finally, the client fired the therapist. Later, she told me that she and her partner had found a way to stay committed, improve their relationship, and raise their children together. The therapist in this case was a highly regarded professional, a "therapist's therapist" in the community.

It was an experience that happened to a couple who are close to my family that radicalized me about how today's therapists deal with commitment. It's a story like many others I've heard from clients, colleagues, and friends. Monica's life was thrown into chaos the day that Rob, her husband of 18 years, announced that he was having an affair with her best friend and wanted an "open marriage." When Monica refused, Rob bolted from the house and was found the next day wandering around aimlessly in a nearby woods. After two weeks in a mental hospital, diagnosed with an acute, psychotic depression, he was released to outpatient treatment. Though he claimed during his hospitalization that he wanted a divorce, his therapist had the good sense to urge him to not make any major decisions until he was feeling better.

Meanwhile, Monica was beside herself. She had two young children at home, held a demanding job, and was struggling with a serious chronic illness diagnosed a year before. Indeed, Rob had never been able to cope with her diagnosis, or with his own job loss six months later. (He was now working again.) In addition, the family had just recently moved to a new city.

Clearly, this couple had been through a lot of stress. For a former straight-arrow man with strong religious and moral values, Rob was acting in a completely uncharacteristic way. Monica was depressed, agitated, and confused. Being an intelligent consumer, she sought out recommendations and found a highly regarded clinical psychologist. Rob continued in individual outpatient psychotherapy, while living alone in an apartment. He still wanted a divorce.

As Monica recounted, her therapist, after two sessions of assessment and crisis intervention, suggested that she pursue the divorce. She resisted, affirming her hope that the real Rob would reemerge from his mid-life crisis. She suspected that the affair with her friend would be short-lived (as it was). She was angry and hurt, she said, but determined not to give up on an 18-year marriage after only one month of hell. The therapist, according to Monica, interpreted her resistance to "moving on with her life" as stemming from an inability to "grieve the end of her marriage." He then connected this inability to the loss of her mother when Monica was a small child. Monica's difficulty in letting go of a failed marriage, he claimed, stemmed from unfinished mourning over her mother's death.

Fortunately, Monica had the strength to fire the therapist. Not many clients would be able to do that, especially in the face of such expert pathologizing of their moral commitment. It was equally fortunate that Monica and Rob found a good marital therapist, who saw them through their crisis and onward to an ultimately healthier marriage. When I last saw them, Rob was more emotionally available than I'd ever seen him before. He and Monica had survived an intervention that I call therapist-assisted marital suicide.

The therapist's blundering in this case stemmed not from clinical incompetence in knowledge and technique, but from his values and beliefs. He simply didn't recognize the importance of a commitment made "for better or worse." Like attorneys who automatically fight their clients' opponents, some therapists encourage clients to rid themselves of currently toxic spouses, rather than working hard to see what can be salvaged and restored. This approach may be wrongheaded, even when it comes to individual well-being. Recent research by sociologist Linda Waite has found that the great majority of unhappy spouses who persevere in their (nonviolent) marriages for five years report marked improvements in their marriages, and that divorce, on average, doesn't make people in unhappy marriages any better off in personal well-being.

Ultimately, clinical skills aren't enough in couples therapy, because here, more than in any other form of therapy, our clinical skills and values intersect. Treating a client's depression or anxiety doesn't involve the kind of value judgments that working with couples does. Feminists were among the first to point out the inevitability of moral positions in couples work. You can't work with heterosexual couples without a framework that addresses justice and equality in gender relations. If you claim to be neutral, you'll enact whatever traditional value orientation you have about women and men and how they should make a life together. The same is true for race and sexual orientation. Not to have a moral framework is to have an unacknowledged one, and in mainstream American culture, that will probably be individualistic rather than relational or communitarian.

Just as clients who value gender equality won't be well served by therapists with traditional value orientations about gender, clients who cherish their moral commitment to their marriage, as Monica did, won't be safe in the hands of clinically skilled couples therapists who have individualistic orientations. Such clients need therapists who understand the wisdom of Thornton Wilder when he wrote: "I didn't marry you because you were perfect. I didn't even marry you because I loved you. I married you because you gave me a promise. That promise made up for your faults. And the promise I gave you made up for mine. Two imperfect people got married and it was the promise that made the marriage. And when our children were growing up, it wasn't a house that protected them; and it wasn't our love that protected them--it was that promise."

The biggest problem in couples therapy, beyond the raw incompetence that sadly abounds, is the myth of therapist neutrality, which keeps us from talking about our values with one another and our clients. If you think you're neutral, you can't frame clinical decisions in moral terms, let alone make your values known to your clients. That's partly why stepfamilies and fragile couples get such bad treatment from even good therapists. Stepfamily life is like a morality play with conflicting claims for justice, loyalty, and preferential treatment. You can't work with remarried couples without a moral compass. Fragile couples are caught in a moral crucible, trying to discern whether their personal suffering is enough to cancel their lifetime commitment, and whether their dreams for a better life outweigh their children's needs for a stable family. The therapist's moral values are writ large on these clinical landscapes, but we can't talk about them without violating the neutrality taboo. And for clients, there's the scary fact that what therapists can't talk about may be decisive in the process and outcome of their therapy.

