We had another lovey event at Michael's at Shoreline, this time for a luncheon presentation by Kalpana Asok, LMFT, titled "The Psychological Burden of the Immigrant Child." It was again a small and intimate crowd, joined by our live stream attendees via Zoom. The luncheon buffet was outstanding, as always, and seeing colleagues in person once again, was a joy for all of us who attended. 

A recording of the event is available to everyone who registered, and also for purchase by anyone else who would like to view it, and receive the 1.5 CEUs for an additional fee. Much thanks to Kalpana, for her thoughtful and informative presentation and to all the volunteers who helped make this event possible!

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Presentation Review by Kathryn Ford, MD

Aperture Awareness is the superpower for couples’ relationships. And I am convinced that when we, therapists, are doing our best work, what we are tuning into is emotional aperture—ours and our clients. On August 27 I had a chance to talk to some of my fellow aperture experts about how to develop Aperture Awareness in our couples as part of helping them with loving connection.

Aperture refers to our dynamically changing emotional openness to each other in the present moment. Aperture Awareness refers to our ability to sense our own state of openness and that of other people. Couples are trying to optimize for loving contact and safety: Developing Aperture Awareness helps them to do this. When couples interact with closed apertures, they are likely to injure each other and their relationship. When they interact with open apertures they are more likely to get the contact they want—to be seen, heard, and understood.

Aperture Awareness is an in-the moment experience. My training in meditation began simultaneously with my psychiatric training. Thus, the importance and power of tuning in to what is happening in the present moment has guided my development as a therapist. As I began to work with couples, I noticed that they would come in and tell me stories about things that had happened in the past. In order to work with what was happening in the present moment, I began structuring my sessions so that instead of talking to me about encounters they had last week or last year, they talk to each other, with me observing from the sidelines. As I observed couples interacting, I began to move my various mental models and theories to the side of my awareness in order to pay attention to what was happening in the room. As I did, I tuned in to something very simple: my ability to sense, in the moment, the openness, or closedness of these two people to each other. I began to develop what I started to call my Aperture Awareness. I then began to talk to my couples about their aperture awareness and to help them develop it by pausing to tune into it and to describe it on a 1-10 scale.

Our brains are very well designed for Aperture Awareness with limbic systems that are constantly processing information about the internal states of other mammals. Our limbic systems (amygdala, thalamus, hippocampus) are responsible for the “danger, danger” response that is triggered at any sign of threat including the danger that other mammals are not well disposed toward us. The amygdala, in particular, makes sure we are not going to get eaten, or experience the emotional equivalent of that, when a friendly face suddenly darkens. When a potential threat is detected, the amygdala responds with lightning speed. The “danger, danger” signal is activated sending various body systems into a state of tension and readiness, and closing our emotional apertures. This system, like our breath, functions whether we pay attention or not. Tuning in to our sense of aperture provides us valuable information that helps us steer in relationships.

So what does it mean to use Aperture Awareness to steer in relationships? What you do with aperture awareness can be described quite simply. Depending on the 1-10 assessment given by the clients:
•    Stop on red: these are apertures of 1-4;
•    Go on green: apertures of 5-10, and
•    Pause on yellow for those tiny closures that happen continuously during a challenging conversation. I call this pausing on yellow “riding the waves”, meaning waiting for a brief wave of aperture closure to pass before speaking, thus avoiding escalation of tension as one aperture closure triggers another.

An example: your partner complains about your lateness. Speaking from your closing aperture you might say: “Are you kidding me?! I most certainly was not the one who made us late to the party!” With a few seconds to reflect and return to open aperture, you might sound more like, “Wow, I’m surprised to hear you say that. I didn’t even realize I was late.”  

Then there are the times in conversation when apertures fall below 5 for more than a few seconds. When couples continue to try to interact with closed apertures, they end up frustrated, discouraged and injured. Teaching them to stop when apertures fall below 5 helps them to avoid this. When either partner notices that their own aperture or their partner’s has closed below a 5 they need to:
•    Stop
•    Reassure
•    Inquire
They then work together to figure out what closed either or both apertures and to help each other to reopen, possibly by adjusting something about the way they were talking to each other. When both apertures are five or above, they are good to GO.

Slowing down is the first step in paying attention to what is happening in the moment and developing Aperture Awareness. In any conversation, there is far more happening than we can possibly be aware of. We are exchanging content, having memories, feeling emotions, making associations, and getting distracted. We are thinking of what to say, noticing our own experience, listening to our partner, and watching their reactions. All of these factors are then influencing our brain and the opening and closing of our apertures.

The pace of most conversations barely allows us to exchange information, much less sort through all the complex reactions and interactions. Things move fast, often without pauses or silences. And when emotions heighten, we tend to speed up—usually the opposite of what is needed. Researchers have demonstrated that slowing down speech can help us modulate emotional arousal in conversation. We need time to process our words, thoughts, and feelings, and those of our partner. Aperture Awareness and the related skills of dialogue, mindfulness, and learning all get easier when we slow down.

Here is my favorite exercise for helping couples to slow down and arrive in the present moment.

Exercise: Slowing It Down
Slowing down can be harder than it sounds. So in this exercise, you will be exaggerating the change, slowing things way down so that you can truly feel the difference.

After selecting a topic, you will plan to talk for 20 minutes. The difference, this time, is that each time you speak, you will allow yourself only one or two sentences. Then after each person speaks, you will both pause in silence for about 30 seconds—or approximately as long as the speaker was speaking.

Eventually, you will get a rhythm: Speak – pause – speak – pause. It should feel a little like a rally in a tennis match. For most of the time, the ball is not being hit by either player, but is in the air between them. And during that time players are observing very carefully—watching the ball, watching the opponent, getting their own body in position. This rhythm will probably feel strange, even awkward. You may be tempted to speak for longer, or to omit the pauses, or both. Support each other in resisting this temptation. Hang in there and let this slower pace help you to observe.

Choose a topic to discuss. Set the timer for 20 minutes and stop when the time is up. Do not continue the conversation.

Reflect and write.

• What was hard about this exercise?
• What did you like about it?
• What else did you observe about the effects of the pace of the conversation?

Discuss.

• Spend a few minutes talking to each other about your experience of this exercise.

Purchase the recording from THIS PAGE.

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Luncheon Presentation Review by Tim Baima, PhD, LMFT

SCV-CAMFT graciously invited me to give a luncheon presentation on family play therapy on Friday May 21st. I was happy to provide 90-minute training. This was also my first time joining a SCV-CAMFT event, and I was delighted to connect with such a friendly community.

My presentation briefly reviewed several of the benefits of family play therapy. The majority of the presentation focused on case examples I hoped would illuminate these benefits. For this newsletter, I will review the rationale for incorporating play and family therapy. I will also provide guidelines for a few family play activities.

The Perfect Pair – (They just don’t know it yet)
Before I started graduate school to become an MFT, I spent approximately seven years working as a support counselor for highly marginalized and traumatized children and adolescents at group homes and foster care agencies. Through these experiences I grew to appreciate the healing potential in play, art, and other recreational activities. I learned that a good activity could break through the defenses of even the most highly guarded adolescent. I also witnessed how much more powerful an experience of something can be than a conversation about something.

Therefore, when I started graduate school to become a family therapist, I simply assumed that most family therapists incorporated play and art in their work. I was surprised to learn that this is often not the case. With the exception of Virginia Satir, family therapists have traditionally relied heavily on talk-based interventions. Talk-based therapy often sidelines family members who are not willing to talk, or those who have not yet developed the linguistic abilities to adequately express themselves with words (Gil, 2015). Furthermore, therapy may not be conducted in the primary language of one or more family members. Regardless of fluency in the language used to conduct therapy, one or more family members may not be speaking the language of their heart. Furthermore, talk is often used as a defense mechanism, keeping vulnerable content in a cerebral space. Incorporating play into family therapy can help overcome these limitations of talk-based therapy.

