Coping with Infidelity in Professional Couples

Posted on by Psychotherapy.net Team

Couples seek therapy for many reasons, but among the thorniest issues are those involving infidelity. Of course, circumstances vary widely, so it’s difficult to isolate causes that are equally relevant for all. Given that, I’ll focus on themes that have emerged with some professional couples with whom I have worked that have been married for some time (10+ years), with demanding careers, and for whom these issues arise after having children.

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They may have met in college or graduate school. They became fast friends first, and they never imagined that would change. Both were career-minded and imagined living a life of significance, healthier and happier than that of their parents. They recognized one another as good, bright and hard-working persons. They felt heard, understood, and supported. They shared a vision of life.

Then, as the demands of their careers pulled them into individual tracks of ambition and responsibility, and as they began to have children, their friendship suffered—intimacy too. It wasn’t fully conscious yet, but they had become rutted in role-based “necessities” of duty and obligation. A shift occurred from a vital pursuit of happiness to accountabilities to children, home, and career—life felt burdensome.

The Sources of Disenchantment

The relative ease with which life’s demands were managed in the early, pre-parental years were gone. Back then, there was more time, unpressured and less distracted opportunities to talk. Everything was easier then, even though financial resources were limited. So, what had their success really purchased?

The couple was left feeling that life had somehow gotten away from them. They were overwhelmed and learning that feelings are a complex and nuanced form of meaning, confusing enough to experience let alone to articulate. It was easier when there was more breathing space, when they could get away for a weekend of hiking or big-city stimulation. Sometimes that alone, without talk was enough.

Taking on work-related duties, struggling to realize career aspirations, life became more serious. Then, with kids and parenting added to the mix, along with the financial demands of mortgage, child care, and interruption to a second income; it all added up to a loss of the enchanted vision of life they had in the beginning. Exchanges became strained. Soon they decided it just wasn’t worth the effort to argue.
They began wondering “is this all there is?” Exhausted by work strain, stressed by unrelenting demands, and lacking the friendship they once provided one another, they began to foreclose on the possibility of making things better. But settling is not very satisfying is it? Thus, arises the restless yearning.

Desperate Delusions

For these couples there is seldom a desire to abandon one’s partner. Very few had seriously considered divorce even as they began to look elsewhere for affection. Intact bonds remained that coexisted with urgent needs for emotional intimacy. They could not see a way to reconnect within the marriage. It’s a cognitive, emotional, and moral quandary that they’re unable to resolve, it looks impossible.
That’s where the desperation comes in. It may be equally felt by both members of the couple. But neither is able to frame the issues, broach the conversation, and make them “discussable.” They’ve learned (come to believe) that contentious tones, demanding voices and fault-finding quickly follows. So, they conclude, “I can’t meet my needs here; the situation won’t allow it.”

What they believe they cannot achieve in reality, they seek to address through fantasy and delusion, or perhaps more benignly framed—wishful thinking. Yes, there’s also the sense that they deserve something more and better given how hard they’re working. So, they seek “justice” through a kind of “let’s pretend.” They want to believe that there’ll be no harm as long as no one finds out. Sometimes drinking helps contain the cognitive dissonance. It’s regression in service of play, to invoke Freud, and a symptom of arrested development in the marriage.

The Bubble Bursts, Work Begins

When the truth comes out, a period of crisis ensues. Soon it becomes clear that the act of infidelity only ruptured a relationship that was already suffering from deep, long-standing strains. Upon reflection, both knew things were not going the way they wanted them to. In some cases, partners had even taken separate bedrooms, started vacationing separately, becoming more roommate than spouse.
But the initial disclosure brings jolting pain. Anger, embarrassment, and betrayal are only a few of the emotions that should be expected. It’s not a victimless act. The aggrieved party is deeply hurt. And the unfaithful party frequently suffers a different shame and loss of self-respect that he or she must endure without much sympathy while seeking redemption and forgiveness.

The saving grace for many of these couples is that they usually have reason enough to at least attempt reconciliation and repair. And if they seek help soon enough, before acting out their emotions in ways that make their problem even more difficult to address, their odds improve immensely. Because they are bright and hard-working, they may be able to use that ethic to persevere with the task at hand in some or all of the following ways.

Containment. The couple must have a safe place to process their feelings, and therapy must help them learn how to do even more of this outside the consulting room. Initially, they’ll struggle with managing the intensity of their exchanges outside of therapy.

Learning. The couple must now acquire the interpersonal communications skills to navigate emotionally charged conversations that they had earlier concluded were not possible. They will learn that doing good in their relationship requires knowing how to do good.

Forgiveness. Learning that infidelity is at least partly attributable to arrested development as a couple, a lack of insight, knowledge, skill, and hope concerning what was missing and how to correct it, helps both find a way to forgive.

Forgiveness is something we do for ourselves as much as for our partner. When we lose our capacity for the love, openness, and honesty to discuss the divide that is growing between us, it is not because we willfully intend to do harm to one another. We fail due to our fears and ignorance, our desperation and loss of hope. We lose the ability to focus more on coulds than shoulds.

This is what they learn in therapy.  

Judith Grisel on Addiction, Neuroscience and Choice

Posted on by rezendevknowfully.com

The Age of Neurophilia

Lawrence Rubin: Hi Dr. Grisel. I first became aware of you when Terry Gross interviewed you on her NPR show, Fresh Air, about your book, Never Enough. You mentioned that after that interview, they led you through a room where they store the hundreds of books they receive each week for consideration. I’m wondering, why did they pick yours from that pile?
Judith Grisel: Three things I guess. One is that we are really in a time in history where we’re very interested in the brain and in science. So, seventh graders appreciate things about the brain that we didn’t even know 30 years ago, and
I think there’s a neurophilia going on
I think there’s a neurophilia going on. Second, addiction is so widespread, practically everybody is touched by it. And third, I also think on my part, being at a liberal arts university and having to speak to students about complex ideas on a daily basis, I must be able to mine the minutiae of scientific inquiry and translate and explain its general principles in a way that people can understand.
LR: That reminds me of Stephen Hawking’s tiny volume, A Brief History of Time. Bringing it to the people, so to speak. What do you hope your slender volume will do that others haven’t in this conversation around the neuroscience of addiction?
JG: My hope is that the readers who aren’t scientists will learn about and be able to appreciate the core principles of brain adaptation—how it adapts to every single drug-related repeated experience that alters the way we feel. Seatbelts and sunscreen were not considered life-saving before the research taught us differently. Now, we understand the risks of not wearing seatbelts or using sunscreen, and both are seemingly simple, but most definitely life-saving practices. I want people to develop that kind of understanding about the brain’s adaptive capacity and drug use. My secondary hope is that scientists who read it will come closer to appreciating what it’s like to be an addict. My hope is that I was able to explain that in a way that made sense to both audiences.

Our Brain on Drugs

LR: You use this term, “neurophilia.” The folks who are going to read this interview may have some neuroscience interest, background or even training. Some may be neurophobic, but many, I suspect are armchair neuroscientists using trendy brain-based buzzwords, but who don’t know how to integrate the fruits of neuroscience into their psychotherapy. How can your book and your work around the neuroscience of addiction help neurophobic psychotherapists?
JG: Well, the first thing I would say—even though I’m not a therapist (and neuroscientists don’t understand it all that well, themselves) is that
there’s a difference between understanding the implications for people suffering with addictions and simply collecting piles of data
there’s a difference between understanding the implications for people suffering with addictions and simply collecting piles of data. I think that there’s definitely a place for all voices and insights to come together and try to work on this problem. It’s certainly not as if neuroscientists have made any great strides. So, that should alleviate some fear.

I also think that scientists like me who are working at a chemistry bench top or with laboratory mice, are looking at little trees or even particular leaves on particular trees. In contrast, I think clinicians are more trained to see the big picture—the psychological and social factors beyond the brain chemistry. I think we need a lot more communication and interaction between the neuroscientists and social scientists and the clinicians actually working day to day with addicts. 
LR: I interviewed Jose Rey, a psychopharmacologist, a while back and he spoke similarly of the importance of communication between disciplines, especially behavioral scientists like therapists. But you are both neuroscientists and I worry that our psychotherapist audience needs a bit of a primer—addiction neuroscience 101, if you will.
JG: I’d first define addiction, even though there is some controversy over that, and the definition changes quite frequently as anybody who looks at the DSM would know. I would say that there are five characteristics of addiction: Tolerance, dependence, craving, the drug use or the activity needs to be detrimental to the person and to their community, and denial. Those five things coming together are what I’m interested in understanding better. And the tolerance, dependence and craving are due to the brain’s adaptive capacity.

Any experience or drug that alters our neutral or baseline affective state—and this is a little different for each person, forces the brain to adapt to try to bring the chemistry in the brain, and associated behavior, back to that neutral baseline. Some people are naturally lighthearted and happy and some are naturally a little depressive and melancholy. Whatever their particular neutral is, it is the brain’s business to try to figure that out and return to its neutral position. The pathology arises when that neutral baseline is going up and down like wild all the time because of constant ingestion of drugs, because, in part, the brain is unable to sort what’s happening and do something about it.

I drink coffee every day, and what is going on in my brain is a good example. I am completely addicted to coffee. The only good news is it doesn’t cause any problems for me, so you can say maybe I’m not addicted; I’m just dependent. When I wake up in the morning, I am unable to really think or communicate until I get the coffee. I don’t wake up like my 16-year-old does, hopping out of bed and ready to go. I wake up like I’m in a coma. I get a big cup of coffee, and then I feel normal. That is true for every drug. If you take benzodiazepines regularly to deal with anxiety, your brain produces tension and anxiety so that now the benzos make you feel okay and without them you’re a wreck. The brain does something similar, but in the other direction with opiates.