In the end, we need to cultivate wise couples therapists, not just competent ones. Wise therapists see the whole context of people's lives, and can reflect openly and deeply on values and broader social forces influencing the profession. My wisdom won't be the same as yours, but we have to engage one another on the big questions, instead of hiding behind the wizard's veil of clinical neutrality. The philosopher Alasdair MacIntrye wrote that, in a world that seduces professionals into seeing their work as the delivery of technical services stripped of larger social context and moral meaning, the hallmark of a true profession is a never-ending argument about whether it's being true to its fundamental values, principles, and practices. In other words, becoming a competent couples therapist is just the first step in becoming a good one.

William Doherty, Ph.D., is professor and director of the marriage and family therapy program at the University of Minnesota. Address: Family Social Science, University of Minnesota, 290 McNeal Hall, St. Paul, MN 55108. E-mails to the author may be sent to


It Takes One to Tango

You Don't Need Both Partners to Do Couples Therapy

by Michele Weiner-Davis

In our first session, Lynn, a sullen looking 27-year-old, had plenty to complain about. Her husband, Jeff, had been extremely critical of late and seemed emotionally distant from both Lynn and their 18-month-old son, Jason. Lynn felt that Jeff spent too much time with friends after work and on the weekends, and when he was home, he constantly picked on her. With little help around the house, no assistance on the parenting front and virtually no affection from Jeff, Lynn felt desperately unhappy, Lynn longed ' for things to be the way they had once been. "We were better friends back then," she recalled. "We spent a lot of time together and it really didn't matter what we were doing, as long as we were together." I asked, "Lynn, when your relationship was more loving, how was Jeff different?" Without hesitation, she replied, "He was thoughtful and very sensitive to my needs. He had a great sense of humor and was lots of fun to be with." "And how were you different, Lynn?" 1 asked. "I was a much happier person back then, no doubt about it."

"When you were a happier person, how were you different with Jeff?"

Lynn admitted that, because she was so unhappy, she was "crabbier" than she had been in the past. "I guess I used to be a lot nicer to him." She offered a long list of endearing acts of kindness, like putting love notes in Jeff's lunches or calling him at work just to let him know that she was thinking of him. She often used to initiate lovemaking, something she never did anymore. After thinking about the "old Lynn," she wistfully admitted that she liked herself more back then and disliked the angry, resentful person she had become much of the time.

As Lynn described the problems in her marriage, the circular nature of her interactions with Jeff became apparent. Were Lynn's crabbiness and standoffishness a result of Jeff's long absences from home and/or his criticisms of her, or were Jeff's absences and critical tone a result of Lynn's moodiness and withdrawal from him? Knowing that the correct answer was probably "both," I suggested an escape route out of their marital merry-go-round. "Starting tonight, no matter what you're thinking or feeling about Jeff, act like the old Lynn. Do the things you used to do when you liked yourself more, and watch Jeff very closely to see how he responds."

When she returned for our next appointment two weeks later, Lynn was eager to tell me about her experiment with Jeff. Right after our session, he had come home in a grouchy mood and made a critical comment during dinner. But instead of getting angry and defensive, Lynn simply agreed. She said that Jeff actually looked up at her in amazement and that the rest of the meal went without incident. In fact, Jeff discussed a situation at work that had been troubling him, something he hadn't done in months. When Lynn offered her opinion, he seemed unusually receptive. Lynn felt encouraged.

Later that week, Lynn realized that they hadn't spent time alone for months and reminded herself that she used to be a "social coordinator" of sorts in their marriage, and that Jeff seemed to appreciate this quality in her. So, despite the fact that she wasn't completely certain of how things would turn out, she arranged for a babysitter and made dinner reservations at one of Jeff favorite restaurants. Their evening went extremely well and when they got home, they stayed up late talking.

In the days that followed, Jeff seemed more relaxed and less critical of Lynn.

Nevertheless, the time between sessions was not without its rough spots. On a couple of occasions when Jeff made inflammatory comments, Lynn responded in kind and the tension between them escalated. Although Lynn felt discouraged when this happened, she was beginning to understand how her actions during these tension-filled times impacted on Jeff's when she allowed her buttons to get pushed, their unpleasant interactions got even more unpleasant.

She also recognized that no matter what Jeff did or said, no matter how his comments or actions "made her" feel, she was still in control of how she responded. She felt empowered by this realization, and in tense situations asked herself, "What's my goal here? What do I want to have happen?" and then quickly assessed whether what she was about to do would achieve those ends.

I asked Lynn to rate how well things were going in her relationship on a 1 to 10 scale, with 10 being great and 1 being the pits. She replied, "Four weeks ago I would have told you 2. In these last two weeks, I'd have to say 7. Then I asked, "Where on the scale would you need to be to feel satisfied?" She said 8 or 9. So I asked "What would be one or two things that could happen in your relationship that would bring you up to an 8?" and she said, "He would have to say, 'I love you' again and we'd have to make love." I urged her to keep being the "old Lynn," and take note of Jeff's reactions. We scheduled a third meeting and she left.