Given the significance of the family system for children and adolescents, one might also assume that play therapists would be drawn to work with families. However, the vast majority of play therapists are reluctant to engage families in treatment, often citing a lack of family therapy training, and personal fears as their primary reasons for not doing so (Gil, 2015). Treatment that does not include families often misses opportunities to facilitate second order change in a child’s family context. Carr’s (2018) research indicates that family treatment can be more effective and have longer lasting results than individual psychotherapy.

The Benefits of Family Play Therapy
There are numerous benefits to weaving play and family therapy together. I summarized several of these benefits during the training, and list them again below. (Gil, 2015 is a reference for the following points unless otherwise noted.)

• Play allows families to engage with each other, even about difficult topics, in fun and disarming ways.
• Play is the language of children. Therefore, it allows family members at each developmental stage to contribute meaningfully to a session.
• Play can provide a layer of distance from intense, painful, and/or taboo topics. This layer of distance supports families to engage around challenging issues in ways that are often more comfortable than direct dialogue.
• Play may contain a cathartic component, allowing for a discharge of emotion.
• Play is rich in symbol and metaphor. Evan Imber-Black, Janine Roberts, and Richard Whiting’s  (2003) groundbreaking work on rituals points out that symbols are invaluable in family therapy as they can:
• 1. mean different things to different people at the same time
  2. hold complex, even seemingly contradictory meaning
  3. hold meaning that evolves over time
• Because of the complex and fluid nature of symbols, play in family therapy can be used to shift and expand family member’s rigid views of one another.
• Play can provide family members with various ways to encounter their problems and experiences. For example, larger-than-life distress is miniaturized and manipulated in a sand tray, or family members embody and act out “small” disowned parts of themselves.
• Finally, many clients will describe a family play session as the most fun their family has had together in a long time. I believe that the significance of providing a family with a way to enjoy being together cannot be overstated.

OK! I’m Convinced. So, what are some family play activities I can try?

Symbol Scavenger Hunts: I opened the luncheon training with an activity that can be modified for use with a couple or family. I asked each participant to take a few minutes to hunt around for something that symbolized a family member who has had a significant impact on who they are as a therapist today. Once these objects were found, participants gathered in breakout rooms to say as much or as little as they liked about what they selected. I started using these “scavenger hunts” with families when COVID forced everything to go online. I might ask family members to find objects that say something about each family member, or to find symbols for events, such as a happy memory, a difficult event, a family strength, a wish, etc. I like the idea of recognizing the symbolism in objects that are in our everyday environment, and infusing those objects with meaning associated with experiences in therapy sessions.   

Family Play Genograms:  Family play genograms were created by Monica McGoldrick and Eliana Gil (2015). First, a family genogram is created on a large sheet of paper. Each family member then selects figurines to represent each family member. Next, they take turns sharing as much or as little as they’d like about what they selected. Lines can then be drawn between family members on the genogram to represent relationships. Next, family members select figurines to represent something about each relationship, and share about what they have selected.

Modified Family Play Genogram: Traditional family play genograms have the benefit of showing how everyone in a family is connected. While I sometimes use this approach, I have developed a modified version that incorporates symbol, art, storytelling, and drama. In my modified version, I ask the family to create space on a large piece of paper for each family member. Some families draw simple shapes, while others will draw images to represent their area on the paper. The process of simply selecting an area on the paper, deciding what to draw, where each person’s space is in relation to others, etc. can all be very revealing. Next, family members are asked to choose figurines that say something about each family member, including themselves. Selected figurines are placed in the area made to represent that person (i.e. all figurines chosen for Dad are placed in Dad’s area). After this, family members each share as much or as little as they’d like about what the selected. Finally, I like to ask family members to create stories with the figurines that have been selected. At times I draw upon Gil’s (2015) family puppet interview and ask family members to use the selected figurines to create a story with a beginning, middle, and end. Families are instructed to act out the story instead of narrating it (Gil, 2015). Another version is to ask each family member to enact a series of 30 second stories. In this variation, family members are given a prompt, and then act out a quick story using two or more figurines. For example, I might ask a family member to enact a story between two figurines that would love to meet each other, would be afraid of each other, could help each other, etc.

Unity Poster: The unity poster is a wonderful intervention to highlight intersections of autonomy and connection in a family. To prepare for the unity poster activity, the therapist follows these steps before the family arrives:

1. Draw a circle about the size of a dinner plate in the center of a large piece of heavy poster paper. Make sure the circle is bold and easily visible.
2. Use jigsaw puzzle style lines to cut the poster into equal parts – one part for each family member.
3. Now you will have jigsaw puzzle pieces with a bold line in the corner of one side.

At the start of the activity, give each family member one corner of the poster. Tell the family that you will give them a few prompts and invite them to decorate their small poster in response to these prompts. Prompts can be anything you wish for them to respond to. I am personally fond of prompts such as: An important event in your life, something you’re proud of, something you feel strongly about, and a secret dream. Ask them to leave the area past the line on their poster blank, but to draw, write, or make collage to respond to these prompts on the rest of the paper.
After each family member is finished decorating their individual posters, they take turns describing what they created. After everyone has had a turn, the therapist reveals that each of their pieces will fit together to create one whole poster. Ask them to figure out how their pieces fit together, and provide them with tape so they can bind the pieces together. The family will now see that the lines form a circle in the middle of the poster. Explain to them that this is the unity area, and invite them to work together to decorate it however they’d like. When they are done decorating the unity area, the therapist can end the activity by asking the family to title their poster and decide what they would like to do with it.

Conclusion
  I hope these ideas and activities will inspire many of you to try some play activities with families. I want to acknowledge Dr. Eliana Gil as the person from whom I have learned nearly everything I know about family play therapy.

Her books are informative, inspirational, and highly enjoyable to read. If you would like to read more about family play therapy, I suggest the following:

Play in Family Therapy Second Edition (2015) Guilford.
Posttraumatic Play in Children: What Clinicians Need to Know (2017) Guilford

Helping Abused and Traumatized Children: Integrating Directive and Nondirective Approaches (2006) Guilford.

References
Carr, A. (2019). Family therapy and systemic interventions for child‐focused problems: The
current evidence base. Journal of Family Therapy, 41(2), 153–213. https://doi-org.paloaltou.idm.oclc.org/10.1111/1467-6427.12226

Gil, E. (2015). Play in family therapy. Second edition. Guilford.
Imber-Black, E., Roberts, J. E., & Whiting, R. A. (2002). Rituals in families and family therapy.
Revised edition. W.W. Norton & Co.

Timothy Baima, Ph.D. is an Associate Professor in the MA Counseling Program at Palo Alto University where he serves as the coordinator for the Marriage, Family, and Child Counseling emphasis area. He is also a licensed Marriage and Family Therapist with a private practice in San Mateo, California where he specializes in family therapy with adolescents, and couple therapy. He is an AAMFT Approved Supervisor, training three MFT associates in his private practice. He has served on the Board of Directors for the American Family Therapy Academy since 2017. He has long held an interest in play therapy and has been receiving consultation from Dr. Eliana Gil for the past 5 years. His current research interests center on whiteness, and training the “self” of the therapist. He has published in The Expanded Family Life Cycle 5th Edition, The Journal of Marital and Family Therapy, and the Journal of Family Psychotherapy.   

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back to the Winter 2020 Newsletter

By Mary Van Riper, Director of Special Events

Our Annual Membership Celebration was held on November 7^th over Zoom. After Jacqui Gerritsen welcomed members, we experienced a Mindful Eating meditation, then viewed contestants’ submissions for the breakfast contest, and learned about ingredients and recipes.

We met in small groups to connect with each other. Finally, we thanked SCV-CAMFT 2020 volunteers and introduced the SCV-CAMFT 2021 Board of Directors. Members reported it was a fun and productive meeting, and that they felt a sense of connection.