Opiates affect our neutral or baseline affective state. They make us feel great. The brain makes us feel crappy to counteract that and bring us back to an affective neutral. When we take away the opiates, then we just feel bad and miserable. And that’s true for any drug: alcohol, stimulants, marijuana. I think, if I were
working with clients, I would want them to understand that their using has diminishing returns as the brain adapts
working with clients, I would want them to understand that their using has diminishing returns as the brain adapts. 
LR: The brain is always trying to pull the body and affect back to neutral?
JG: That’s right. It’s necessary for survival.
LR: Can you quickly run through the different classes of drugs and how they affect the brain and behavior differently?
JG: Let's start with the most complicated drug, which is also the smallest molecule—alcohol. Because it's so small and can go anywhere, it diffuses easily through membranes, and acts very promiscuously throughout the brain, including making us sedated, euphoric and less anxious.

At the other end of the spectrum are the stimulants; the class of drugs that includes methamphetamine, amphetamine, MDMA. They act in particular spots in the brain to enhance the amount of monoamines—dopamine, norepinephrine, and serotonin—in the synaptic spaces. By acting locally that way, they do two things. They make you more active behaviorally, so that's why they're stimulants, and they also make you euphoric, because dopamine works more directly in the mesolimbic system.

THC also acts all over the brain, like alcohol, but unlike stimulants it has a unique mechanism of action. THC mimics the endocannabinoids which can swim upstream across a synapse—it's a really unique pharmacology. The presynaptic cell sends a message to the postsynaptic cell, which on occasion makes these endocannabinoids tell the presynaptic cell, "What you just told me was really important." It can do that all over the brain, because we never know which circuits are going to be responsible for keeping track of important things. And when it does that with THC, then the whole brain thinks things are important, which is why Rice-A-Roni is delicious when you’re stoned.

And then there is LSD and the psychedelics—mescaline, peyote, and DMT, or the stuff in ayahuasca; and those four chemicals are unbelievably selective. They're agonists, so they mimic serotonin at the serotonin 2A receptor, and that action causes the serotonin filter to turn off. So, we can think of serotonin normally as kind of dampening or inhibiting most of the neural activity in the cortex. It's like a widespread filter. And when the filter comes off, things go wild. And so, there's it's kind of unfiltered cortical activation.

The benzodiazepines and the barbiturates are basically alcohol in a pill. The difference between benzos and barbiturates is that the barbiturates can be lethal, and the benzodiazepines cannot, although they both make a mean dependence.
LR: Is this new craze around cannabidiol (CBD) products potentially problematic, because they're touted as non-addictive and non-pharmacological, but useful for everything—like pharmacological duct tape, I guess.
JG: Placebos work for everything, though it's very hard to sort the science from the hype, and I think people are completely lost. On the other hand,
CBD is not dangerous, as far as we know, and if anything, it inhibits the effects of THC
CBD is not dangerous, as far as we know, and if anything, it inhibits the effects of THC, which has been linked to psychosis. There is also some evidence that CBD can inhibit psychosis. So, CBD is not addictive and it's an antagonist to THC. There is great evidence that CBD blocks certain seizures in children. I think overall that the evidence for THC is 10 times messier than for CBD. And one important way it's messy is that we can see that acutely, it helps somebody sleep or it helps anxiety. But because you develop tolerance, my strong prediction is that those returns are going to diminish with time and, in fact, the drug will create anxiety and insomnia, which is what regular users say. They cannot sleep without it. They cannot get through a day without it.

Self-Regulation

LR: When I teach abnormal psychology to my graduate students, I discuss addictions, eating disorders, gambling and even obsessive-compulsive disorders under the broad umbrella of disturbances of self-regulation. Our society seems so hellbent on opposing the body’s natural need to regulate itself into a neutral state.
JG: I first want to point out that this is a terrific example of what we were just saying—that we need both sides. We need the information that neuroscience provides at the molecular level but also the broader perspective that your observation implies. Your broad perspective suggests that all addictive disorders can fall under the umbrella of obsessive-compulsive disorders. Maybe obsessive-compulsive disorders, in turn, are under the umbrella of self-regulation. So, I really think it’s helpful because we’re focusing on some little, tiny detail and missing the big landscape.

I do want to say that we’re absolutely clear in neuroscience that everybody’s innate capacity for self-regulation is not the same. So, some people are fortunate with metabolism of monoamines, for instance, in a way that makes them a little more cautious and less impulsive. Impulsivity certainly counteracts self-regulation. So does frontal-lobe capacity. If you have a large frontal lobe, you’re better able to do it. I think community support and teaching can contribute to that, so I think everybody’s capable of it. I’m still working on it, myself. It’s not easy for me.

I’m somebody who tends toward extremes right away. I think, just to point out another big-picture view of this, it makes sense from an evolutionary perspective that some of us would be tending toward self-regulation and conscientiousness and careful thought and consideration before acting, and some of us would be more likely to swim to the other shore right away without even considering the implications—whether it’s good for the population—because you need both extremes. So, I think if everybody were reserved or everybody was impulsive, it would be detrimental for the whole group.

I do think in certain conditions, like the ones that you alluded to now of our current social institutions, we definitely value more highly the ability to pause, and you’ll do better if you’re not too impulsive, especially with all these drugs widely available. They are high potency and easy to administer. It’s not a good time and place for people who are poor at self-regulation, that’s for sure. 
LR: You say opiates are popular because they are the perfect antidote to suffering. Are we allergic to suffering in this society? We rush to mask it. We rush to medicate it. We rush to therapize it. What is it about suffering that is so abhorrent that it drives millions to drugs and other addictions?
JG: I really love that question. It’s really out of my expertise, so it’s going to be my opinion that I give here, and I can do that best from my own experience. I really did suffer for no good reason as a child. I think I was overly sensitive and tuned in to other people’s plights and confused by the values that seemed to be expressed around me. I don’t know, but I think if I had had an opportunity to talk about this kind of existential confusion, maybe I wouldn’t have found marijuana and alcohol such a sell.

It’s almost a knee-jerk reaction among otherwise sober, sane people to suppress and deny and minimize and escape any feelings of discomfort. Maybe I’m too heavy handed here, but as someone who couldn’t afford to do that anymore, I really think my suffering was the very thing that led to the not so much happy, as the well person.
I think it’s impossible to be well if you can’t face darkness
I think it’s impossible to be well if you can’t face darkness. We don’t have a lot of ways—I know I didn’t find any—to help people face the darkness. If you’re not taking medicinal alcohol, you’re taking medical marijuana. And if you’re not taking either of those, you’re taking prescriptions. If we look at the percentage of people in western societies who are medicating their existence, we are not talking about a physical malady, so much as a psychological malady. I think it’s hard to find people who are models for walking through it. I think that might be a dead end. I have gotten a lot of notes and letters from young people who say, “This is so hypocritical. My parents say, ‘Don’t smoke weed’, My parents say, ‘Don’t do this,’ but they do these things.” I even had a therapist the other day tell me, “Well, alcohol’s not really a drug.” I think that we’re all in denial, I guess. Not maybe you, but many of us. 
LR: Well, it seems that—and I know you’ve studied evolution—that an anesthetized and a medicated society does not build a stronger society.
JG: So true. If there was ever a time not to check out, maybe you could say this at any time, but I’m saying it now.
This is not the time to escape our reality.
This is not the time to escape our reality.

Choice Versus Addiction

LR: In the latter part of your book, you say the opposite of addiction is choice. Some would argue that’s a bit on the simplistic side; especially those who say it’s a disease.   
JG: I’ve gotten a fair amount of pushback about that. We were so bad at solving addiction and the NIH and NSF were funding all this research on addiction and Congress, probably about 15 or 20 years ago, said, “What’s wrong with you guys? Fix it.” At that time, we didn’t understand how the brain works. Like the “No Child Left Behind,” they thought if they made an edict, it would solve the problem.

So, scientists realized, “Well, we’re not going to fix it if our criterion is that people are well.” So, we’ve said, now, that you can minimize the harm—reduce the harm—and that’s partly strategic to say, “Look. We are being successful.” Suboxone is better than overdosing on fentanyl. I completely agree. So, I’m not dualistic about this; that you’re either clean or you’re not and too bad. I really think every single strategy should be employed.

I think we’re diminishing our potential by capitulating to this quasi-existence where we’re not really engaged with reality but we’re also not dying. So, I think short-term strategies are terrific, but I object to giving someone a prescription for a substitute drug and sending them on their way. The causes of their excessive use, I think, need to be looked at. For me, it was a really hard, multipronged effort on my part and on the part of a fair number of professionals before I was willing to take responsibility.