Two weeks later a very happy Lynn greeted me at the door. "Well, it happened. We made love and right after we were done, he turned to me and said, 'Lynn, I really love you.' It felt great because he hasn't said that in a long time. I can't believe he's changed so much so quickly." Lynn described quite a few things she had done to maintain the changes and divert unnecessary arguments in the last few weeks. As she spoke, I felt confident that she understood the "magic" behind the "new Jeff." To help her plan for future challenges, I said, "You will undoubtedly hit bumps in the road in the future. If things between you and Jeff start to go downhill, what will you do to get back on track?" With a huge smile on her face Lynn replied, "I'd remember everything we talked about here that I got things on track all by myself the first time, and that I can do that again." Lynn's look of confidence was striking. That was the last I saw of her.

From my perspective, there is nothing remarkable about this case. I helped Lynn figure out what she needed to do differently to spark a change in Jeff and in their relationship, and assumed that a positive change in Jeff would be so reinforcing that it would be the beginning of a solution avalanche. It was Systems Theory 101 "A change in one part of the system leads to changes in other parts of the system." Yet, when I discuss Lynn's case and others like it in the workshops I give on solution-oriented therapy, working with one partner to elicit relationship change isn't as mainstream a practice as I once believed. Many therapists question whether Lynn's reports of change were real. Some worry whether, since Jeff hadn't participated in therapy, the changes will stick. Others argue that the burden for relationship change should not have been left solely on Lynn's shoulders. But the most burning question turns out to be the most basic "How is it possible to do couples therapy with just one partner?"

This question stems from the fact that many therapists define the type of therapy they practice by taking a head count: if one person is present, they're practicing individual therapy; if two or more people are present, it's couples or family therapy. I believe this is misguided the key to determining which brand of therapy is in use at any given point lies in the therapist's orientation and focus, not the number of people occupying space in the room.

Individual therapy and couples therapy are based on very different premises and require completely different clinical skills. Individual therapists delve into intrapsychic processes. They help clients gain insight into themselves, their family of origin and how these childhood experiences have impacted on their present behavior, attitudes and feelings. It is the individual therapist's belief that insight is the vehicle for change; that is, once clients understand why they do what they do, they will then be able to change.

Couples/family therapists, on the other hand, are focused on the observable connections between people in the here and now. They're interested in patterns of interaction what people say and do with one another. According to this theoretical orientation, change is brought about not by going inward, but by changing observable interactions among people.

Another reason some therapists can't fathom doing couples therapy with individuals is that they are trained to believe that relationship problems are best resolved by helping people identify, process and express their feelings to one another. With this perspective as a starting point, it's easy to see why one would be skeptical about the possibilities for positive relationship change when only one partner is present. Teaching active listening skills to just one person in the relationship is like listening to the sound of one hand clapping.

But couples therapy with individuals is based on different premises. Although good communication skills go a long way toward creating healthy relationships, talking things out isn't the only, nor necessarily the best, way to resolve recurring problems. While we are affected by what our partners say to us, we are also greatly affected by what they do. For instance, although Lynn had tried for months to convince Jeff to be more loving toward her, nothing she said ever made a difference. It wasn't until she stopped talking and started changing her actions that Jeff became more responsive.

There might be a familiar ring to Jeff's tuning out Lynn's words, but not her actions. During the last few years, we've learned a lot about gender differences. In particular, we've become aware that women, in general, are more verbal than men, who tend to favor action over words. That's why when women tell me, "I talk until I'm blue in the face" or "I've told him a million times," instead of teaching them new and better ways to express themselves, I encourage them to say less and do more. And, since women are much more likely to come in to therapy solo, teaching action-oriented techniques should be tops on therapists' lists of things to do.

The fact that action-oriented techniques may work better with women under certain circumstances is no consolation to therapists who feel that doing couples therapy with women is a bad idea because it places all the burden of improving relationships on women's shoulders. "Why should women have to dream up ways of approaching men? Why can't men take responsibility for finding more creative ways of reaching women?" This position, in my opinion, stems from a lack of understanding of the systemic laws governing change. Change is like a chain reaction. She tips over the first domino, then he changes. When a woman who is dissatisfied in her relationship decides to change her method of getting through to her partner, she isn't doing "all the work." Assuming responsibility for creating positive change in life isn't working harder, it's working smarter.

Despite my emphasis on the merits of this approach with women, it's important to point out that I practice couples therapy with men, with similar results. Even when the marriage teeters dangerously on the brink of divorce, there is much therapists can do when the man is willing to change.

For example, Ben's wife had asked him to leave the house a week before she filed for divorce. When he scheduled an appointment, he had moved out and was desperately unhappy. He didn't want their 20-year marriage to end and wanted to know if there was anything he could do to make her change her mind.

I asked Ben, "If your wife were here now, what would she say you've been doing recently in regard to your marriage?" He said, "She would tell you that I've been pressuring her all the time and that she can't stand it anymore. I've been calling her several times every day and begging her to change her mind. I've been reminding her about all the good times we've shared and have sent her flowers four times. I leave Hallmark cards for her around the house." I asked if this was working, and he said, "No, I've been making things worse."

I explained to Ben that relationships are like seesaws the more of something one person does, the less the other person does of it. "If you do all the longing for your marriage, it allows her to focus only on the bad points. If you are the emotional one, it gives her room to be cold and withdrawing. So, if you want her to stop pulling away from you, you're going to have to stop pushing her."