Mary Van Riper led the Mindful Eating mediation. Some members reported the Mindful Eating script helped them to eat with intentionality. Check-out the Mindful Eating script (written by Christine Milovani, LCSW). 

Four attendees registered for the Breakfast Contest and had the opportunity to share about the recipes for their breakfast: Rowena Dodson, Jyoti Nadani, Elaine Gee-Wong, and Margot Minnium. The non-board member registrants won $25 Amazon gift certificates for their entries. Members enjoyed hearing tips to produce these delicious breakfasts. Thank you, Nancy Orr, for facilitating this contest.

In small groups, we had the opportunity to connect with each other. In addition to discussing the Mindful Eating experience, members processed the late-breaking Presidential Election results, shared about self-care during the pandemic, and introduced some of their cute pets.

Our 2020 SCV-CAMFT volunteers were honored for their many contributions with words of praise and with $25 Amazon Gift Certificates: Junko Yamauchi (Pre-licensed Support Group Leader and South Region Luncheon Committee Member), Della Fernandes (Newly Licensed Support Group Leader), Jim Arjani (Pre-licensed Support Group Leader), Barbara Pannoni (Newly Licensed Support Group Leader), Dominique Yarritu (Chair of the Editorial Committee), Tomilu Stuart (Chair of South Region Luncheon Committee) and Jayne Marsh (South Region Luncheon Committee member).

Jacqui Gerritsen, President, appreciated Junko Yamauchi in her volunteer role with the Lunch Program:

●      Junko Yamauchi can always be counted on to help out at the registration table at our south region luncheons in Los Gatos.  She’s such a dedicated volunteer on the committee and goes above and beyond what is asked of her.  One example of this has to do with our pricing categories for walk-in fees. Junko took the initiative to create a flow chart for the volunteers to use at the table, and it has become essential for the team. Junko Yamauchi also facilitates her pre-licensed group on the 1st Fri, 11am-1pm since Feb 2019. 

Junko Yamauchi, Director of Newly and Pre-Licensed Support Groups, appreciated the other Newly and Pre-Licensed Support Group leaders who have transitioned to leading online support groups during this COVID time:

●      Della Fernandes has been a newly-licensed group leader since January 2019. She presents practice-building ideas and provides encouragement to support new therapists. She also brings in speakers on topics relevant to building a practice. Della's group meets on the 3rd Saturday of the month from 1pm-3pm. 

●      Jim Arjani has been leading his pre-licensed group since June 2018. He has been a constant support for trainees and associates on their long journey to become therapists. His group meets on the 1st Saturday of the month from 11am-1pm.

●      Barbara Pannoni began facilitating her newly-licensed group in October 2019. Barbara facilitates the sharing of practice ideas and professional development strategies among her monthly group of new therapists. Her group meets on the 2nd Friday of the month from 11am-1pm.

Rowena Dodson, Director at Large, appreciated Dominique Yarritu (Chair of the Editorial Committee):

●      Dominique Yarritu volunteered to work on the newsletter last February and already contributed significantly to the March edition. For the March edition, she solicited and edited the article on working with Transgender teens and contributed her own article about Uplift and supporting teens in crisis. She clearly had a passion for being part of the team and she and I quickly developed a strong relationship. Happily, Dominique agreed to be the Chair of the Editorial Committee and our June issue showed her significant imprint. She was ambitious about finding authors, she supported authors in writing their best pieces, she was/is a fastidious editor, and was full of new ideas about what the newsletter could be. She has continued to contribute articles and interview pieces. Dominique highly values collaboration. With the September issue, we worked with Nancy Orr, Chapter Coordinator, to upgrade the format and usability of the newsletter. Throughout this past year, Dominique has worked more hours than we can count. We so appreciate her hard work and the results have been outstanding for our chapter.

Jacqui Gerritsen, appreciated the Lunch Program volunteers for Elizabeth Basile, Director of Lunch Programs:

●      Tomilu Stuart has been a volunteer for the South Region Luncheon Committee in Los Gatos for many years, and graciously took over the reins as chairperson three years ago when the previous co-chairs stepped down. She has done a phenomenal job selecting interesting and diverse topics given by superb presenters. The luncheons she has organized always have a huge turnout of attendees, confirming the chosen topics are of great interest to our members. She has kept the committee running so smoothly and continues to keep our luncheon volunteers enthused about being a part of this committee. She always makes sure they are well taken care of. It is because of Tomilu’s hard work that the south region luncheon committee has continued to thrive. I’ve enjoyed working with Tomilu over the years, and am so grateful to have been able to collaborate with her. Many a time we’ve had to trouble-shoot one issue or another the day of a luncheon, and thanks to her we’ve always resolved whatever problem has come our way.

●      Jayne Marsh has also been such a dedicated and dependable volunteer on the south region luncheon committee for years, and I’m so grateful that she has also remained a part of the team.  She organizes the registration table so well, and thanks to her we have a good system for minimizing any backups whenever we have a rush of attendees arriving. I know that the registration table is in good hands when I need to step away to tend to something else. I also always look forward to chatting with her at the registration table while we check people in. Thanks to her and the other volunteers we’ve become a close-knit team. 

Jacqui Gerritsen introduced our 2021 SCV-CAMFT Board of Directors: Jacqui Gerritsen (President), Debra Rojas (Historian), Jia Rebecca Li (Chief Financial Officer), Elizabeth Basile (Director of Programs), Nancy Andersen (Secretary), Jyoti Nadhani (Director of Ethics), Junko Yamauchi (Director of Newly and Pre-Licensed Support Groups), and Rowena Dodson (Director at Large).

Overall, the Annual Membership Celebration was an enjoyable meeting with many positive comments from members such as: “I really enjoyed this meeting. It’s great to connect with people who are here and learn what everyone’s up to.” “I appreciate everyone’s advice and support. It was wonderful to meet everyone!”

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Luncheon Review by Marty Klein, PhD, LMFT

Dr. Marty Klein has been an MFT and certified sex therapist working with men, women, and couples for 39 years. He is an award-winning author and appears frequently in the popular media. Visit his website to learn more about him, and to sign up for his monthly newsletter: martyklein.com. 

Last fall, the SCV-CAMFT chapter asked me to do an all-day training program on couples therapy. I gladly agreed, and we scheduled it for mid-May 2020.

On May 15 & 16, eight weeks into the COVID lockdown, I gave that six-hour training program—by zoom. I noted how none of us was prepared to support clients while we ourselves were part of an active collective trauma. Regardless of prior experience, none of us expected that we’d be working while struggling with the same deprivations as our clients.

So I spent the first 90 minutes discussing therapy-by-video—which was then still pretty new to most therapists. I admit I don’t especially like video therapy, which feels like counseling with a condom on your head.

I started with logistics, and said we shouldn’t treat our professional needs as temporary. Spend some money, I said, on practical things to make video therapy more comfortable for you. Think about lighting, seating, privacy, the visual background, internet connectivity. Give yourself extra time between sessions, as video therapy is more tiring, both physically and psychologically. 

And think about clinical boundaries—perhaps talking to patients about starting and ending sessions on time, and gently challenging patients who are careless about privacy or interruptions. I discussed some of my own recent frustrations: patients who wanted to drink wine during session, allow their cats to jump on and off their lap during session, and who expected to supervise their kids’ playtime during session. 

With video therapy, unfortunately, some of our tools are diminished or lost. It’s harder to create the norm that clients do nothing else during session. It’s almost impossible to use our body to communicate. It’s much harder to use silence effectively. 

I even talked about one of my biggest clinical losses—my inability to require couples to sit separately, facing each other. On video, couples sit shoulder-to-shoulder and face me, which discourages disagreement and inhibits difficult conversation with each other. This drives me crazy. Of course, not every therapist feels that way.