This may sound trite, but
in order to be free, you have to take responsibility
in order to be free, you have to take responsibility. I think, in some cases, people don’t want that. Initially, I sure didn’t want that. I’m so grateful for it today, because sometimes I have a really rough period or day and it does occur to me, “Oh, my gosh. I would just like a brief—” 
LR: Escape.
JG: Escape. I go to the movies or take a hot bath. That’s my option. I think that surviving that, awake, looking at the factors in me that contributed to that discontent, or those things I can’t control, I think that’s powerful.
LR: Can we get back to the notion of choice as a path away from addiction. The choice between addiction and what? What did you mean?
JG: What I meant comes from my experience. When I was using, occasionally I would think, "Mm, it's probably not a good idea to use today." Like, I was going to my grandfather's funeral or I was going to be traveling on a plane, or I had a final exam, or something pretty big, you know. So, the thought would come to my head, "I should not do this." And then I would compulsively steer right for it, recognizing for a moment that it was going to be bad. It was going to hurt, cost me, but I couldn't stop.
So, I think the obsession to use is still occasionally in my brain
So, I think the obsession to use is still occasionally in my brain. But what's different is I have some space now between the thought and the act. And I guess what I meant was that having that space is the opposite, because addicts often don't want to use but it’s just inevitable because they don’t have that space.
LR: So, it's a matter of expanding that space that's left if you confront the impulse, if you wait 5 seconds, although I know it's not as easy as counting to 10 to break an addiction.
JG: Are you kidding? No, I counted to 10 many, many times, and also walked around the block and, you know, chewed on spaghetti sticks and just kind of disconnect that habit part of my brain, the striatal part, which
by the time you become an addict, you might as well be a rat in a cage, because it's just press the bar, press the bar, press the bar
by the time you become an addict, you might as well be a rat in a cage, because it's just press the bar, press the bar, press the bar. Even if nothing is coming out.
LR: Like you said, helping build a tolerance to those spaces that feel like crap or those existential spaces where life doesn't have any meaning and life is still not going to have meaning after you stop using. It's how to deal with that lack of meaning.
JG: Yeah, or disappointment, which is a huge trigger for people like me, because disappointment is sort of low dopamine, you know? But I think that a therapist can have a great role here. Instead of trying to avoid the obsessions, to experience the obsessions with somebody who helps us get that distance would be useful. I remember it slowly dawning on me, wow, just because it occurs to me doesn't mean I have to do it, and that was a novel thought.
LR: Where do you land on the debate between those who advocate abstinence versus controlled use, and how can you help therapists understand that distinction?
JG:
I am not against drug use. I am really against addiction
I am not against drug use. I am really against addiction. I don’t think there’s good evidence that people who are addicted can manage a controlled use, ever. Sometimes, they grow out of it, if they’re young enough, so that can happen if they get stopped really early like before they’re 20. The way I think of controlled use is being on a perpetual diet at a holiday party. It’s just miserable because—and for me, it really would be. How can I control myself? There are all these tasty things. So, it’s just the cost—I think the goal should be freedom. I think that’s hard for most people like me to imagine if I was trying to manage my drug use. I’ve heard a million creative ways of doing it and they all look miserable.
LR: What about the difference between those who have a bone fide addiction and those who are midway down a punitive trajectory?
JG: I guess I would ask you a question about that. When I was in abnormal psychology—and this is in the ‘80s—I thought that my teacher told me that the understanding of pathology was qualitative. So, you’re either sick or you’re well, basically. I thought that seemed surprising, but it was a great relief because I was among the well, I thought, for most things. My understanding of the way it is now is that we see most disorders as spectra and at some point, normal functioning becomes pathological.

For addiction, I think that, at some point, the reward pathway—this mesolimbic dopamine pathway that mediates the pleasure we get from addictive drugs–becomes altered. For some people controlled, moderate use—making other things like your children’s wellbeing, for instance, more important than your getting high—those kinds of things become impossible. I guess I see that in my own life. What happened is all I really cared about was drugs. There was nothing—no consequence—that I wasn’t willing to pay. I basically gave it all away so I could have this momentary escape. I think that is so compelling for some of us, either at birth or as a result of experience or probably both, that it’s a point of no return. I think age might influence that. 

I’m really concerned for kids. We know 80 percent of substance abusers—people who have addictions—start before they’re 18. Using moderation or avoiding excessive use before their brain is done developing around 23 or 25 might be the way for them to avoid addiction. I think it’s possible, then, to grow out of it, if you can back away.
Maybe addictions that develop in adulthood might be neurologically different than the ones that come on early
Maybe addictions that develop in adulthood might be neurologically different than the ones that come on early.

Teens and Drugs

LR: That’s interesting because a lot of therapists in our audience work with adolescents who live in a very confusing world full of stress, contradictions, widespread drug availability and increasingly pro-marijuana legislation. What must these therapists understand?
JG: The one thing I didn’t understand was: since when do adolescents worry about death? Don’t they think they’re immune to it? Isn’t their ability to self-regulate naturally and appropriately diminished? Isn’t this the time in life when they’re supposed to be taking risks?

I just want to say to the psychotherapists working with adolescents that this seems to me to be incredibly important. For children growing up today, it is, as you say, unbelievably confusing and drugs are everywhere. You can smoke pot now in school right in your seat where you’re taking your math test with no one knowing it. I think that it’s a treacherous time to try to find yourself and a place for yourself in such a confusing world. I think that our future depends on these kids.
LR: How do we convey the information of neuroscience and addiction to adolescents without their eyes rolling back and them dismissing us? Do we do it through the parents? Do we do it through the therapists? Do we teach adolescents about neuroscience and about the vulnerabilities of their brain and their neurocircuitry?
JG: I think that the kids in my town are very interested in neuroscience and I think most kids are interested in information. One of the things that’s really had a big impact, surprisingly, because they don’t worry about their own death so much or their own mortality, is this idea of the transgenerational effects from epigenetics. There was pretty alarming data piling up and we don’t understand it so well.

We understand the mechanism but it just seems incredibly inconvenient that if an adolescent is exposed to a drug like marijuana or alcohol and then grows up normally—doesn’t get any more of the drug, the offspring of that adolescent partier are prone to anxiety and depression and higher self-administration of drugs of abuse. I have to wonder if the epidemic of anxiety and depression is in part due to what our parents were doing in the 60s and ‘70s. Talk about a complicated, systemic way of understanding suffering, so that you reap what you sow. Also, most of the blame has been on the mothers, on the women who, somehow, were crappy. In fact, we know that the pathway for the sperm through the epididymis is marked by these experiences. We have a mechanism for how this can happen. Fathers to sons and grandsons is clear in the lab. Another analogy for even younger people that I talk about—and I don’t know if this will impact them or not—but it’s almost like you have a bank.
You start out with a certain amount of money in your bank and that’s your affective state. When you use a drug to feel great, you’re withdrawing from that. It is always the case that you have to pay it back; quickly or slowly.
You start out with a certain amount of money in your bank and that’s your affective state. When you use a drug to feel great, you’re withdrawing from that. It is always the case that you have to pay it back; quickly or slowly. 

So, a hangover is a little payback of the great time you had last night but there is no influx of funds coming from any place else. They have to come from us, so that’s why, if you withdraw a little bit at a time and you put money in, maybe, by learning the kinds of self-regulation and purposeful nourishing of yourself and your goals, having a little treat every now and then isn’t going to cause bankruptcy. 
LR: So, parents of adolescents might benefit from a far less restrictive approach to substance use. It might be helpful for therapists to help parents of teenagers not get so crazy about occasional or small-dose usage, rather than talk to the parents about the importance of absolute abstinence.
JG: If we had a perfect world, I would say nobody would overdo it.

I think kids don’t listen to parents making rules so that’s not a great strategy because you cannot enforce this. They do what they do. I hesitate to say, “Help them do it at home,” or, “help them learn moderation,” because, really,
any time the brain gets a big enough taste of a drug to feel great, especially in adolescence, that’s likely to have a lasting impact in the opposite direction
any time the brain gets a big enough taste of a drug to feel great, especially in adolescence, that’s likely to have a lasting impact in the opposite direction.

So, I’m quite convinced that my brain is less sensitive to pleasure and reward, so that when I got married or had my daughter or any other kind of peak experiences, which were good, they might have been even better if I hadn’t dampened my sensitivity to that. While we know this to be the case, I agree with you, though, that coming down hard and fast is a waste of time.

It’s impractical. In general, I tried to bribe my children. I said, “If you can not get wasted until you’re 21, I’ll buy you a plane ticket anywhere.” That’s what I would like. I don’t think it worked but I do think they’ve, in some way, taken it to heart. I mean, we talk about it an awful lot. 
LR: I’ll bet you do.
JG: I put different pictures of the brain impacted by drugs in the book, by the way, because I think those pictures have an impact on kids. So, seeing how chronic pot smoking decreases the number of brain receptors that respond to pot, I think that might help.
LR: Well, there’s also the irony or maybe a paradox that—as you said in the beginning—teenagers are invincible. They see themselves as unbreakable. Unless they’ve had real adverse experiences with alcohol or pot, beyond a bad hangover the next morning, they haven’t been threatened with death. They don’t see their synapses deteriorating. They don’t see brain centers shrinking. So, at a point where the most damage can be done, they’re least amenable to contradictory information. It’s tough.
JG: I have heard, though, from dozens, maybe hundreds, of kids, 15, 16, 17, 18 who completely identify with the lost, empty feeling that they cannot get enough of a drug. If these kids can stop early, their brain is much more capable of restoring things than it would be if they wait ‘till their 30. So, on the other hand, just because they have an increased risk of developing addiction, they also have an increased aptitude for recovering. Maybe this is a unique opportunity for them to begin to understand that these drugs really are so potent and so widely used, that it really is a dead end.
LR: Are you suggesting that it may be more therapeutically useful to point out to adolescents how crappy they feel when they’re not using the drug because the brain is trying to adapt, than how crappy or perhaps stupid and self-destructive they were feeling and acting when they were using the drug?
JG: Absolutely.
LR: So, the real danger is in what their body is experiencing when it’s craving or when they’re doing ridiculous and/or destructive things to acquire the drug.
JG: For me and for many pot smokers, what that looks like is that everything is just completely boring and flat and uninteresting. I mean,
I remember not caring about anything unless I was stoned
I remember not caring about anything unless I was stoned. That is profoundly painful. It’s a big deal.
LR: So, it’s helping our young to build up resistance to feelings of loneliness. To existential pain. To sadness. To injustice. Giving them the skills not so much to battle addiction but to battle the natural response to the pains of life.
JG: I’m interested that you say battle it. I guess I wouldn’t expect that. Is it that we want them to battle the pains or do we want them to negotiate the pains?
LR: Negotiate.
JG: Yeah, and one way that’s helped me a lot is to realize it’s overwhelming if I look at everything. If I just pick something that’s important to me, one thing that’s important to me, and live my life to show that, then that’s enough. I don’t have to get overwhelmed by what’s going on in Yemen or what’s going on with the rising water—these are things that are beyond my scope, but I can do a little bit and that is, I think, maybe a message that’s lost to them right now. That there’s a place for each of us.
LR: I guess the irony, also, is that because they have increased cognitive ability and they can think about thinking and think beyond their skin, the problems of the world become their problems—they have to worry about everything at once. They’re not worrying about Yemen or Syria or rising tides or climate. They’re not doing their job, but it’s in taking on the world just because they can that they forget to take on themselves and what they can control.
JG: Then, you point out the incredible irony, which is that they’re aware of all of this, and how do they deal with it? They completely erase it all by getting high, and by becoming withdrawn into themselves and their own private mental state which is being further manipulated by the drugs they are using. It’s simply not functional or adaptive.
LR: It seems from what you’re saying is that the antidote to addiction is connection.
JG: I think so. Connection! I mean, this is probably, blatantly obvious, but requires another side. Others who need us. I don’t think we can do it outside of the support of wise people. Connecting to art. Connecting to our bodies. Connecting to the earth. Connecting to mentors.
LR: Therapists can play a very powerful role, there.
JG: Absolutely.