I then asked him, "What could you do or say that would make Lois sit up and take notice?" Ben responded, "I guess I should stop calling her every day. I should stop saying 'I love you,' because I know it only makes her mad. I should stop asking her if she's changed her mind." I told Ben that he was on the right track and wondered what else he could think of to turn things around. He said, "I'm always so depressed around her. I guess that's not too attractive. If I were more upbeat, and even somewhat enthusiastic about anything in my life, she would really be shocked. That would be noticeable instantly."

I sent Ben home with the following-instructions. "Start experimenting by changing how you act when you are in Lois's presence. Do all the things you discussed here today. When you do, one of two things might happen. The first is nothing. When you change, it might not make a difference at all. That's a real possibility. Or she might be intrigued by your changes and start to show some interest in being with you. But I'm warning you, if you get overly enthusiastic and try to get her to move along quickly, she will definitely back off. You must move slowly. Don't discuss the future of your marriage at all for now. And don't move back home until the issues that separated you have been worked out."

Ben was lucky. When he gave Lois some breathing room, she did show interest in revitalizing their relationship. It was a slow process and required a lot of support on my part to keep Ben from becoming impatient. But in the end, without having Lois ever come in for therapy, they resolved some long-standing issues and he did return home. As far as I know, they are still living happily ever after.

My couples work. With individuals can be broken down into three simple steps. First, I help clients figure out what they really want from their partners by establishing clear, concrete goals that always remain in our peripheral vision. I urge clients to talk about what their partners will be doing differently when the relationship is more satisfying. I help clients picture a new, more positive relationship by asking questions such as, "When you start to feel closer and more connected to your husband, what will he be doing differently?" and "If I were a fly on the wall, what would I see the two of you doing differently when your relationship improves?" I emphasize observable actions rather than subjective feelings, to help clients develop clearer signposts for change.

The next item of business is to help my clients become "solution detectives." I want people to view their relationships as a trial-and-error process: when there's a problem, they do something to solve it. They then should watch closely for the results. If what they do is working, they should keep doing it. If not, they should switch gears.

Although simple in theory, this is not so simple in practice. People get glued to their favorite problem-solving strategies, believing that whatever they're doing to improve their relationships is the right thing to do. In fact, they think miserable results often signal the need to crank the particular strategy up a notch, i.e., do it one more time, with feeling.

Once we establish goals, the third step is to investigate what my clients have done in the past to accomplish these goals. I want to access what's worked and what hasn't. A trademark of the solution-focused therapy approach is to ask clients about problem-free times or periods that are the exceptions. For example, I might say to a client, "Tell me, I know you've been fighting a lot lately, but there must be times when you get along better. What's different about the times the two of you are more at peace with each other? What does he do differently then? What do you do differently then?" We begin to weed through the frustration and anger provoked by the problems in their relationships and discover what can be learned from the times they get along well. As clients identify what's different about the times things go well, the solution comes into view. My clients can then begin to do what works the moment they leave my office.

Although analyzing the good times is uplifting and informative, I also want to know what hasn't been working. To help clients ascertain dead-end strategies, I ask, "If your partner were here now and you weren't, and I asked, 'What does she do that drives you nuts,' what would he say?" I show them how their actions, no matter how effective they "should" have been in theory, have, in reality, caused their partners to dig in their heels even further. In other words, I train clients to pay attention to "what is" as opposed to "how things should be." Once we identify what would constitute a new and different approach to the ongoing problem, I send clients home to experiment.

In contrast to therapists who question the value of doing couples therapy with individuals, this approach is often my method of choice for a variety of reasons. I find it can empower people by showing them that they no longer have to play the waiting game of "I'll change if you change first."

Instead, they find themselves back in the driver's seat of their own lives. This is no small feat, given the helplessness arid hopelessness people feel when their partners present impenetrable walls.

Secondly, working with only one partner allows me to both join with arid confront that person in ways that wouldn't be possible if the other partner were present. For example, I can let my client know how well I understand what he or she is feeling about the relationship or about the other partner. It allows me to connect with the person without alienating the partner. On the other hand, because I'm perceived as an ally, I am at liberty to be bolder, more challenging and, at times, less balanced than would be the case if the other partner were present.

Furthermore, working with only one partner can avoid the unfortunate "ping-pong effect" in therapy, whereby one partner escalates his point of view, triggering the other partner to do the same and so on, until they're completely polarized. It has been my experience that when seen alone, many people are quite willing to take a closer look at their partners' points of view, since they don't feel coerced or that they're losing face. Once they put themselves into their partners' shoes, they're usually more conciliatory. Working with one partner doesn't work all the time, even in less challenging situations. This method is not a therapeutic panacea. There are times when one person changes and the other doesn't notice or, worse yet, doesn't care. Sometimes the relationship changes aren't in the desired direction or of the hoped-for magnitude. Occasionally, your client won't stop blaming his or her partner long enough to switch gears. But nothing works all the time. When my clients and 1 aren't getting positive results, we try something else. Working with one partner is only a good strategy if it works.