After a break, I proceeded to discuss a wide range of issues in couples therapy. Here are a few highlights:

I.   Myths about intimacy—which patients sometimes have, too:

• Gender stereotypes (women are more feeling oriented than men; men want sex more than        women),
• Good attachment leads to good sex; poor sex results from poor attachment,
• You can measure intimacy by the amount of time people spend together; by whether they share a bedtime; by how much sex they have; by how much they love each other,
• Why we shouldn’t accept “more intimacy” as a therapeutic contract too soon.

II.  Communication

• The importance of couples knowing when they’re discussing feelings and thinking out loud (“Wouldn’t it be great to leave the Bay Area one day?”), versus when they’re discussing policy (“I really want our kids to learn to swim”).
• What ISN’T a communication problem:

III.  Managing conflict

• Dealing with couples who focus primarily on rehashing the Fight Of The Week
• What does a real apology look like? Why is it important to NOT accept an apology too quickly?
  
• Fair fighting:
  

IV.  Labels and categories—patients’ and ours

• Teaching couples the concept of “narratives”—and encouraging them to see their own,
• Narratives of powerlessness are especially common in couples seeking therapy,
• Examples of labels that couples use to avoid discussing their feelings: passive-aggressive; conflict avoidant; emotional affair; porn addict; trust issues. Such categories tend to end conversations,
• How do therapists collude with the use of such categories, rather than gently insisting that patients describe their actual feelings?
  

IV.  Infidelity: After an affair, who owns the relationship? 

• Power dynamics: Does Betrayer now have to do everything Betrayed wants? Has Betrayer incurred a debt that can never be fully paid off?
  
• Why the Betrayer revealing every detail the Betrayed demands (which restaurants, how many birthday cards, etc.) is usually a mistake,
• The Betrayed may feel conflicting agendas: I want to express my feelings AND I may want to explore reconciliation. When expressing your anger and hurt, don’t damage the relationship so much that reconciliation is impossible,
• Reconciliation can’t happen between one good person and one bad person,
• The importance of discussing a couple’s sex life—even if they don’t want to.

Along the way I presented several cases, giving examples of helpful responses such as reframing. And yet, COVID was in everyone’s thoughts, so I recalled these century-old words: “The undisguised brutality of our time is weighing heavily upon us.”  –Sigmund Freud (1920), whose daughter Sophie had recently died in the Spanish flu pandemic.

For a copy of my slides, go to www.MartyKlein.com/couples2020

Note

Marty is an invited Master Presenter at this year’s CAMFT Virtual Annual Conference. If you register for the conference, you can attend his live Q&A sessions on September 21 (on intakes) and October 9 (on sexuality).

Zur Institute is launching a 5-session zoom case consultation group featuring Marty starting September 17. For information see www.ZurInstitute.com.

Dr. Klein is the award-winning author of seven books on sexuality and relationships, including the ground-breaking Sexual Intelligence. Psychology Today simply says “To improve your sex life, buy this book.” Dan Savage says Marty's current book on pornography “makes me feel sane.”

Marty appears frequently in the popular media, such as The New York Times and The New Yorker, National Public Radio and The Daily Show. He recently gave two Congressional briefings on evidence-based sex education. Marty’s Sexual Intelligence blog and e-newsletter are frequently cited as sources of innovative thinking about sexuality, culture, politics, and the media.           

back to Fall 2020 Newsletter

by Elaine Brady, PhD, LMFT

If you knew that, since 2014, we have been mandated (via AB 1775) to report anyone who looks at child pornography, pat yourself on the back and join the informed few who attended the SCV-CAMFT luncheon on 28 February for my presentation.

However, if you are like the majority of therapists who attended and had no clue as to this mandated responsibility, I would like to share with you why it is important for you to know about it and give you some ideas on how to manage it within your practice.

At this point you may be tempted to stop reading this article, telling yourself that it does not apply to your work.  After all, you do not even work with clients who look at pornography, much less child pornography!  In fact, what my presentation tried to bring home to members and colleagues is that you very likely work with clients who access pornography but you are not aware of it.  Particularly given that:

• Adult entertainment ranks 7th on the list of leading categories utilized online,
• Pornhub, one of the biggest providers of adult material, boasts of 92 million visitors a day,
• 30% of men and 3% of women are daily viewers of pornography,
• 13% of men admitted to a pornography addiction,
• Due to its addictive and habituation forming quality, viewers can be drawn into more shocking and illegal aspects of pornography—such as child pornography—chasing the high they cannot get from regular pornography anymore.

Apart from child pornography, both therapists and divorce lawyers have reported a significant negative impact of the internet on marital relationships.  One poll of lawyers actually broke this down into categories:

• Excessive time on the computer    47% of cases
• Excessive time in chat rooms, which tend to be highly sexualized    33% of cases
• Obsession with pornography sites     56% of cases
• New love met online 68% of cases

Tragically, children are also being swept away by this surge of online sludge, both as viewers and as victims:

• 90% of youth between the ages of 8 and 16 claim to have seen pornography,
• Children under 10 years of age now account for 22% of porn viewers under 18,
• Many children find their parents’ favorite pornography websites and pictures,
• 1 in 10 of 12 to 13 year old users fear they may be addicted to pornography,
• Commonly used children’s apps like Snapchat, Twitter, and Kik have been saturated with both pornography and pedophiles.

Even sexting among teenagers is considered child pornography.  Given that California has no laws regarding teen sexting, teen offenders can suffer significant repercussions socially, financially, and legally.  Hence, if a young teen client mentions she sent a topless picture to her boyfriend, guess what: you are mandated to report her for the production and distribution of child pornography (AB 1775, 2014).

In addition to child pornography, I also covered various other forms of Cybersex Criminal Activities (CCA) (AB 1775, 2014) a client might become involved in, such as:

• Soliciting another person for sex with intent to pay for or sell prostitution,
• Meeting with a minor with sexual intent,
• Revenge porn: posting sexual images of someone without their permission,
• Sextortion: threatening to send sexual images to friends/family,
• Sexual cyberbullying: harassing and/or stalking someone.

Unfortunately, your clients are not likely to disclose their online pornography habits, their casual or illegal sexting, or their own victimization.  Given the personal nature of these activities and the threats accompanying most criminal behaviors (like solicitations of a minor or sextortion), you can expect them to remain stealth addicts and silent victims.  

Therefore, as professional caregivers we are morally, ethically, and legally obligated to assess for and address Problematic Cybersex Activities (PCA). The first step in beginning this process is to overcome our own denial.  Just as we finally recognized the impact of alcoholism on individuals and families thirty years ago and started assessing for it, we must make internet use and abuse assessment a normal part of our intake process.   

 
Even a simple CAGE-like assessment (for alcohol addiction) can be useful in opening a conversation about internet use and possible problems.  I have developed a model called PCOC, which addresses the core elements of addiction: Progressive, Compulsive, Obsessive, and Consequences.  An example of your questions could be: P- Has your use increased over time?   C- Have you tried to cut back or stop?  O- Are you preoccupied with thoughts of being online or/and what you have seen?  C- Have people complained about your use?  Have you spent more money than you planned to?  Have you gotten into trouble at work/school?

So, what happens if a teenager or an adult client does reveal some form of reportable activity as prescribed by AB 1775?  Legally, you are mandated to report your discovery to CPS and/or the police.  While failure to do so is only a misdemeanor, extenuating circumstances of a case may result in significant charges, fines, and loss of your license. (For more information about AB 1775, refer to several resources cited at the end of this article).

Tragically, after my presentation in February, word of COVID-19 and the subsequent order to shelter in place occurred: we all became housebound.  Since then, various sources have warned of a significant increase in mental health and substance abuse problems.  I would like to add to that a probable increase in individuals becoming addicted to internet-related activities and a rapid progression of already existing problems.  Therefore, I sincerely hope that all practitioners will begin to evaluate current and future clients for these underlying internet and pornography addiction problems.