Loose Ends

LR: May we shift gears here for a bit because I have, and I know our readers have, so many more questions, like about the recent FDA approval of esketamine nasal spray for severe depression.
JG: Every new drug, when it comes out, has all kinds of promise and no side effects and that turns out to be true for a few months, until we get some data. I think
it’s absolutely clear that the existing pharmacological treatment we have for depression is largely useless
it’s absolutely clear that the existing pharmacological treatment we have for depression is largely useless, and if nothing else, is really benefiting drug companies.
LR: Thomas Szasz’s notion of “pharmacracy,” government and control by and for the pharmaceutical industry.
JG: I don’t think we have good pharmacological interventions, going back to what you said earlier. I think we are a society always looking for a quick fix. I’m not against this. What I like about this new drug is it’s finally a novel mechanism of action. It’s also not something you take every day. The chemical esketamine, though, is a little bit of a baloney because the drug that it’s copying, ketamine, is cheap and old. What do they have to do, because the patent’s out on that? They have to develop a fancy version on that, which is no more efficacious, but it’s going to earn a lot more money.

I think people are desperate for treatment for depression. There are so many people who are pleading, “Please, let me have brain surgery to alleviate my depression.” So, we clearly need something. I don’t think that it’s going to be a magic bullet, but maybe it’s good to see some movement in that area. 
LR: We may start seeing esketamine clinics and esketamine overdoses and illicit copies of esketamine. It will be helpful to some perhaps, but will the societal consequences be far worse?
JG: You know, it’s possible. It’s a dissociative anesthetic. It’s Special K, basically, which is abused.
LR: You mentioned that women metabolize alcohol and some drugs differently than men because of the greater distribution and density of fat, as opposed to muscle. I know you’re not a therapist and I’m not asking you to be one, but you have some really good insights and you’re raising a young person. Do we have to work differently in therapy with girls and women as opposed to men and boys?
JG: Oh, my gosh. That is worth an hour in itself. I think it’s critical. We basically did 96 percent of our research until the turn of the century on white males. They are not the default population, so it turns out—especially with drugs of abuse,but much more than anybody suspected—women respond differently. That’s evident in the clinic because
women progress toward addiction and to toxic side effects much more quickly than men
women progress toward addiction and to toxic side effects much more quickly than men.

Women need lower doses. I think the reasons for using are different. I suspect—and it’s borne out by some data that’s accumulating—women use drugs more to cope and men use more to get off—to enjoy it. Those are really two different things. I think for men anger and resentment are big precipitating factors. For women, anxiety and insecurity are the precipitating factors. 
LR: So, as you said earlier in the interview, we need to address the core issues that girls and women struggle with by virtue of being girls and women in a patriarchal society. Do you have any final thoughts you’d like to share with our readers?
JG: I think the conversation was really enriching for me because I think we are both interested in the same goals but from different perspectives. I think it’s important to have these conversations, these bridges between what I know and what you know and our shared experiences from these different sides. So, I think that was really pleasant and novel for me because everybody only wants to talk about the brain molecules, evading these big, important, systemic, and social and spiritual questions.
LR: Did I betray my roots? My psychosocial roots?
JG: I hope so.
LR: You really have some powerful insights and I think your wisdom goes beyond mice and the lab. I think it also transcends neural circuitry. I think you understand the bigger issues and I hope more neuroscientists recognize the importance of the psychosocial elements of addiction and disease. I did an interview with Allen Frances a while back. He, like you, thinks that we really need to create bridges between the scientists—the behavioral scientists and the neuroscientists.
JG: Can I tell you, lastly, why I think you don’t have to worry about that? The neuroscience is not yielding answers. So, it’s going to be the data itself or the lack of data—the lack of understanding, the lack of impact—that brings us back to the wider community—to these connections outside of ourselves. As I say in the book, we thought that the brain was acting like Oz behind the curtain.
Now, we realize, “Oh, the brain is just a way that the environment influences us.”
Now, we realize, “Oh, the brain is just a way that the environment influences us.” We are coming full circle, I think, and we will, eventually, get to the same place where we realize everything’s social, psychological and biological.
LR: So, what do you say to those psychotherapists out there who are addicted to neuroscience research and who have fallen in love with the brain and who are rabid neurophiliacs?
JG: I would say they don’t understand it. I guess they’re selling something but it’s not understanding. It’s not wisdom.
LR: So, psychotherapists need, as you said, to position themselves along the spectrum somewhere between the extremes of neurophilia and neurophobia?
JG: Absolutely.
LR: On that note, Judy, thank you so much for sharing your time, research and wisdom with our readers.
JG: Thank you.

Finally Getting Sober

Posted on by Psychotherapy.net Team

The email from my former client arrived on a recent Wednesday morning.

I smiled as I read it, “Just thought you would like to know that I’m celebrating my first year of sobriety and with no slips! Thanks again for all your help.”

Pausing to reflect on our work together over a three-year period of regular and very challenging therapy sessions, I marveled at his present sobriety, given how severe his drinking had become. When he had arrived at my office in early 2016, he was consuming up to two bottles of wine a night and was often experiencing blackouts.

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As with all my clients who struggle with substance abuse and related issues, we had started our work by examining the criteria for a substance use disorder, and in his situation, an alcohol use disorder. He had met 6 of the 11 criteria, including some of the most common issues I look for including tolerance and experiencing regular cravings for alcohol. It had helped my client build his motivation to change when he realized that his drinking habit was actually a diagnosable disorder, and it had allowed him to puncture some of the denial he was experiencing about the severity and destructive nature of his alcohol use.

Once we had established that he did indeed have an alcohol use disorder, I had asked about his drinking goals. I have learned that it is important to not assume a client wants to get sober. In fact, most clients, even those with severe substance issues, generally want to strive for moderation rather than abstinence. If they sense I have an agenda for them to quit, they often withdraw from therapy prematurely. Thankfully, my client had recognized that he was unable to drink moderately and was committed to finally getting sober–complete abstinence.

We had started our work with the goal of gradually reducing his drinking, with the idea that if he was unable to significantly alter his intake through individual therapy, we would consider outpatient treatment centers to further support his recovery. We aimed to reduce his drinking by 25% each week, as this would be sufficiently challenging while not overwhelming. I had asked him about his daily drinking patterns, and we paid special attention to his triggers. For him, fights with his partner would leave him feeling frustrated, angry and alone, and would inevitably lead to heavy drinking that night. He would also associate arriving home from work with going directly to the fridge to pour a sizable glass of wine, often before he had even removed his coat. Another potent trigger was social functions associated with his job—he would often drink too much and not remember much from the previous night.

“The key to getting sober is to anticipate which evenings will be threatening to your sobriety and then develop a concrete plan to get through them,” I had told him.

Each week, we spent time talking about upcoming events that worried him because there would be alcohol present. We worked out how many drinks he could have based on our reduction goals. We also reduced the window of time where he would be out of the house, thereby giving him less time and opportunity to drink. He would arrive late to the various events and leave early. We also discussed some effective strategies he could use, such as having a big glass of water between each drink, eating a meal before going out to slow the absorption of the alcohol, and only bringing the necessary cash to buy our predetermined number of drinks—he would leave his cards at home to reduce temptation.

At the beginning of each session, we would review how the previous week had transpired and we would adjust our goals or strategies accordingly. I would often remind my client that getting sober is not a linear process, there will be inevitable slips and even potentially full relapses. I assured him that this was normal and reminded him to not be too critical of himself if he drank too much one night. He just needed to continue moving forward, learning from his slips and applying that knowledge to the next experience.

My client had struggled in those initial months to meet our goals for reducing his drinking, so we had agreed that he would also start attending Smart Recovery, a weekly support and psycho-education group. This additional support was what he needed, and we began to see a steady decline in his overall drinking.

Several months into our work, I recall him arriving at our session one morning and he was beaming. He sat down, stared at me and waited for me to ask, “How did it go this week?”

“I didn’t drink a thing,” he reported through a smile. “I can’t believe I actually did it.” My client was ready in every possible way to change his relationship with alcohol and worked diligently toward that goal.

I was brought back to the present moment with the sound of my kids demanding something from upstairs. I quickly reread his email, felt quietly proud for his recovery, and continued with my day, a bit lighter. 

That Certain Feeling: “How Ya Gonna Keep ’em Down on the Farm (After They’ve Seen Paree?)”

Posted on by Psychotherapy.net Team

I used to drink bad coffee. Growing up with canned Maxwell House, how would I have known any better? Coffee shops at college served percolated coffee, which wasn’t any better. The paper filter and easy access to whole roasted beans changed things. I didn’t really want to taste the difference, because I thought the procedure of grinding and pour-overs was snooty, and because in fact the flavor (which I now recognize as “coffee”) set a new standard of expectations. It wasn’t only that I knew that from then on that there was something I had been missing; it was also that I knew not to be satisfied with less. I suppose I might move to an even higher standard someday, if exposed to something even more delicious and not too expensive.