In the spirit of sharing what's worked for me, I want to encourage the skeptics I've encountered, and those I have not, to do a few things. First of all, stop telling clients, "Unless he/she joins us, therapy won't work" or, "If your husband isn't willing to come in, it means he's not committed to working on your relationship." Some people who are totally committed to their partners wouldn't dream of stepping into a therapist's office. (My own husband of 20-something years happens to be one of them.) Ascribing negative intent to those who prefer to steer clear of therapy is unfair, often incorrect and almost always hurtful to those who wish their partners would share their enthusiasm about the benefits of therapy. They end up blaming their partners even more intensely.

Furthermore, make a commitment to temporarily suspend judgment about the viability of working with individuals on relationship issues. Therapists who agree to work with individuals whose partners won't come in, but see it as a second-rate approach, worry me. We clinicians communicate our presuppositions about people and how they change when we do our work. If we begin therapy with a "this is better than nothing" attitude, we undoubtedly broadcast a pessimistic message about the possibilities for change.

Instead, the next time you hear, "My partner won't come in," try viewing the situation as an opportunity rather than a relationship death-sentence. Act as if you expect your work with your client to be successful. The results might be surprising! A change in you might just be a powerful catalyst for change in your clients.

Michele Weiner-Davis, M.S.W., is in private practice in Woodstock, Illinois. Her books include In Search of Solutions, Divorce Busting and most recently A Woman's Guide to Changing Her Man. Address: The Divorce Rusting Center, P. O. Box 197, Woodstock, Illinois, 60098; web site:; e-mail:


The Good, the Bad and the Ugly

Turning Ambivalence into Possibility

by Bill O'Hanlon

Nearly a decade ago, I treated a man named Abel, who was severely obsessive. He taught in a college communications program and loved words, but he'd become so obsessed with how human beings communicate that he could no longer put together words and meanings. He loved to read, but he could no longer concentrate because he obsessed about page margins and typefaces. He obsessed about art, sex, and his own writing. If one obsession went away, another took its place, from the moment he woke up till the moment he went to sleep. Nothing he tried brought any relief.

I thought hypnosis might help with his symptoms, but Abel, who'd unsuccessfully tried practically every form of therapy, including hypnosis, didn't think so. I assured him that I used a different approach to hypnosis, and he agreed to give it a try. During our second hypnosis session, he was symptom-free for about 15 minutes, and he continued to be for about 2 hours afterward. Even though he didn't entirely believe he'd been in trance, he was impressed and happy that something finally had helped.

In the third session, I began once more with hypnosis: "Okay, you can keep your eyes open, or you can close them, or they might open and close on their own," I said. Abel closed his eyes. "And as you're sitting there, you may be thinking you're not going to be able to go into trance. You can have that thought--that's okay. You may be thinking that this trance isn't going to work. You can think that--that's okay. You may be distracted by one of your symptoms, maybe by the tension in your jaw or your neck. You may even think you're too tense to go into trance--that's okay. You can be tense and you can still go into trance and you might relax as the moments go on. You don't have to relax to go into trance. You may be obsessing--that's okay. You can just let yourself feel what you feel, think what you think, experience what you're experiencing, and not think what you don't think, not experience what you don't experience, not feel what you don't feel, and you can still go into trance."

At that point Abel's eyes popped open. "That's it," he said. "Do more of that. That's what helped me last time."

"You mean do more trance?" I asked.

"No, no. I don't think I'm going into trance. But what you're doing now is exactly what I need. Do more of that."

"What do you mean?" I asked again.

"The way you're talking now is what's helping me. Because, somehow, when you talk that way, I get the sense I can't do anything wrong. It's the only time in my life when I can't do anything wrong. I long for that sense."

While Abel's symptoms didn't completely disappear, from this point on, he began to make progress in therapy. For the first time in years, he could relax his obsessive vigilance and begin to live his life instead of endlessly worrying about the details around life's edges.

Erickson and Not-Doing

I first learned this permissive approach watching Milton Erickson's work in the late 1970s, particularly the way Erickson used hypnosis and challenged standard ideas about hypnotic techniques and affects. Many considered hypnosis a rigid procedure, which could be effective only if certain exacting conditions were met: a person had to be physically and mentally relaxed to go into a trance; once in a trance, the person was supposed to be unaware of his or her surroundings except for the hypnotist's voice. So rigid were the requirements for succeeding at being hypnotized that many people believed they didn't have the ability to "go under" the hypnotist's spell.

Erickson's view was different. For him, trance was more of a not-doing than a doing. He understood that the hypnotist had to take the pressure off people, and make them realize that they didn't have to experience specific mental and physical stages in a particular order to go into trance. He invited people to just allow their own experiences to happen as they happened, without having to force anything. He used language that neutralized the mind's tendency to break experience down into dualistic opposites--this or that, right or wrong, correct or incorrect.

In a sense, he gave his clients permission to experience simultaneously or in rapid succession contradictory emotions and states of mind and body, emphasizing that no reaction excluded any other, and that all were "right." From Erickson, I learned to make statements like: "You can listen to and hear everything I say and you don't have to. You may remember what I say and you may not. You don't have to believe anything about this."