Unfortunately, there are no local treatment facilities for internet-related addiction.  As far as I know, there are only a few local therapists who have any training in this area.  Of those, I believe I am the only one who also has training in sex-related internet issues.  If any of you have such training please let me know so I can add you to my referral list.  For further educational resources, please read the following:

• Additional assessment tools are available at: netaddiction.com and recoveryzone.com,
• Resources for addressing PCAs are available through: netaddiction.com and zurinstitute.com/internet-addiction,
• If you are interested in learning more about AB 1775:

Child abuse and neglect reporting act: Sexual abuse, AB 1775. (2014). Retrieved from https://leginfo.legislature.ca.gov/
Weiss, R. (2015). Wake up California therapists! Protecting client confidentiality per proposed California law AB 1775. (9 June 2015). PsychCentral. Retrieved from http://blogs.psychcentral.com.

If you have concerns about AB 1775, it is currently in the California Supreme Court due to efforts to repeal it. Don Matthews, LMFT, of the Impulse Treatment Center in Walnut Creek, CA, has been fighting the bill for six years and has asked for financial support to continue his efforts.  You can refer to his request for financial support page at: https://www.gofundme.com/f/stopAB1775.

Elaine Brady, Ph.D., MFT
1190 S. Bascom Ave., Ste. 130
San Jose, CA 95128
elainebrady.com
docelaine@elainebrady.com
Cell: 408-637-1022

Dr. Elaine Brady, has over thirty-five years of experience working in the addiction field and is a Certified Addiction Specialist as well as a Certified Sex Addiction Therapist.  She has published a number of articles, taught at several local colleges, is a frequent presenter at professional conferences, has appeared on television, and has served as an expert witness on numerous court cases.   In 2012, Dr. Brady opened Net Worth Recovery, an Internet Addiction treatment center in San Jose, and in 2015, she published her first book, “Forged in Fire,” the survival story of a young girl growing up in an abusive home.

by Edna Wallace, LMFT

On May 31st, 2019, I presented on treating older adults suffering from major depression, severe anxiety, or bipolar disorder. We had a full house for this luncheon talk, against the backdrop of beautiful Shoreline Park and delicious food at Michael’s Restaurant.

The talk started with an exploration of loss. The “golden years,” as some refer to that stage, are often times of great loss. I had the participants talk at their tables about “what I stand to lose (or have lost).” Lots of roundtable discussion was generated; of course, all aspects of loss were expressed—from deaths of people closest to them through to divorce, loss of independence, loss of capabilities, loss of memory, and loss of purpose. Audience members expressed feelings of fear and grief, thinking of all these losses.

I went on to discuss features of depression, anxiety, and bipolar disorder in older adults. I talked about isolation, mounting mail and bills, hoarding, cognitive and physical impairments, chronic pain, staying in bed all day, anhedonia, and rumination (being stuck in regrets). If the last stage in the Ericksonian Stages of Development is Integrity vs. Despair, the depressed older adult looks back over their life with huge regrets. Some of the precipitants to depression and severe anxiety include the failure to navigate the transition to retirement; feelings of incompetence (or “being left behind”); pain and illnesses; avoidance of help and senior resources, and discomfort with psychotherapy (for dealing with childhood abuse or trauma). I talked about the higher suicide completion rate for older adults than their younger counterparts. I discussed how some medical conditions, surgeries, or medications can lead to depression or anxiety in older adults (for example, heart surgery has a link to depression, and Parkinson’s comes with high anxiety).

I went on to discuss treatment of these disorders, focusing on the psychiatric programs that El Camino Hospital offers. These are group-based day programs, with a mixture of CBT, DBT, Process, Art, and occupational therapy groups—where the patient comes in for the whole day (in the partial hospitalization level of care) or for half a day (in the intensive outpatient milieu). There is weekly case management/therapy and weekly psychiatrist visits for patients needing acute care due to their anxiety, depression, or bipolar disorder. For older adults, there is also OATS, a 15-week outpatient, psychiatric program with 2 groups a week (process and psychoeducational) and monthly case management and psychiatrist visits.

I stated that “patients get better just by coming in.” That is, with acute depression or anxiety, the older adult has been isolating for so long and ruminating all day in their private hell, that by coming in and being around other people, learning from the other patients, acquiring skills, and eating lunch together, the patients start rallying and getting out of themselves. They learn the lesson “I am not alone in my pain and distress” in a very visceral way. They start developing hope and focusing on what they can still do. They start making plans; taking “baby steps”; setting SMART goals for the weekend. And, of course, there is the medication management, as the program psychiatrist sees the patient weekly in the PHP and IOP levels of care and monthly in OATS. There are also nurses, with whom the patient can consult on a daily basis, as necessary. Transportation to these programs is included (and paid for) by El Camino Hospital, enabling the older adult who can no longer drive safely to come in. This counters the oft-heard rationale, “But I can’t drive that far for treatment.”

I talked about the value of reminiscence therapy in treatment of older adults. I had my captive audience of marriage and family therapists do a second round of roundtable discussion: this time on “one’s favorite oldie music” and “one’s best or worst job.” This discussion was hard to wrap up; people really got into it! I talked about how that’s the same case for older adults with depression and anxiety. Not only do they get into it with relish, but they forget (for the moment) their worries and upsets and are totally in the moment, reviewing fond memories, connecting with others.

I talked about the needs of older adults. The audience did my job for me: they came up with a whole slew of needs. I emphasized many of them: need for visibility, purpose, connection, empathy, respect, and compassion. I talked about how these needs are addressed in the intensive programs that El Camino Hospital offers. I talked about how we encourage the depressed, anxious, or bipolar patient to get re-engaged in their community. I gave out a handout on “choosing after-care activities.” I talked about resistance and how the patient often puts up obstacles (withholding feelings, low self-esteem, worry, substance abuse, or denial). I said, “recovery is not a linear process.” I talked about how the patient is expected to provide a “discharge plan” before she graduates. This plan includes aspects such as “my primary coping skills; how I will stay well; my support people, early signs of relapse; emotions that get me into trouble; positive self-talk; my mantras; my pleasurable activities; why I can’t go back to the way I was; and how I will ask for help”. I gave some case examples, such as Mike (not his name), who came into OATS from the community and had been extremely isolated. In the beginning of the program, Mike had needed the hospital tables for protection from the other group members; by the end of his 15 weeks in OATS, he said “you couldn’t shut me up” and would go out with the other patients for lunch on Thursdays. I provided a list for some geriatric community resources, including the Village concept, senior centers, and geriatric care managers.

I ended my talk by emphasizing how much we rely on the audience! That is, we need community psychotherapists in conjunction with our Mental Health and Addictions programs at El Camino Hospital. We need the MFTs not only for referrals, but for ongoing treatment as well, because in both the IOP and the OATs levels of care, the depressed or anxious patient must have an outside therapist for weekly or fortnightly therapeutic sessions.

The talk was superbly successful, with positive evaluations, and lots of questions and comments. This is obviously a topic that generates concern, curiosity, fear (because who isn’t getting older?) and tons of engagement! Thank you for the privilege of allowing me to share my experience with a dedicated group of marriage and family therapists!

Edna Wallace has been providing psychotherapy for over 15 years. She has worked with the older adult community for the majority of that time. She has a private practice in Los Altos and co-leads a weekly interpersonal process group with Dr. Benjamin Page. Edna can be reached at www.ednawallace.com.

At the SCV-CAMFT South Region Luncheon at the Los Gatos Lodge on April 19, Steve Darrow, LCSW and Mary Cook, LMFT, CADCII, LPCC, LAADC, presented on Conjoint Couples Counseling. They have been offering Conjoint Couples Counseling for “high risk” couples for over 15 years as an adjunct to their regular private practices.

Conjoint Couples Counseling occurs when there are two therapists working with one couple. In this model, all four meet together at some sessions, and each partner meets with one of the therapists separately as needed.