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One thing all kinds of therapy have in common is that they produce and consolidate certain feelings and psychological states that clients are not used to experiencing. For example, a depressed client might have a moment of joy, or an anxious client may feel serene. Technique aside, if the therapy dyad or the couple or the family can appreciate the moment, a number of positive consequences may follow. The client might have proof that she is capable of serenity, for example, or a couple may recognize that they are capable of making each other laugh, or a family may see that a disruptive child is capable of cooperation. The focus then turns from whether the client is capable of positive behavior to when, under what circumstances, this occurs, and how to reproduce it.

Once a desirable feeling or psychological state occurs, clients can see what they are missing and begin to insist on it. The depressed person becomes motivated to change not by a promise of paradise but by a taste of honey. Parents relinquish the self-protection of “nothing works,” and they try to reproduce the cooperation they experienced firsthand. Just as I never knew what good coffee tasted like, some people go on dates and don’t know what curious attention feels like. They don’t then insist on it (by not continuing to date someone who doesn’t provide it). They also drive away people who do provide it, since their prospective partner’s curious attention falls on deaf ears, and the partner feels the way talented baristas feel when they prepare a delicious cup and the customer gulps it down without tasting it.

Virtually every client can be construed as wrestling with aspects of themselves that don’t fit the narrative they are promoting, internally and externally, about who they are. In whatever manner those ignored aspects of the self eventually get integrated into the total self, it goes more smoothly if they are seen as natural and welcome facets of the human condition. Thus, the feeling of being understood is central to therapeutic growth. Once the marginalized aspects of the self learn what this feels like, they can insist on it. (I’m talking about feeling understood, which is different from being catered to). Clients are then likely to stop doing things that defensively drive away other people, because the feeling of being understood undermines a sense of being repulsive or unacceptable. Clients who feel understood are likely to seek opportunities to feel it again, and collaborative, mutual relationships follow.

Therapists are people, too. No therapist can provide a collaborative mutual relationship if they don’t know what it feels like, and no therapist can provide it in therapy if they know only how to provide it in romance or friendship. You don’t necessarily need to have felt truly understood in your own therapy to become a good therapist, but it helps, just as drinking great coffee is a good foundation for becoming a master roaster. Therapists can also feel understood in supervision or peer consultation groups, where showing mistakes plays a role similar to revealing marginalized aspects of the self in therapy.

Seven Mistakes in Clinical Supervision and How to Avoid Them

Posted on by Psychotherapy.net Team

Clinical supervision is the “signature pedagogy” of choice in psychotherapy (1). I’ve benefited a great deal from the lessons of my supervisors. Some of their words from a decade ago not only still echo but have become first principles I keep close in my own clinical and supervisory work and teaching. Most of us regard clinical supervision as highly integral to our professional development. It’s hard to imagine not having someone to turn to for case consultation and guidance, especially when stuck in a rut and not making expected or desired progress with a particular client.

Supervision and Clinical Impact

Given the benefit we often feel from clinical supervision, the logical next question to ask is whether clinical supervision actually translates into meaningful impact on our client’s wellbeing? About 8 years ago, Edward Watkins Jr., a researcher from the University of North Texas, conducted a review of 18 empirical studies that examined the impact of supervision on client outcomes. Based on the big picture analysis, Watkins said “…the collective data appears to shed little new light on the matter. We do not seem to be able to say anything new now, (as opposed to 30 years ago), that psychotherapy supervision contributes to client outcomes.” (2)

More recently, a team of researchers set out to investigate this question based on a large five-year dataset comprising 6521 clients seen in naturalistic settings by 175 therapists and guided by 23 clinical supervisors (3). Not only did factors such as supervisors’ experience level, profession (social work vs. psychology), and qualifications not predict differences between supervisors, the role of clinical supervisors explained less than 1% of the variance in client outcomes. Said in another way, and contrary to expectations, clinical supervision as we know it has little to no significant impact on improved outcomes in the lives of our client’s lives.

Taken together, we may very well feel the benefit from clinical supervision, but it doesn’t seem to translate into improved clinical outcomes.

Rethinking Clinical Supervision

This begs the question. Why is clinical supervision not translating to actual improvement of client outcomes? Given that we invest so much time and effort in our “signature pedagogy,” perhaps we need to rethink our current practices in supervision. Drawing from the existing psychotherapy evidence and the development of expertise literature outside of our field (4), here are seven supervisory mistakes I see us making, along with speculation on how these relate to apparent clinical stalemate:

1. Too Much Theory Talk

2. Pat-on-the-Back

3. Lack of Monitoring Client Progress

4. Lack of Monitoring Engagement Level in Supervision

5. Not Analyzing the Game

6. Overemphasis on the Self and Neglecting the Impact on Client

7. Lack of Focus on Therapist’s Learning Objectives

8. Too Much Theory-Talk

Often, the clinical supervision encounter revolves around cases discussion, case formulation and theorizing about the clinical pathology. This fits under the umbrella of clinical conceptual knowledge and does not actually delve into moment-by-moment interactional patterns that unfold in a therapy hour. We often end up waxing lyrical on how a case may be conceptualized in a psychodynamic framework or in an emotion focused or from a CBT perspective. Not only does this disembody the conversational nature of reality in therapy, we assume that the key is to obtain a thorough case formulation of the problem at hand. In 1939, Carl Rogers aptly pointed out, “…A full knowledge of psychiatric and psychological information, with a brilliant intellect capable of applying this knowledge, is of itself no guarantee of therapeutic skill.” (5)

2. Pat-on-the-Back

In my work with supervisors and therapists, I often hear this chant, “…But your client still comes back to see you right?” In actuality, a small percentage of clients (~10%) account for the largest percentage (~60-70%) of behavioral health care expenditures, showing a continued use of services without successful outcomes (6).

While it is vital to take care of the supervisee’s sense of self, what feels good doesn’t equate to what helps us grow. About a third of our clients continue therapy without experiencing reliable improvement in their well-being. If we continue to bolster their esteem with praises or consolations without helping them identify their growth edge and improve the outcomes of “stuck” cases, we are doing our therapists and clients a disservice.

3. Lack of Monitoring Client Progress

We therapists are an optimistic bunch. In the absence of real-time monitoring of outcomes and engagement, session-by-session, we fail to detect deterioration and dropouts. A groundswell of studies now show that the use of measures such as a real-time feedback tool not only reduces deterioration in client well-being by a third, but cuts drop-out by half, and as much as doubles the overall effectiveness of therapy (7). Even when we use routine outcome monitoring devices, like the Outcome Rating Scale (ORS) & Session Rating Scale (SRS), Outcome Questionnaire (OQ-45),or Clinical Outcome Routine Evaluation-Outcome Measure (CORE-OM),we fail to meaningfully integrate this into the supervisory process. We stick to using the measures as an assessment tool, and not as a conversational tool.

4. Lack of Monitoring Engagement Level in Supervision

For those of you who are already using routine outcome measures as a source of feedback, you know that it’s hard for clients to give feedback to the therapist. It’s also hard, if not harder, for a supervisee to provide feedback about the engagement levels in supervision — especially if the supervisor is a colleague.

The reality is, supervisors have a tough enough job of ensuring that their input has a ripple effect not only on the therapist, but also on their clients. Having some kind of formal procedure to elicit what’s been working for the learner can help the process of focus. In addition, given that supervisors and supervisees might have overlapping roles or collegial bonds outside of supervision, having a formalized feedback procedure in supervision allows for both parties to take a pit stop and address issues in real time — not 6 months down the road when it’s too late — that might be brushed aside.

5. Not Analyzing the Game

In any other domain of performance (e.g., sports, music), if one were to seek a coach’s help in improving their game, it would be unheard of for the performer not to analyze her performance. Yet, in the field of psychotherapy, we do less of examining the moment-by- moment dynamics of the therapy hour and more theorizing (see point #1). Most supervisors do not use the practice of watching snippets-segments of the video recording highlighting specific areas that the therapist can work on.

Much like other fields (music, sports), it’s important to record sessions in order to receive feedback about actual performance rather than feedback about a perceived or reported performance. Feedback is useful when it’s based on a well-defined objective, observables, and specifics.

6. Overemphasis on the Self and Neglecting the Impact on Client

You may not agree with this point, but there is an over-emphasis on the self of the therapist at the expense of impact on the client. Too much supervisory time is spent on superfluous issues such patting the supervisee on the back (see # 2), while not enough time is spent on using real-time progress monitoring to guide the conversation (see #3).

7. Lack of Focus on Therapist’s Learning Objectives

Finally, I would argue that there is a lack of focus on the therapist’s learning objectives. This is one of the four tenets in deliberate practice (8). (Stay tuned as we will cover this in future blog posts). This may be the most vital yet lacking element in a practitioner’s professional development. Too often, we engage in clinical supervision on a case-by-case basis, with no coherent thread weaving in the therapist’s learning needs and clinical case concerns. Even when we do so, there is often a lack of systematic tracking of the supervisee’s development. As useful as client feedback is to clinical practice — spotting anything glaring or missing and pointing out if the session is on-track or not — this does not help therapists improve on their therapeutic skill, based on the developmental stage of their profession.

Consider another example: A top musical performer does not benefit from the feedback of the crowd (the decibels of the audience’s applause, the verbal comments about the performance, etc.), as much as the nuanced and specific feedback they might receive from their maestro or producer.

***

In the upcoming blog posts, I will cover each of the seven points raised about the flaws in our default ways in clinical supervision, and I will provide specific pathways out for each of them.

References

(1) Watkins, C. E. (2010). Psychotherapy Supervision Since 1909: Some Friendly Observations About its First Century. Journal of Contemporary Psychotherapy, 1-11

(2) Watkins, C. E. (2011). Does Psychotherapy Supervision Contribute to Patient Outcomes? Considering Thirty Years of Research. The Clinical Supervisor, 30(2), 235-256.