Abel's response to this approach--that it made him feel he couldn't do anything wrong--crystallized something for me. Here was a way to break up unconscious logjams; permissions enabled clients to experience two seemingly contradictory states simultaneously. The structure of hypnotic language freed people from the tyranny of having to choose, and choose correctly, what to feel and how to proceed. I began to appreciate the extraordinary power of permission, with or without hypnosis, particularly with my most challenging cases.

So I began focusing on how to most productively include the good, the bad, the ugly, and the in-between of my clients' experience to help them expand their sense of possibilities in life. But this was the mid-1980s, the height of the popularity of various forms of solution-based therapy, and people would sometimes come up to me at my workshops and say, "I really like your positive approach," thinking they were complimenting me, in spite of the fact that I wasn't particularly interested in accentuating the positive.

Around the same time, therapist David Nylund told me that the staff at his clinic had noticed a problem with therapists who were too focused on highlighting the positive. As they watched from behind the one-way mirror, they were struck by how often they saw therapists straining relentlessly to keep clients focused on solutions and solution-talk. Often, the effect was that clients became more and more frustrated and alienated, while the oblivious therapists continued asking about what was going better. Nylund and his colleagues named this phenomenon solution-forced therapy.

So, in my training workshops, I began emphasizing the importance of not excluding those thoughts and feelings that didn't look like solutions to anything. As valuable as it is to help people focus on solving their problems, it's equally important to validate people's experiences, however negative. The essence of good therapy is to be able to descend with people into their hell and at the same time keep one foot in the land of hope and possibility. I once heard a radio interview about research conducted with people who'd survived jumping off the Golden Gate Bridge. The only common factor among them seemed to be that on the way down each of them had had more or less the same thought: Hmmm. Maybe this wasn't such a good idea.

As therapists, we must recognize the complexity and ambivalence at the core of human experience. Inevitably our therapy theories invite us to oversimplify, and solution-focused therapists aren't the only ones guilty of that: the client's problem is "cathected introjects"; she needs to "express her feelings"; he needs to "take responsibility for his life"; clients have to "reexperience their abuse to heal from it." Whatever ideas we therapists get are going to be helpful in some situations with some clients, but they necessarily diminish and impoverish our clients' inner realities. Recognizing this, we need to remind ourselves that whatever conclusions we come to about our clients, it's always more complicated than that.

The Power of Permission

People run into problems when their lives are dictated by rigid beliefs that make the stories they're living out too restrictive. One common set of beliefs is about what you must or should do. For example: "I must always be perfect," or "I should always smile and be happy," or "Females should take care of others' needs." Another common set of beliefs is about what you can't or shouldn't do: "I can't be angry," or "Big boys don't cry."

Permission counters these commands and prohibitions. The therapist who offers permission goes beyond accepting clients as they are and moves into encouraging them to expand their life stories and their sense of themselves. In effect, the therapist who offers permission is saying, "There's more to you than this story you've lived out up to this point." Permissions can introduce choice and possibilities into circumstances that have been limited by necessity and impossibility.

How do permissions work in practice? Some years ago, I worked with a woman who'd been sexually abused by a cousin in childhood. He routinely brought her to orgasm, which she liked and felt bad about--because she didn't like him and felt manipulated and coerced by him. As an adult, she never got sexually excited or had orgasms until she became involved in S&M in her early twenties. After a frightening experience in which she was almost killed, she left the S&M scene.

Now, after many years of therapy, she lived with her fiance and was still unresponsive sexually. She'd begin to get sexually excited, and then get frightened and go numb. She'd accepted that this was the way things were with her. Once, at a professional conference, she'd started chatting with a fellow attendee and had gone into an elevator with him. As the doors closed, sparks seemed to jump between them and they had sex in the elevator. She was surprised that she was doing this wild thing, and even more surprised to have an orgasm during the short encounter.

In our therapy, she realized she was operating under two beliefs: "You shouldn't enjoy sex, because it's bad," or, "You're bad if you're sexually excited or have an orgasm." Because she'd been coerced to be sexually aroused, she'd developed the idea that she had to be sexually aroused and have orgasms in any sexual situation, whether she felt like it or not. I gave her two permissions: "It's okay to have sexual pleasure and not be punished. It's also okay not to be sexually aroused and okay not to have sex." I started interspersing into our conversations permissions such as, "You can be a good person and be sexual." And "You don't have to be bad to be aroused." But also, "You don't have to have sex, if you don't feel like it." And, "You don't have to have orgasms when you have sex."

How did she begin putting these permissions into practice? She decided to let her partner know she became afraid or numb when they were having sex. She'd tell him she needed to stop and talk, or not have sex right then. He was understanding and appreciated that she was honest with him, rather than just forcing herself to go through the motions. The fact that he responded so well confirmed for her that she did not have to have sex or have an orgasm. Her new freedom actually enabled her to have orgasms with her fiance more often.

Although you can give the permission to or the permission not to, giving both permissions at the same is often most effective: "It's okay to be sexual, and you don't have to be sexual." If you give only one permission for one type of response, clients may feel pressured to experience only one part of the equation, or they may find the other side emerging in a more compelling and disturbing way.

In certain situations, it's important to give permission for feelings, not actions. For instance, "It's okay to feel like cutting yourself, and you don't have to feel like cutting yourself." Needless to say, never give permission for harmful, destructive behavior.