There are a number of therapeutic advantages to this approach:

1. Both members of the couple have an advocate.

2. Individual issues can be dealt with within the safety of the existing therapeutic relationship.

3. Individual counseling sessions maximize the couples counseling time together.

4. One therapist can be “process observing” for additional insight.

5. Couples benefit from the richness of having access to the experiences of two different counselors.

Concerns about this method include cost, claims that clarity regarding transference can be confused, destructive competitiveness between the therapists, or that co-therapists may become too close, shut out others and destroy healthy interchange.

At this presentation Steve and Mary introduced the conjoint model of working specifically with high risk couples and presented the model they work with themselves.

Initially Steve and Mary meet with the couple for an intake appointment to explore the presenting problem. It is then determined which therapist should work individually with which partner of the relationship. For a period of several months, Steve and Mary engage in individual therapy with their respective individual clients to establish a solid alliance, clarify individual goals and prepare for the couples therapy. The conjoint model they use explicitly refers to the following structure:

1. Each person in the couple meets with either Mary or Steve every two weeks.

2. The couple meets with both Steve and Mary every two weeks.

3. The division into therapeutic dyads is not necessarily gender specific, but is based on a clinical assessment of client compatibility needs both in style and issue focus.

Throughout the program, Steve and Mary discussed the challenges to establishing a good working relationship with a co-therapist and outlined the nine phases of co-therapy team development by Dugo and Beck (1991).

These phases are:

• Creating a contract
• Forming an identity
• Building a team
• Developing closeness
• Defining strengths and limitations
• Exploring possibilities
• Supporting self-confrontation
• Implementing and integrating changes
• Closing

Crucial factors in developing a successful co-therapy team include respect, openness, trust, support, and complementary personalities and therapy styles. The success of the relationship depends on the openness and willingness of the therapists to communicate about differences that arise.

Steve and Mary presented a past case, outlining how they applied the model and the challenges with their own countertransference. Steve pointed out that working with high conflict couples can be quite difficult but that he and Mary infuse humor into their work which has benefited their couples.

They were encouraging other therapists to partner up and attempt to use it as well, and both reported to enjoy working together in this intense style as couples work becomes accelerated.

Steve Darrow can be contacted at 408-985-1217 and Mary Cook can be contacted at 408-449-0333.

Sharon Mead, LMFT gave a luncheon presentation on June 23, 2017 at the Los Gatos Lodge titled "Change the Music, Change the Dance: How Emotionally Focused Couple Therapy can Transform the Way You Work with Couples."

Emotionally Focused Therapy (EFT) for couples is my passion.  I spoke to the group not as an expert, but as an avid and enthusiastic learner.  It was clear from my first training that EFT made sense and spoke to my preference for a humanistic, bottom-up therapy.  I was thrilled to see the hard science backing it up.  I spoke to the group because I believe so much in EFT that I’d like to see a lot more therapists near me discover EFT as well.

I love EFT because of what I don’t have to do.

• I don’t have to teach couples different words to use.  Words, no matter how skillful, can be cutting if they come from an internal state of anger or resentment.  John Gottman found that happy couples do not talk to each other in any more “skilled” or “insightful” ways than do unhappy couples. (Johnson, Hold me Tight)
  
• I don’t have to challenge what they are thinking.  The couples who come to see us have had real life experiences to back up their thoughts and beliefs. The heart knows what it knows and doesn’t want to listen to other ways to look at things.  
  
• I don’t have to give my clients homework – which they probably won’t do anyway.  Or, even worse, one will do it and come in upset because the other didn’t!
  

I also love EFT because of what I do have.

• I have a roadmap to romantic love and a couple’s distress. Through attachment theory I can make sense of the conflicting and tangled emotions couples present.  I can help them organize what feels chaotic to them.  With that roadmap, I have specific researched tools to help them.
  
• I have empirical validation to back me up.  EFT is the most researched couple therapy approach.  It shows high levels of efficacy - 70% of couples report recovery from distress, 90% report improvement, and 63% report continued relief from distress after 2 years. Research also shows applicability to many populations (including LGBTQ couples, various cultures, and nationalities) and problems (depression, trauma, illness).  See ICCEFT website URL below for details and references.
  
• I have a community of therapists to learn and grow with. EFT is not a simple approach to do well.  Although it is extremely gratifying, couple therapy can be emotionally demanding.  It’s important to connect to other therapists having the same struggles.  In the Bay Area, we have the Northern California Community for EFT (NCCEFT).  It holds quarterly meetings and trainings, where you can get to know other EFT therapists.  The International Center for Excellence in EFT (ICEEFT) also facilitates communication among EFT therapists internationally through a listserv.  Therapists can post clinical problems they encounter and other therapists will offer ideas and encouragement.  Often Sue Johnson, originator of EFT, will weigh in on the discussion.
  

Finally, despite what I am not doing, couples clients will, as the result of therapy:

• Use different, softer words with each other that come from their hearts.
  
• See each other differently because they will have had new experiences with each other in session.  They will be able to rewire the negative patterns of past experiences into new positive patterns.
  
• Create a “secure bond that can withstand differences, wounds, and the test of time” (Johnson, Hold me Tight).
  

Origins of EFT
EFT was originated by Dr. Susan Johnson and Dr. Leslie Greenberg in the 1980’s.  When they were developing EFT, they were going against then current ideas about couple therapy.  At that time, it was thought that healthy love relationships were rational bargains, that too much emotion was the basic problem in most marriages, and that healthy adults should not depend on each other too much.  Instead, they began to follow the ideas of John Bowlby, the father of attachment theory, which holds that an effective dependence on each other is critical to healthy emotional life.  Bowlby’s original work was with children, but he also observed World War II widows and concluded that his ideas applied equally well to adult relationships.

“Throughout adult life the availability of a responsive attachment figure remains the source of a person’s feeling secure.  All of us, from the cradle to the grave are happiest when life is organized as a series of excursions, long or short, from the secure base provided by our attachment figures.” -John Bowlby (1988) A Secure Base

Neurobiology of Relationships
Current interpersonal neurobiology research on the relational brain supports Bowlby’s theories about adult attachment.  Our nervous systems react to the threat of loss of an important attachment figure in the same way as physical threat or pain.  Disconnection triggers a fight or flight response. Connection soothes the nervous system. There are now several studies that show the positive impact of a supportive other on how the brain interprets various stressors.  There was an fMRI study showing how EFT can affect the perception of pain.  See this video for a description of one of these studies, Soothing the Threatened Brain - YouTube.  

Patterns of Interaction
Another important part of the roadmap of couple distress is systems theory.  Systems theory explains why couples get into rigid negative patterns of interaction.  The danger response to loss of connection, for example, “Why don’t you ever help me?” signals danger to the other partner who responds, for example, by leaving the room to avoid a fight.  The first partner becomes even more alarmed and escalates his or her protest.  This circular causality, rigid negative cycle, allows us (and the clients) to see that both partners are caught in their reactions to signals of potential loss.  Both have valid perspectives drawn from valid emotional experiences even though they appear to be contradictory.    We help them see the cycle as the enemy rather than each other. 

In EFT, the negative cycle is sometimes referred to as a dance, and the emotions are the music.  The interventions of EFT are aimed at soothing the emotional responses to the threat of disconnection, slowing the music, and thus changing the dance.  In successful therapy, the couple will form secure bonds with each other and change their interactional patterns to a positive cycle of connection.  At the luncheon, I used a clip from the movie The Breakup to illustrate the process and the interventions.  

With a secure bond, couples can calm their nervous systems so that even if one does go into a protest, they don’t go into such a rigid pattern.  They recognize their need for each other, soothe each other, make up more easily, and get triggered less often.  They know the other person will be there for them, cares for them, and is willing and interested to know the other and be known by the other.

Training
The first formal therapist training is a 4-day externship.  After the externship, there is Core Skills training consisting of 4 weekends.  There are many Certified EFT supervisors who can provide guidance as you learn the model and help you to become a Certified EFT therapist. See the web sites below for more information about training.   In addition to the resources listed below, there are many videos posted on YouTube about EFT.