(3) Tony G. Rousmaniere, Joshua K. Swift, Robbie Babins-Wagner, Jason L. Whipple & Sandy Berzins (2014): Supervisor variance in psychotherapy outcome in routine practice, Psychotherapy Research, 26(2), 196-205.

(4) A. Ericsson, K. A., Hoffman, R., Kozbelt, A., & Williams, A. (Eds.). (2018). The Cambridge Handbook of Expertise and Expert Performance (2 ed.). Cambridge: Cambridge University Press. B. Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.

Miller, S. D., Hubble, M., & Chow, (2020). Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness. American Psychological Association.

(5) Carl Rogers, 1939, p. 284 The Clinical Treatment of the Problem Child.

(6) Lambert, M. J., Whipple, J. L., Hawkins, E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W. (2003). Is It Time for Clinicians to Routinely Track Patient Outcome? A Meta-Analysis. Clinical Psychology: Science and Practice, 10(3), 288-301.

(7) Schuckard, E., Miller, S. D., & Hubble, M. A. (2017). Feedback-informed treatment: Historical and empirical foundations. Prescott, David S [Ed]; Maeschalck, Cynthia L [Ed]; Miller, Scott D [Ed] (2017) Feedback-informed treatment in clinical practice: Reaching for excellence (pp 13-35) x, 368 pp Washington, DC, US: American Psychological Association; US, 13-35.

(8) Chow, D. (2017). The practice and the practical: Pushing your clinical performance to the next level. In D. S. Prescott, C. L. Maeschalck, & S. D. Miller (Eds.), Feedback-informed treatment in clinical practice: Reaching for excellence (pp. 323-355). American Psychological Association.

Questions for Thought and Discussion

What kind of clinical supervision do you value and why?

Which of the author’s seven mistakes have you or do you currently engage in?

What have you done recently to improve the quality of your clinical skills?

What style of supervision do you practice, or would like to practice?

Tips for Working with Vegan Clients

Posted on by Psychotherapy.net Team

What do you do when a potential new client calls and asks if you work with vegan clients? Perhaps you say no because you never have before (or didn’t know you had) and don’t know much, if anything, about veganism. Maybe you say yes but are not sure what working with a vegan client might entail and figure you’ll wing it and hope for the best. And then it’s highly possible that no one has ever asked you that question. I think it’s fair to say that most of us don’t have experience working with every issue nor with every population that contacts us. However, as veganism continues to grow, it’s increasingly likely that we’ll be finding more vegans reaching out to us.

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The one question I am continuously asked is, does eating a diet free of animal products in itself make a person vegan? The short answer is no. The longer answer is eating plant-based is a major part of being vegan, but veganism isn’t just about what people eat; it’s about the way one views and treats all animals, human and non-human. People following a vegan lifestyle can’t help thinking about the exploitation of animals because they’re continuously confronted with it. Sitting next to people eating meat, walking behind someone wearing fur or leather, or overhearing conversations about hunting and fishing trips or visits to circuses and zoos, are all constant reminders. In my clinical experience, the thought of institutionalized animal exploitation is what prompts many vegans with whom I have worked to seek therapy for depression, anxiety, relationship issues and sometimes, trauma. How these issues may manifest in a session can be illustrated in my work with Tessa, a former client.

When 32 year-old Tessa contacted me, she announced that she was vegan and had been searching for either a vegan therapist or, she quipped, one who was “vegan-friendly, like a restaurant.” Consequently, I had a hunch her issue(s) would be vegan-related. However, I had worked with individuals requesting a vegan-friendly therapist where that wasn’t the focus-?they just wanted assurance I would be supportive, if the issue came up. And it did come up with Tessa. Parenthetically, my therapeutic style is direct and eclectic. I have been influenced by various therapeutic approaches, including psychodynamic, Somatic Experiencing, hypnotherapy, cognitive/behavioral, ecotherapy, Internal Family Systems, and Existentialism. I believe we must look not only inside ourselves for what ails us but also to our relationship with the world around us. In this context, I work with individuals who are grappling with a wide variety of issues including, but not limited to relationships, life transitions, animal bereavement and ethical veganism, which is both a mindset and lifestyle practiced by people who care deeply about all animals and oppose harming them in any way.

Tessa smiled weakly as she slumped onto my couch, silent for a few moments. She had been feeling “very low, very anxious. My heart races or my stomach feels like someone’s on a trampoline.” Her difficulties began after watching two videos detailing animal exploitation–she used the words, “animal abuse.” She transitioned to a vegan lifestyle after seeing the second video. Tessa felt immense guilt “that she had been part of the problem,” chastised herself for “not knowing sooner,” and felt “hopeless about the situation.” When confronted with the frequent images of animal abuse on social media, she’d break down. Often these images would spontaneously pop into her mind.

When discussing this subject with family and friends, responses were dismissive of her and/or the issue: “there are more important things to worry about”, “you’re being way too sensitive”, “get a life!”

Before reaching out to me, she had been seeing another therapist. While the “person was very nice,” her questions repeatedly intimated that the root of Tessa’s problems lay elsewhere. Consistently feeling misunderstood, Tessa ultimately decided to find a therapist “who got that someone could be depressed thinking about all the abused animals in the world.”

In working with Tessa, I took a three-prong approach. My first goal was validation that sensitivity to animal exploitation could lead to depression and anxiety. She also needed to trust I could handle her intense emotions, without judgment.

My next objective was helping her find effective ways to calm herself when triggered by disturbing images, thoughts, or conversations. I used various techniques, including several from somatic experiencing and hypnotherapy. For example, I helped her transform distressing images into ones less fraught. Intrusive thoughts about animal abuse were attenuated by both diverse breathing techniques and anxiety-reducing visualization exercises. To recharge and reset, she created a mental image of a special place, one filled with calming images, sounds, and smells. Formerly a meditator, I suggested she resume her practice to help let go of unwelcome thoughts. Reducing her time on social media was also discussed.

The third prong was to address her hopelessness by exploring options for helping animals. Because everyone has different talents, interests, and time constraints it was important that whatever actions we came up with were realistic. Being a “people person”, she decided to research animal welfare groups whose focus was public outreach. Tessa loved planning and hosting parties so organizing fund-raising events for animal organizations sounded appealing.

Within a few months, Tessa began feeling better. She now had tools for calming her mind and nervous system and strategies for advocating for animals. Perhaps most importantly, she felt she had been understood.

As you can see, the techniques for working with vegan clients are the same we’d use with anyone else. So with this newfound knowledge and an open mind, the next time someone calls and asks if you know anything about working with vegans, you can say, absolutely!  

Anxiety Management: It

Posted on by Psychotherapy.net Team

Les relâches is a winter break that every Swiss public-school system takes in February, though the actual dates vary from canton (state) to canton. In French, “la relâche” means “rest,” but as this week usually involves skiing in Switzerland, it is the least restful week of my year! Personally, I call it anxiety management week. It is the one week every year that this psychotherapist becomes her own private client. I set a goal each time to try to keep up with my family on the trails for at least a couple of hours during the week. Sometimes I succeed, but, mostly, I just keep trying.

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During ski week, my empathy skyrockets for past and current clients who combat anxiety on a daily and sometimes hourly basis. I join their ranks in that need for anxiety management anytime my personal context intersects with a few notable laws of physics that involve speed and momentum. I employ copious doses of the cognitive, behavioral, and affect regulation strategies I often prescribe to the people I work with. These strategies become my lifelines on those steep mountains, which are crowded with other skiers who could literally carve laps around my effort-filled descents. My five-and-a-half-year-old daughter and my eight-year-old son are two of them.

I recognize that real danger is inherent in practicing a sport in which momentum is needed to perform accurately, and where the physical environment often includes steep, rock-and-tree-filled obstacles, much less the human-made ones. Learning to ski involves mitigating the risks of navigating changing terrain and conditions, avoiding falls and collisions with stable objects or other skiers, and maintaining one’s personal equilibrium within the bounds of one’s own ability and limits, all while attempting not to become the obstacle in other skiers’ paths! (From this angle, it actually sounds a lot like practicing therapy!)

This constant processing of rapidly evolving environmental data can frankly be quite physically and mentally exhausting! However, the rewards of learning to synchronize with oneself, with nature, and with others can also be quite rewarding, sometimes comical, and usually humbling.

My daughter and I had the makings of a beautiful mother-daughter moment together one afternoon on a blue trail when she decided to ski beside me, about three feet away. She excitedly exclaimed, “Mommy, you’re going fast now!” Her broad smile showed me that she meant this as a compliment and was proud of the progress I had made through the daily lessons I had been taking during the week. Several thoughts traversed my mind in rapid succession as I processed her spontaneous and heartfelt gesture and as my anxiety welled:

“Why are you looking at me and not straight ahead where you are going?”
“How on Earth do you ski without looking where you are going?!”
“How do you manage to get so close to others and not veer into their path?”
“Oh Heavens, you are close!”

As much as I was in awe of her ability to remain calm, cool, collected, and courageous in her posture (as we were speeding downhill, nonetheless), I began to have palpable concerns for her safety in skiing so close to me. Instead of relishing that beautiful mother-daughter moment she created, my thoughts raced, my anxiety overflowed, and I awkwardly blurted out, “Honey, please ski a little further away (so that if I crash and burn with the newfound awareness your astute speed observation evokes, I won’t be able to take you down with me)! I need a little more room to turn here.” She shrugged, then proceeded full speed down the mountain, making perfect “S” turns with her skis in parallel, catching up easily with her brother and father below.

My speed on skis, and my ability to go with the flow of it (instead of fighting it), is usually a great source of vexation for me and my family. My “pilates” approach to finishing a trail involves turning with intention, methodically repeating to myself, “Up… turn… down,” and mechanically pacing my breath to the piston-like movements I consciously will my knees to make. My family is greatly annoyed about the mid-trail wait times this entails for them, especially when we agree to stay together.