Other times, it's helpful to give a client permission to do two things at once. Such was the case with Josie, whom I'd seen for a few sessions when she came in very agitated. She said she had something to tell me, but was terrified to talk about it. I told her it was okay not to tell me until she was comfortable enough to do so. Josie responded that she had to tell me, or she felt she'd be wasting her time and money in therapy. I told her to go ahead and tell me in whatever way felt right.

She seemed to struggle for a while and then said, "I can't tell you. I'm too afraid." We went back and forth like that until I began to understand Josie's dilemma and said, "Okay, I know this may not make sense, but what I'm going to say can be understood somewhere deep inside. You can find a way to tell me and not tell me at the same time."

In response, Josie closed her eyes and her hands began to move in elaborate movements that reminded me of "hand dancing" I had seen done by Thai performers. After some time, she opened her eyes and smiled, obviously relieved. "There," she said, "you were right. I told you and didn't tell you at the same time. My hands told you the whole story of my abuse. Now I can tell you in words."

"That's good," I thought to myself, "because I didn't get the hand thing at all." Josie went on to tell me what had happened to her. Although she knew it was irrational, she'd feared that if she told me, she'd somehow be responsible if I had a car accident or a heart attack. Telling her story was a great relief to her. Once she could find a way out of her bind, she could embrace the possibility of breaking her "curse."

The Power of Inclusive Thinking

Sometimes the key to helping someone who seems hopelessly stuck is to invite them to experience two seemingly contradictory feelings or states without putting them in conflict. What's central is the use of the word and: "You can feel tense, and you could relax. You might think you can't change, and you might be surprised to discover that you're changing. You want to change, and you're so afraid to change." This contrasts with how most people unconsciously put things together: "I have to feel this or feel that. I feel this, but I should be feeling that." Instead of reinforcing one-dimensional definitions of ourselves, such permissions go beyond mere acceptance to actively encouraging clients to simultaneously experience thoughts and feelings that they consider irreconcilable. It's as if the therapist is saying, "Your story has become too small for you. Give yourself permission to begin to envision and live out a larger story."

I remember doing therapy with a woman who'd been severely and persistently abused as a child. She lived six hours away and we met every month or so for three-hour sessions. She'd struggled with suicidal impulses for years, and the work we were doing was leaving her emotionally raw. She called one day and told me she couldn't go on in the therapy. "You're getting too close, and I feel too vulnerable," she said. "Plus you're too far away, and I can't come easily for an emergency appointment if I need one."

"I understand," I replied, "and I think this isn't a good time to end treatment. So let's talk for a minute and see if we can get you through until the next appointment. You can find a way to be vulnerable and protected. And you can regulate the distance and closeness to make it work for you. I can be right there with you while I'm here. You can be right here with me while you're there. I can be as far away as you need me to be and as close as you need me to be. And I can be far away and close at the same time." I went on in a similar vein for a few minutes--trying to establish in her a direct feeling sense that she could have her cake and eat it, too. It seemed to work. "Okay. You're right," she said. "I can do that. I'll see you next appointment."

As therapists, we must always be sensitive to the enormous life-restricting pull of either/or thinking. This abused client believed she had to be either vulnerable or safe. But there were situations in which this particular client had been able to be both vulnerable and safe. She said she felt that I was getting too close. I suspected just the opposite as well: she felt that I was too far away, emotionally as well as physically. So I included both possibilities, instead of one or the other.

Typically, when people are stuck, it's like two people trying to go through a door at once. The two are present simultaneously: I want to change, and I'm afraid to change. Inclusion expands the doorway, leaving room for both--and perhaps more--aspects of self to move freely. Merely giving language to this double presence by inviting people to recast their life stories to match their expanded sense of themselves, is often enough to free them from the insidious internal demand to see themselves and their reactions monolithically.

Not long ago, I consulted at a hospital with a woman who was depressed, suicidal, self-mutilating, and defiant.

"How long have you been so depressed?" I asked.

"Since I was 8 years old," she said.

"That's a long time. I'm surprised you've lasted this long."

"Well, two times over the years I almost succeeded in killing myself."

I was curious about how she'd kept herself alive. She told me she'd struggled against the depression so long because in some ways she wanted to live and find a way out of depression. Nobody really understood that, she added, because she was always talking about killing herself.

A few weeks earlier, I'd seen Mike Wallace on 60 Minutes interviewing a woman with a degenerative illness, who was fighting through the courts for the right to die. Wallace asked her why she was suicidal. She replied, "I'm not suicidal. I just don't want to live like this, and I want the right to choose to die." Wallace insisted that, since she was fighting for the right to die, she must be suicidal. "No," she replied, "I love life. I just don't want to live like this. I love life."

I told the woman at the hospital the story and said, "You've lived all this time because you want to live. You've made it this far, by luck, or because the angels were watching over you, or because someone cared for you at times, but mostly because you just kept yourself going. You want to die and you want to live, but you definitely don't want to live like this."

"That's it exactly," she said. "No one has understood that. I'm suicidal and I'm not!"

Now you might say that these women really didn't want to die. But I think that's the cheap version of their reality. They did want to die in a certain way, and (there's that word again) they were still alive, which spoke powerfully for their desire to go on living. Only by recognizing the complex truth of the matter, taking it seriously, giving words to and accepting these dual realities can this permissive, inclusive method work. So clients really do want to live. And the reality that you must come to terms with is that they may really die.