Conclusion
If you’d like a personal experience of the model, I recommend attending a “Hold Me Tight” workshop with your partner.  It is also a great resource for your clients.  The closest people offering the workshop are Sam Jinich and Michelle Gannon, two very experienced EFT therapists and trainers.  You can find information at https://www.holdmetightworkshop.com/.  

I enjoyed giving this presentation very much and I am grateful for the full house we had to hear it and the positive responses I received.  If you would like to receive a copy of the handouts from this presentation, email me at Sharon.Mead.MA@gmail.com.

Sharon is a Licensed Marriage and Family Therapist with a private practice in San Jose. She specializes in working with couples using Emotionally Focused Therapy (EFT). She is currently working with an EFT supervisor toward certification in EFT. She can be reached at Sharon.Mead.MA@gmail.com.

Resources

Books for clients:

• Hold Me Tight: Seven Conversations for a Lifetime of Love, by Sue Johnson 
  
• Love Sense: The Revolutionary New Science of Romantic Relationships, by Sue Johnson  
  
• An Emotionally Focused Workbook for Couples: The Two of Us, by Veronica Kallos-Lilly Jennifer Fitzgerald
  
• Emotionally Focused Couple Therapy for Dummies, by Brent Bradley, James Furrow

Books for clinicians:

• The Practice of Emotionally Focused Couple Therapy: Creating Connection by Susan M. Johnson (2004).  Main textbook.
  
• Becoming an Emotionally Focused Couple Therapist: The Workbook by Susan M. Johnson, Brent Bradley, James L. Furrow and Alison Lee (2005).
  
• Emotionally Focused Couple Therapy with Trauma Survivors: Strengthening Attachment Bonds by Susan M. Johnson (2005).

Web sites:

• International Centre for Excellence in Emotionally Focused Therapy – ICCEFT Information about EFT, research, training materials and listings of live trainings around the world with dates.  http://www.iceeft.com/
  
• San Francisco Center for Emotionally Focused Therapy Training Center offers information and many trainings for EFT. http://www.sfceft.com/  
  
• Northern California Community for EFT (NCCEFT): short trainings and community    http://www.ncceft.com/
  
• Training and Research Institute for Emotionally Focused Therapy Alliant (TRI EFT Alliant) Information, training materials and listings of live trainings. http://trieft.org/

Kate reviews her presentation at the May 20th luncheon titled "Betrayal, Secrets and Lies: Rebuilding Trust and Healing Sex Addiction Induced Trauma."

This article describes the phenomenon of Sex Addiction-Induced Trauma (SAIT) and contrasts two different sex addiction treatment models.  In particular, I focus on the merits of the trauma-informed model as opposed to the more traditional addict-centric model.  I also discuss the damage that can be caused by the treatment process itself (treatment-induced trauma).  For the sake of simplicity I refer to the addict as male and partner as female, and make the assumption that both parties are choosing to stay in the relationship and do the life-changing and oftentimes gut-wrenching work.   

First, let me define “sex addiction”.  Sex addiction is defined as any sexually-related compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones, and/or one’s work environment.  The criteria are the same as those of other addictions:  progression in the intensity of use, increased tolerance (more is required over time), repeated attempts to quit the behavior, continued use despite consequences.  While it is true that sex addiction is not a current diagnosis in the DSM, the term is now commonly used in our everyday language.  It is how many clients self identify when seeking treatment for their compulsive sexual behavior.

The traditional sex addiction treatment model views the addict as identified patient, and the intimate partner as co-addict and as adjunctive support to the addict’s treatment.  It promotes separate recovery programs, with limited opportunity for connection and attachment repair.  The partner is considered to be out of control and/or controlling, rather than adapting to life with an addict.  For instance, after discovery if a partner needs information about the addict’s travel plans or his commitment to recovery, these would be considered none of her business:  she is instructed to focus solely on herself.        

Conversely, the trauma model is partner sensitive and trauma informed and views the relationship through the partner’s experience and needs as well as through the needs of the addict.  The betrayals as well as, the multitude of lies, contribute to the trauma that most partners of sex addicts experience upon discovery.  A study conducted by author and clinician Barbara Steffens, PhD, showed that 70% of partners meet criteria for complex/PTSD, presenting with symptoms such as helplessness, sleeplessness, immobility, reliving of the event, anger, hypervigilence, anxiety, nightmares, intrusive thoughts, avoidance, mood swings, panic attacks, restlessness, confusion, etc.  In my practice this number is even higher.  Partners present with a vast array of symptoms, but at the core there is always a shattering of reality, disbelief and profound despair. 

The trauma-sensitive model acknowledges this experience of shattering as true and appropriate to the situation, and promotes empathy on the part of the addict and treatment team.  Ideally both addict and partner need to focus on their individual recovery and trauma work, and the model also critically supports relational and systemic healing. Therefore, for instance, a partner is given the information she needs.  This is considered reasonable and appropriate given the situation.  She is validated for seeking safety, rather than being controlling.  Her symptoms are acknowledged as predictable reactions to traumatic stress.  Furthermore, the model validates the partner’s pain; encourages the partner to share her story in safe settings and a guided format to ease the pain as well as other trauma specific work; places the responsibility for the addiction on the sex addict, not on the partner; and supports the partner in setting clear boundaries.  (Steffens page 73-74) 

Omar Minwalla, PhD, brilliantly describes Sex Addiction-Induced Trauma (SAIT) in his article, “The Thirteen Dimensions of Sex Addiction-Induced Trauma”.  The thirteen dimensions are highlighted below.  Not all are relevant for every partner.  Trauma is subjective and individuals are completely different and unique.  For the complete article see Bibliography.  

1.     Discovery Trauma whereby the partner “accidentally” discovers evidence of his acting out, and her pre-existing reality is shattered as she confronts his compartmentalized reality  
2.    Each Disclosure is the process of being told about some aspect of the deceptive, compartmentalized reality-system (factual or not) and is a critical trauma-inducing incident, even though ultimately it is necessary for the partner to know the truth in order to grasp a cohesive narrative necessary for healing
3.    Reality-Ego fragmentation occurs as reality is shattered
4.    Psychobiological symptoms involves trauma to one’s physical body such as, hair loss, insomnia, vaginal spasms, etc.
5.    External crisis and destabilization refers to all the practical, sudden or long-term changes and the overwhelming chaos that ensues and endures as a direct result of sex addiction such as, concerns related to finances, shifts in residence, legal issues, etc.
6.    Hypervigilence and re-experiencing as described in the DSM description of PTSD  
7.    Psychological trauma and the phenomenon of gaslighting refers to the intentional manipulation of partner’s reality, thoughts and feelings in order that the victim will submit her will
8.    Sexual Trauma is often similar to that of women who have been raped or otherwise sexually traumatized
9.    Gender wounds refers to how partners are often profoundly impacted at the core of their gender
10.Relational trauma and attachment wounds means the “Us” itself is traumatized
11.  Family, communal and social wounds speaks to the far-reaching implications for other relationships, including the parent-child bond, social world, etc.
12. Treatment-induced trauma is a clinical intervention or omission which causes harm
13. Existential and spiritual trauma refers to a loss of faith in the goodness of life

• 
  

Relational trauma involves exposure to an extreme stressor such as sexual

 addiction, by which trust is desimated and the experience of the relationship as safe is diminished.  The Multidimensional Partner Trauma Model (MPTM) builds on Minwalla’s SAIT model and includes focused education on the traumatic impact of the relationally offending behaviors and that of partner trauma.  It serves to provide safety for the partner and relationship, and fosters internal motivation for change towards empathy.  This means specifically, that the addict is taught and encouraged to participate in helping her heal by providing empathy, compassion, honesty and accountability. 