When in difficulty, staying together comprises part of the rules and common-courtesy practices that skiers adhere to for safety, along with signaling dangers to others and calling for or providing help. For the most part, I have been on the receiving end of those practices. But, with a few more ski weeks and the mental and emotional strategies I employ to stave off full-blown panic attacks, I may someday be able to help others as they have helped me on the trails. Until then, skiing with anxiety will continue to be downhill all the way.

Helping clients manage their anxiety through a caring counseling relationship allows them to see that they, too, can benefit from employing strategies discussed in session on their own slippery slopes. We can help them to categorize situations like ski trails to understand how steep the slope (and the learning curve) feels for them: blue for low anxiety, red for mounting anxiety, or black for high anxiety. We can accompany them in using their available and developing resources to recognize the thoughts that make their slopes feel dangerous to them and to process how their body captures, holds, and releases their anxiety, much like skiers must do to evaluate how their skis react to shifting environmental conditions throughout the day. We can urge them to consider how their anxiety affects them and their loved ones, and to call upon those loved ones for support when needed. With time and practice, they will hopefully learn to navigate those more difficult trails with greater agility, crossing their own finish lines in their own time and on their own two skis.

Advanced Harm Reduction: Managing Intoxicated Clients

Posted on by Psychotherapy.net Team

First there was abstinence, then it was abstinence versus harm reduction. Now, “it appears that intoxication management is becoming a necessary skill for therapists”. With the ubiquity of alcohol use and its presence as an increasingly high-end activity, the growing legalization of marijuana, mini-dosing, psychedelic therapy and the ever-growing use of psychiatric drugs at younger ages … what’s a therapist to do?

The Goal of Abstinence

Abstinence has traditionally been the goal of treatment for substance use disorders. And while many therapists, particularly those with 12-step backgrounds, continue to tout abstinence, several factors have challenged its once hallowed position at the top of the treatment goal hierarchy.

Abstinence supporters and opponents alternately argue on the following grounds (supporters in plain type, opponents in italics):

  • Abstinence provides a clear and unambiguous target
  • People will refuse treatment altogether if they must quit entirely
  • In order to participate constructively in therapy, the mind and body must be clear of intoxicants
  • While living in a monastery or being in rehab encourages abstaining, living in the real world requires some substance exposure and use
  • Some drugs create such an intense rush that users must dissociate themselves in order to recalibrate their pleasure responses
  • Those on antidepressants, as well as medications for bipolar and other prescribed medications who encounter problems with using the drug, on the other hand, court lethargy and possibly intolerable dysphoria by quitting
  • While avoiding one substance may be called for, there may be little cross tolerance or susceptibility to problems with use of another
  • Giving in to the urge to use one drug reduces overall willpower strength, according to Roy Baumeister and John Tierney’s best seller on the topic

A Self-Labeled Alcoholic

Joyce drank heavily as a teenager, quitting in her early 20s. She attended AA, remade herself, and moved far away from her home state. Over the years, she smoked pot, and took medication as indicated for pain or sleep or anxiety, but with a wary eye on her penchant for addiction. She succeeded in not using anything excessively or addictively.

Along the way, Joyce developed severe depression, which antidepressants relieved. Eventually, she worried that she had become dependent on the medication, which caused her to stop. But, “when Joyce renewed use of the drug, she had a frightening suicide-ideation reaction”. She has been terrified of that medical category of drug since then. Joyce is prescribed and occasionally takes anti-anxiety medication, which she uses sparingly due to her fear of addiction. She has found opiates very helpful for her moods but understands that they should not be used that way and mindfully avoids traveling too far down that road when prescribed opioids for pain. She continues to consider reintroducing a depression medication into her life if she can get past her fear of them.

Although some cannabis advocates would say that she is using marijuana therapeutically, Joyce views her use of that drug as strictly recreational and restricts her use to evenings. Using the drug in this way doesn’t interfere with her work or other life functions, and she feels she can take the drug or leave it on any given night depending on her mood and what she’s doing. Keep in mind that Joyce remains completely “sober” with regards to alcohol, per her AA experience, though she occasionally uses Nyquil or cooks with alcohol. Many people in her current social group drink moderately, so that Joyce understands such drinking is readily possible.

Drug Use by the Formerly Addicted

An acknowledged “recovering” alcoholic, Joyce is far from being sober by strict 12-step standards. According to her former AA cohort, Joyce is living in dangerous territory. She uses mood-altering substances for fun, and she continues to take a variety of psychoactive medications. She also no longer attends meetings. Yet she is solid in her conviction that she is now a sober individual, and proud of it.

Joyce is in many ways a prototype of the modern American polydrug user. Her life calls into question the meaning of the terms abstinence, sobriety, and recovery. Of course, even the most hard-core abstinence proponents often don’t include cigarettes and coffee in their sobriety calculus, although both are addictive and can have serious negative health consequences. “There is still heated debate among 12-step adherents about taking medications”—their allegiance to abstinence precepts ranges from scorning all medication including not even taking an aspirin under any circumstances, to accepting prescribed medications, to believing use of anything that isn’t your drug of choice is okay (like Joyce’s easy use of cannabis). And this is before even considering the modern harm-reduction movement’s scope, including moderate use of a formerly abused substance, substituting a safer version of an addictive drug like taking suboxone or methadone in place of heroin and even continuing addictive or binge use under safe conditions (e.g., using heroin with clean needles or in a supervised consumption site).

Here are what we believe to be the underlying, fundamental guidelines for discussing continued substance use with people who have been diagnosed with or who themselves believe, as Joyce does regarding alcohol, that they have a substance use disorder:

  • Be open minded and willing to consider all substance use options: abstinence, substitution or replacement with other substances, moderation, safer use, occasional or regulated addictive or intense use.
  • Remain mindful of—and review—experienced outcomes with clients (this opposes the idea of “denial,” taken to mean that clients cannot accurately report their substance-use experiences).
  • Measure the success of treatments against actual life functions—work, family and friends, and especially subjective client feelings.
  • Avoid labeling the client or his or her substance use pejoratively as addictive, bad, or equally as harmful in all forms or methods of use.
  • Consider first and foremost client values and preferences by using motivational techniques in use decision-making.
  • Change is part of the process—the person, their situation, and the interchange between them are always in flux. There is no permanent solution.
We are in a sense in the new frontier of almost infinitely available substance use, considering that illicit opiates and other drugs can be ordered over the “Dark Web.” It does no good to regret or bemoan this reality. “In a sense, we are at the final societal stage of what therapists should regard as the goal in all therapy”—realizing the clients’ agency and freedom of choice in devising their best selves.

Rethinking Non-Problematic Substance Use

The 12 steps can be seen as one expression of American temperance attitudes that consider all forms of intoxicant use and intoxication to be bad or wrong—or, in modern terms, problematic, disordered, or addictive.

Consider Mary, who LOVES to smoke pot. She smokes it all day long, whenever she can, and she always strives to have a supply available. She also drinks, not heavily, but she likes to go out and get a little fuzzy and sparkly with alcohol once or twice a week. Do you think Mary has a substance problem? On the face of it, she uses substances regularly, heavily, and possibly dependently or addictively in the case of marijuana.

Mary owns and manages a local restaurant where she is beloved by workers and customers alike. She is responsible for its financial success as much as the hands-on and the public-facing part of the business. Mary also organizes large rallies and fundraisers for community causes. She is a good citizen. She is strong-willed and plain-spoken. She has a positive marriage. And she is happy with her lifestyle as it is, thank you very much.

“Mary knows something about addiction”. She used to do cocaine heavily, with terrible consequences for her and her husband’s lives. But that was many years in the past. Today, she seems dependent on pot, while her drinking is generally moderate and she doesn’t overdo her use of any other substance, including occasionally prescribed medications. Yet she rejects and is alarmed by destructive substance use, as occurred in her own life with cocaine.

Mary, like Joyce, expresses several contemporary trends in substance use attitudes and practices. She doesn’t accept standard substance use disorder definitions and recommended usage levels. She accepts, even welcomes, mood modification—a.k.a. intoxication when substances aren’t prescribed for therapeutic purposes. And she doesn’t feel limited by her intensely negative, i.e. addictive, former use of cocaine.

Consider Greg. He was a heroin addict in the late ‘60s, long before so much awareness and availability of opioids use had developed. He shot up, lived on the streets, the whole nine yards of addiction. He was lucky because he had a strong family (parents and siblings), and after many years of addiction, he went to a TC (therapeutic community) and finally quit heroin.

Those communities, at that time, allowed clients to reintroduce moderate drinking after a period of abstinence. That idea worked for many TC adherents, although Greg’s idea of moderation seriously exceeded recommended amounts for safe use. Greg drank to intoxication, specifically, two nights a week, although he never touched any other drug. He was positive that if he ever smoked a joint that he would go right back to heroin, and cocaine was just not his thing. But Greg put alcohol in a completely different category.

As he aged, Greg continued to drink two nights a week, but much less heavily. In many ways he followed a typical pathway of natural recovery with alcohol, even as he was a fully recovered heroin addict. And, we should also note, Greg identified personal emotional issues, made substantial changes to his life and created a life he could better live with than when he had been addicted to heroin.

Regarding Greg’s dual pathways to sobriety—one with opioids, one with alcohol—”do we really think that someone who has, for instance, kicked a 10-year heroin habit has relapsed if they have a beer on a hot summer day?” Greg didn’t fit this mold. He was a heavy and, for a time, potentially harmful drinker. But what if a formerly addicted person gets drunk at a class reunion every year? Should we perform an intervention? Or are these simply life events, rather than cases requiring a clinical consult?