Practicing What We Preach

If the approach I've been laying out here was purely a matter of logic, theory, and better clinical outcomes, its principles would be more widely demonstrated in therapists' consulting rooms. But embracing clients' multiple realities inevitably leads therapists to face emotional issues in their own lives, issues that make an inclusive approach much more than a merely intellectual exercise. At least that's what my own experience has taught me. It's been one thing to give clients permission to accept their ambivalence, but quite another to do that in my own life.

Some years ago, my wife Steffanie was stricken with a painful and life-threatening illness. By 1997, she was bedridden, gaunt, and in extreme physical pain. While the doctors could offer many diagnoses, they had no viable treatments. Many told her there was nothing more they could do. Others referred her for assessments or treatments she'd already tried. She was despondent and convinced she was going to die.

I would hear none of it and found it impossible to support her hopelessness. So I unswervingly emphasized the possibilities for treatments yet to be developed, and the need to keep a positive attitude to support her immune system. I thought, of course, that this would be helpful to her, but it often had the effect of sparking terrible arguments between us.

She would tell me, "You want me to feel better, and I don't feel better. What you're saying just makes me feel worse and more alone." But at some level, I felt that if I didn't expend all my energy in fighting her pain and hopelessness, I would be giving in to it, even making it worse. I was terrified that if I accepted her reality, she was doomed and I would lose her.

Finally, help came from an unusual quarter. We'd recently moved to Santa Fe, New Mexico, and rented a house out in the country. It turned out there were some problems with the well because of leaks and some toxic materials stored in the house. I called the landlady, explained the situation, and told her that we intended to move out. The landlady didn't want us to move and, in addition to making the needed repairs, had a suggestion that could only happen in Santa Fe (or perhaps Sedona): she proposed hiring a "house psychic" to do a reading on the house and deal with the problem at a more cosmic level. Skeptical and a bit bemused, Steffanie and I decided we had nothing to lose and agreed to let the house psychic do her thing.

After a few Feng Shui-type suggestions, the house psychic did a reading for us that revealed, she said, that in a previous life Steffanie and I had been a couple living on a large estate in ancient Italy. Steffanie was the heir and I, as the new husband, had taken over managing the estate. But because I had little experience in such things, I was running the estate into bankruptcy and stubbornly refusing to listen to Steffanie, who unsuccessfully kept trying to tell me what to do. In our past life, the psychic told us, our stalemate ultimately had led to tragedy for Steffanie and I'd spent the rest of my life regretting I hadn't listened to her.

I know, I know--only in Santa Fe! But whatever its value as a past-life story, the psychic's tale was so parallel to our situation that it had an electric effect on me. I realized that I hadn't been listening to Steffanie. However inclusive I'd tried to become as a therapist, at home, I'd been determined to screen out her "negativity." As I might have predicted had I had any distance from our situation, the more "positive" I got, the more desperate Steffanie became.

Something about the psychic's making me see how stubbornness can led to tragedy made me think about my own family story. I suddenly made the connection to growing up in a household in which the unwritten injunction was "don't get sick." We kids had to be essentially on our deathbeds to be allowed to stay home from school or work. If we did stay home, we were never coddled. There was no television or other distractions. My mother, a tough farm girl, would leave some 7-Up and soda crackers by the bedside and check back every few hours to make sure we were still alive. No doctors, no medications. It was as if sympathy would somehow reinforce the illness.

From fear that Steffanie might die, I'd been reenacting an old family drama. I saw that I had to quit trying so hard to make everything okay again. I needed to let myself just be with Steffanie in her hell. I remember going into our bedroom and just lying down and holding her for a long time, without saying much of anything. Then, we quietly spoke about the pain she was in. Later, she told me that it was the first time she hadn't felt left alone in her despair. From then on, something shifted between us. I realized that accepting her hopelessness didn't mean I had to give up my own hopes for our future. I could hold them both. Soon, Steffanie began to talk about future plans and other small dreams that indicated she hadn't given up. I could, in turn, speak to her about my fear of losing her and being left alone. She's still far from well, but the tension between us has been replaced by a sense of connection and an awareness of my tendency to "go positive."

It's relatively easy for most of us to think inclusively with our most functional clients, but much harder to do so with those who are difficult and demoralized, or when our own psychological hot buttons are being pushed. But being a therapist means taking the time to get all the pieces of people's reality, spoken and unspoken. At the most basic level, we must discover how to perform the balancing act of simultaneously giving up the need to see clients change while holding open the possibility of change. This attitude requires us to face our own fears (of lawsuits, suicide, failure) and be still with the client's pain, immobility, glaring absence of change, and , at the same time, we must be able to see the "and"--that something more, unrecognized and unspoken, happening beneath the dead calm of an apparently inert sea.

Bill O'Hanlon is a therapist, author, and workshop presenter. His latest books include Do One Thing Different; Try and Make Me; Collaborative, Competency-Based Counseling and Therapy; and Even From a Broken Web. His book A Guide to Inclusive Therapy is due in early 2003. Address: 551 West Cordova Road, Suite 715, Santa Fe, NM 87505. Website:

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