Within the MPTM, the partner’s trauma must be addressed both in her individual therapy as well as, within the relationship.  There is a structured process to this relational healing that usually includes a therapeutic Disclosure.  A Disclosure is a voluntary transfer of information from the addict to partner detailing a thorough and honest history of all acting out behaviors including financial costs.  There is a systematic process to the preparation of the Disclosure document as well, as the sharing.  Although this is often an incredibly distressful process for addict and partner alike, it is crucial because most partners can not adequately heal until they know what they must heal from.  Otherwise, they are haunted by unanswered questions, doubts and fears.  For the addict, secrets fuel shame and shame fuels relapse.  Furthermore, secrets create barriers to the re-building of trust and intimacy.  There is a saying in 12-step recovery:  “we are as sick as our secrets”.  This is applicable to the individual as well as, the couple.  I often liken the Disclosure process and sharing of secrets to one of cleaning out an infected wound.  If the wound is not completely disinfected, the infection continues to cause more and deeper damage, possibly leading to amputation or death.

Once the secrets are divulged, the next step is often a polygraph exam to establish a reliable basis for honesty and the re-building of accountability and trust.  A Sobriety Contract is written and shared with the partner to further promote trust.  Although sobriety is his responsibility, there is transparency into his recovery process.  The couple is also given guidelines for sharing about feelings and recovery at home as soon as they are ready to do so.     

Treatment-induced trauma occurs when the treatment process further injures the partner by ignoring or invalidating her needs and perceptions.  An example is when the therapist believes and even asserts that the addict is not lying, despite evidence and protests by the partner to the contrary.  Other examples include blaming the partner, and excluding the partner from treatment by telling her, “the addict’s recovery is none of your business” and the like.

Often treatment-induced trauma is caused by clinical interventions that are fundamentally organized around the traditional co-sex addiction model, and other traditional interventions.  One such intervention is sex positive therapy, based in failure to recognize or treat SAIT among partners.  Many “sex positive” counselors and educators will too quickly prescribe, “date nights or sex nights”, for traumatized and sexually abused partners and couples.  For a client to reach out for support and be “let down” or “hurt instead of helped” is the utmost of serious violations in human ethics and attachment relationships – to do no harm.

Sometimes referral to a specialist for the purpose of thorough assessment, consultation and/or treatment is recommended.  Certified Sex Addiction Therapists are found at www.sexhelp.com.  The Sex Addiction Screening Test (SAST) is also available from the same site, and can be utilized as an initial assessment.  More comprehensive assessments are available and administered by a CSAT.

To demonstrate some of the complex issues inherent in working with this population, I share the following story.  Robert (not his real name) and I worked together sporadically for three years on what he described as “a fascination with certain pornographic images”.  He insisted repeatedly that this was the full extent of his sexual preoccupation.  If I pushed too much on the subject or inquired about other accompanying activities (such as masturbation or physical contact with others) he would discontinue therapy for weeks or months, outraged at my insinuation. 

One day, I received a frantic phone call from Robert, saying that his wife had discovered a text message on his phone from another woman.  He was “terrified of losing everything”.  With this discovery, his life began to unravel, and the next several months were horrible as they individually as well as, collectively began to face the truth of his secret life and the extent of his betrayal.  Robert revealed to me his extensive history of sexual acting out before and during his marriage including numerous affairs and prostitution.  He eventually prepared and read his full Disclosure to her, 18 pages in all, and was without secrets for the first time.  He passed a polygraph exam, formulated and committed to a Sobriety Contract including working a 12-step recovery program.  He began to learn about honesty, empathy and ultimately, how to rebuild trust and help his wife heal from the trauma of learning the extent to which he had been unfaithful.  Both Robert and his wife now agree (several years later) that the recovery process required more courage and fortitude than any other life experience.  However- as most addicts and partners agree- the quality of their life and current connection is richer and more intimate than they ever dreamed possible.            

This story- similar to stories that I hear in my office every day- is rich with complexity.  Several of the questions are discussed below.    

• ·      How did I- an experienced therapist and specialist- not know that Robert was lying, that there was more to his story than viewing pornography?  The truth is, I didn’t know (although I usually do) because addicts are really good at lying.  It is a skill well-honed over decades that serves to protect, so that the learned behavior and addictive high can continue. 
• ·      What did the addict’s comprehensive assessments indicate that I overlooked in deference to his assertions?  I was reminded (once again) to trust my intuition and clinical expertise, and confirmed that addicts lie, even to their therapist.  They don’t lie because they are bad people, but because there is sufficient fear and shame that prevents them from doing otherwise.  It is usually consequences- or the fear thereof- that eventually force them to risk and live in the truth.
• ·      How does the partner of a sex addict heal a heart shattered by the very person she loves?  One of the questions I am mostly frequently asked by partners after discovery is, “how did I live with this man for all this time and not know what he was doing? ”.  I often respond:  “because sex addicts lie, compartmentalize, deny and scapegoat in order to maintain their secret sexual- and often financial- life.”  Another common question is, “how can I stay?”  This is a very individual decision.  I often offer the wisdom of not making any major decisions for one year.  This allows for emotions to cool and clear thinking to return so the partner can make the best decision for herself and her family.
• ·      How is an addict “terrified of losing everything”, and yet driven to continue activities that- if discovered- will jeopardize what he holds most dear?  Sex addicts often confuse intensity for intimacy, and hurt those whom they most love. 

In conclusion, I would like to leave the reader with three key points: 

1.     The traditional addict-centric treatment model- in and of itself- is inadequate. 
2.    It is imperative that the treatment model is trauma-informed and trauma-sensitive for the sake of the partner as well as, the addict and couple-ship.  Since sex addiction is fundamentally a relational trauma, the healing and recovery process must also be relational and tend to the attachment wounds.
3.    As clinicians we must be careful to not inadvertently collude with the addict at the expense of the partner’s needs, thus damaging potential for healing of the broader system.

• 
  

There is great hope.  Freedom from sex addiction is possible.  Healing from Sex Addiction-Induced Trauma is possible.  My experience with many clients supports this optimism. 

Resources

The Association of Partners of Sex Addicts Trauma (APSATS)

www.apsats.org

Therapists who specialize in the treatment of partner trauma

International Institute for Trauma and Addiction Specialists

www.IITAP.com

Certified Sex Addiction Therapists (CSAT)

www.sexhelp.com

Sex Addiction Screening Test (SAST) and other resources

www.recoveryofselfcounseling.com

Website for Kate Parkinson’s practice

Bibliography

Steffens, Barbara, PhD, (2009).  Your Sexually Addicted Spouse:  How Partners Can Cope and Heal, New Horizon Press.

Minwalla, Omar, PhD, (2014), Thirteen Dimensions of Sex Addiction Induced Trauma Among Partners Impacted by Sex Addiction

http://theinstituteforsexualhealth.com/thirteen-dimensions-of-sex-addiction-induced-trauma-sait-among-partners-and-spouses-impacted-by-sex-addiction/

Weiss, Doug, Helping Her Heal (DVD set) available at:

http://drdougweiss.com/product/helping-her-heal/

Corley, D., Schneider, J., (2012).  Surviving Disclosure:  A Partner’s Guide to for Healing the Betrayal of Intimate Trust, CreateSpace Independent Publishing Platform  

About the author 

Kate Parkinson, MFT, CSAT, CHFP, CEMDR, is the founder of Recovery of Self Counseling and Intensives in Palo Alto.  She is a licensed Marriage and Family Therapist (MFC41470), Certified Sex Addiction Therapist (CSAT), Certified Hope and Freedom Practitioner (CHFP), and is EMDR certified.   Her practice is dedicated primarily to the healing of relationally traumatized couples and families devastated by sexual addiction, sexual anorexia, and other intimacy disorders. 

Kate facilitates Three-Day Intensives for couples, partners of sex addicts, and both male and female sex and love addicts.  Additionally, she specializes in the treatment of complex/PTSD as well as, dissociation, shame, boundary impairments and developmental immaturity.  She offers extended psychotherapy sessions as well as, Three-Day Intensives focused on trauma resolution.  Kate’s approach is informed by her belief in the inherent preciousness of each and every person.