We as Americans think use of some substances is more acceptable than others: antidepressants are consumed in enormous amounts, along with Adderall, sedatives, and anti-anxiety drugs (benzodiazepines) and other psychiatric medications. What about coffee, colas, and energy drinks? Now marijuana, depending on your residence, is used both recreationally and as medicine.

As for painkillers, we love them and we hate them. Americans have a strong urge to eradicate pain. It is normal to seek relief from pain. Yet we now have become overwhelmed by our quest for pain relief, including, seemingly, relief from the mental and emotional distress of daily life. We need to look seriously at what this need for escape says about society, particularly in areas characterized by little education, high unemployment, and so-called crises of despair.

Empowering People to Find Purpose

Allowing people to feel safe in openly discussing their lives with their counselors and providers, to convey what it is they think they are doing rather than what their counselor thinks they are or should be doing, increases trust and allows for a collaborative therapeutic relationship. This open process must include acknowledgment of and handling intoxicant use.

Such a therapeutic alliance encourages the client’s sense of agency. “A path of empowerment by clients’ self-identification of their individual values and goals is the ultimate objective” in this conception of therapy and helping. It is not a therapist’s job to identify how someone should live, but rather to explore and to help illuminate what is their best way in life, their unique purpose, with and without regard to their substance use profile.

Perhaps we should celebrate the availability of a modern cornucopia of substances for driving this point home.  

Talkspace: The New Therapy Room

Posted on by Psychotherapy.net Team

I am always on the lookout for new opportunities and exciting options through which to share my mission of promoting positive mental health. I have been a psychotherapist for over 31 years. Working with adolescents has taught me many things, foremost among which is to expect the unexpected and be open to whatever is happening in the digital world. And it’s not like I’m a dinosaur who’s ignored trends in the digital world, but when did texting become the new form of talking, and can it possibly be an effective form of communication? For therapists?

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Along came Talkspace (TS), a highly sophisticated digital therapy platform which provides for communication with clients through audio and/or video messaging and live video sessions. I thought it was an opportunity, but even more so, a resource, I could not ignore. The “on-boarding” process, as it is called, required a significant commitment including providing my professional credentials, proof of liability insurance and completion of their comprehensive Talkspace University+ training, so that I could understand and effectively use their digital platform. Yes, it is HIPAA compliant.

Clients provide informed consent along with emergency contact information. One hopes to never have to use the emergency contacts, yet it is reassuring to have them readily available, if needed. Talkspace handles all financial transactions, including insurance, private pay and EAP (employee assistance program) fees. Clients are paired with therapists or can choose their own clinician. They complete a general application outlining their presenting problem(s) which triggers an assessment designed to establish a baseline of the frequency and or intensity of the presenting problem(s). Once client and therapist are paired, the therapeutic relationship begins. Rapport building beings and expectations related to frequency and mode of communication are agreed upon. For me, it involves five twice-daily visits to my “room” each week. The client has 24/7 access to their “client room” which is where we maintain contact. The relationship can form surprisingly quickly compared to some of the typical live sessions I have had in my on-ground or in-school clinical work.

Has it been significantly different for me from the traditional face-to-face therapy that I have practiced for so long? Yes and no! The convenience for myself and my clients is incredible. If you have an iPhone or iPad with a wireless connection, you can provide psychotherapy through the Talkspace platform. Italy, here I come! Yes, that does make it sound easy, however just as I have in my on-ground office, it has been important to trust in and use the experience I have accumulated to read through the message in the messages. Do I miss the nonverbal cues? Well, yes! This introduces the challenge of asking additional questions that I might not otherwise ask in my face-to-face work. For example, “What are your feelings about this? How are you processing all of this?” Yes, you ask these questions in face-to-face therapy, however it is typically more in the flow while you are reading the client’s nonverbal cues that insight into their feelings is acquired.

Most of us do not audiotape/review our sessions, we use notes and memory, right? Think about what YOU use to recollect your session. The nature of this digital therapeutic communication is very similar to in-person communication, but the entire exchange is right there on the screen. Client and therapist can read re-read the entire communication. This has allowed me to use the CBT model with greater impact. I encourage my TS clients to reread and review some of our previous messages to reinforce interventions, sometimes cutting and pasting in order to highlight and reinforce a concept. Here is an example of part of an interchange I had with a client:

Client: “I value my friends a lot and I genuinely do whatever I can to make them feel as good as I can get them to be.”

Me: “I am wondering if you can apply that thought/ideal to yourself. I value me a lot and genuinely do whatever I can to make me feel as good as I can for myself. How would that statement/thought feel? Try it on.”

Of course, I asked my client permission to use this. Within my message to ask permission, I once again copied and pasted the previous message for the client—an effective way of reinforcing and restructuring some of the negative thinking that occurs for her. One of the advantages of this platform is the ability to go back with accuracy to reinforce while highlighting the possibility of change. Additionally, I like the use of visuals in therapy such as the CBT triangle (thought, behavior, emotion), but as yet, it has been a challenge to bring these into the Talkspace room. I’ll get there.

The one constant in life, and no less in my evolving professional role, is change. Talkspace has challenged my preconceived ideas about digital therapy and enabled me to bring my clinical skills into the digital sphere. I welcome the research and data to support this work. I recently asked one of my digital international clients to articulate their experience with me on Talkspace. She said, “I don’t know if this could be of any use, but face-to-face therapy here in Saudi Arabia is really limited…I was faced with ignorance and people didn’t know how to handle me.” She continued, “With Talkspace, I truly felt heard and comforted in ways I couldn’t in face-to-face therapy. I’m sure professionals here are extremely good at what they do, but I was blessed to have you as my therapist and like I’m taking a huge step into bettering myself.”

Face-to-face and digital therapy both include rapport building, the establishment of baseline through careful assessment, the development of treatment goals, the creation and implementation of interventions and assessment of treatment outcome. Talkspace has brought me and my therapy room to clients who I, more than likely, would never have had the opportunity to work with. The clinical effectiveness, affordability and accessibility of Talkspace have worked for both me and my clients, allowing me to continue my mission to promote positive mental health. Therapy is not about a room, it is about creating a space for connection and healing. Welcome to the new therapy room. 

Male Survivors of Sexual Abuse: The Prelude to Healing

Posted on by Psychotherapy.net Team

Researcher and clinician Bessel van der Kolk reminds us that when it comes to the immediate and long-lasting impact of trauma, “the body keeps the score.” Psychic and somatic pain are stored, ever-present, ready to break through into consciousness—keeping the survivor in a state of high alert for danger—all the time, everywhere. Helping clients make connections between these painful states and the trauma memories allows them to begin the process of healing and grants the clinician access to this hidden painful domain. In this way, client and therapist can begin to loosen the hold of the trauma, free the victim of its insidious and regressive pull, and help them live less painfully in the present and move less encumbered toward the future.

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Sexual abuse is one form of such trauma that is surprisingly common in my practice with men, and that is associated with painfully held secrets and a seemingly desperate attempt to minimize both psychic and physical pain. In my work with these men, I have found that when the trauma narrative is produced and the pain can be present simultaneously, the healing is (in part) automatic. Surprisingly, in men who have had little if any vocabulary for emotions, words to describe painful and long-buried emotions materialize.

I had the opportunity to work with Mike, a large, burly tattooed man in his early 40’s. Tortured by his excessive masturbation, a pattern of frequency that exceeded his already high-baseline, he self-referred, with trepidation. Shortly into the therapy, as the topic shifted from his repetitive sexualized behavior to a challenging relationship with his son, the product of a recent divorce, things shifted. As he recited both his internal and external struggle, things calmed down. Not coincidentally, with a heavy heart, he revealed that his son was the same age as he was when he was abused for a short period by his then 12-year-old brother, a memory that held not only pain but intense shame, guilt, anger and remorse.

Then there was Gabe, a middle aged man with two young-adult children from his first, somewhat unhappy, marriage. As he reluctantly approached therapy, he talked about a recent episode of sexual acting out during his current, second, much happier marriage. With his ultra-conservative Italian Catholic background, he was perplexed with his actions and the lies he employed to shield them. His behaviors had not yet taken full form, as he had only “flirted” with the notion of being with others. Gabe shared that as a young boy, he was repetitively used as a tool for his much older, post-pubescent sister’s masturbation. There was no penetration and he was not asked to do anything specific to satisfy her. Telling the secret was painful for Gabe, who, as his repressed rage was given voice, allowed the pain as well as the tears to flow.

Raymond held his secret for 50 years in a secluded psychic compartment, a private underground space in his life disguised largely by his out-of-control sexual behavior, never changing despite his 15-year marriage, 2 children, house, successful career and twin dogs. Held under wraps inside this man born of two German parents, this classified information was made known one moment after 5 years in therapy that had included couples therapy for his wife to work through the complex partner trauma, and intermittent individual sessions. With an outpouring of pain he cited a now-conscious awareness of a few sexual incidents during childhood with his older brother, a prodigy who was favored by the parents. This new awareness opened a space to create an honest account and narrative of his pain.

The stories seem never ending as is the pain locked within them, until it is finally released. I am not inferring that with the telling or retelling of the event, all will be cured. Yet, the changes I’ve witnessed that accompany the release of the traumatic stories have been profound and have provided an opening for deeper work. Insight was seemingly insufficient. Access inside the mental network housing the injury and its memory was critical.

One of the greatest, if not primary, clinical challenges I’ve experienced is the inability or difficulty for these men to use words to define their experience. Finding a voice for their wounds began a movement towards healing. Still, not all trauma survivors remember their incident that clearly, cannot report it as such, and many become traumatized by the retelling. In these cases, clients need a safe holding space in order to proceed and a skilled process consultant (a.k.a. therapist) to help work through the emotions as they emerge so they may re-weave a self-affirming and empowering life narrative that is neither permeated nor defined by the pain of trauma.

Resources:

APA Guidelines for Psychological Practice with Boys and Men

Male Survivors of Sexual Abuse

Betrayed as Boys, by Richard Gartner