With the transition to virtual therapy as recommended by CAP, I wanted to investigate the effectiveness of telepsychology. Here is one study I found.
Varker, T., Brand, R. M., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological Services, 16(4), 621–635.
From the study and ICEEFT listserve post from Dr. Robert Allen in Denver: "What is the evidence for these modalities of care, is there adequate research to support their use, are they as effective as care as usual? In this rapid evidence assessment, Varker and colleagues review the existing empirical research on the efficacy of telepsychology programs. They only looked at synchronous telepsychology interventions (i.e., those interventions during which therapist and client are interacting in real time), and not asynchronous use of technology (smartphone apps and chat technologies in which therapist and client are not interacting in real time or are not interacting at all). Synchronous telepsychology is most similar to face to face psychotherapy, and likely the option adopted by most therapists during these times. Health care providers initially adopted telepsychology and telehealth to overcome barriers to access to health care and psychotherapy like distance, stigma, and transportation needs. With the global pandemic related to COVID-19, psychotherapists are increasingly using telepsychology to manage physical distancing requirements while providing services.
Varker and colleagues focused their review on randomized controlled trials and meta-analyses, which researchers consider to be the highest level of evidence for an intervention. The authors found 24 studies that evaluated telepsychology interventions with clinical populations of adults who had depression, anxiety, or PTSD. They found good quality evidence for telephone-delivered therapy (11 studies) and video teleconference-delivered interventions (12 studies). That means that the studies of these modalities were high quality and so results were likely reliable. The evidence indicated that both of these modes of delivering psychotherapy were as effective as face-to-face or treatment as usual. The evidence for internet delivered text-based treatments was not of high quality (3 studies). There were too few studies of this modality, and their quality was low. And so, the authors determined that the evidence for text-based therapy was unknown.
Research on telepsychology interventions is still quite new with a limited number of quality studies attesting to their efficacy. Nevertheless, the findings were promising for telephone delivered psychotherapy and videoconferencing telepsychology, such that psychotherapists can be reasonably confident in using these methods with clients. Text-based delivery of interventions had limited and poor-quality evidence."
Thus, we can safely use telepsychology as an alternative to in-person sessions during this pandemic.
Intended audience: Couples and professionals
Reference: The New Rules of Marriage by Terry Real
Title: Changes in relationships as identified by Terry Real, or No Wonder we don’t seem to be on the same page
Problem identified by author: Terry Real works closely with Esther Perel and they have put on presentations together, so my sense is that if you resonate with Perel, you will probably resonate with Terry Real. I put those two therapists/ authors in the same category as David Schnarch, creator of the Crucible approach and more recently, author of Brain Talk, where he tries to integrate neuroscience into his ideas of differentiation and growth in marriage. Unfortunately, Real’s book appears very heteronormative and focuses on relationships between men and women, making it limited in terms of effectiveness overall, but potentially valuable for opposite sex couples.
In the first chapter of his book, Real describes the changes in relationships from transactional companionship (baby boomers and before) to transformational intimacy (after boomers). As a member of generation X, I think that I’m somewhere in between and members of my generation can seemingly go both ways. Generations of marriage were founded on the expectations of patriarchal gender roles whereby the man’s job is to make money and provide security for this family while the woman’s job is to take care of the household and raise the children. This arrangement seemed to result in certain patterns and expectations, which changed drastically in the latter half of the 20th century. Positively, women became secure on their own, without needing a man, and started to ask for what they actually wanted in relationships – connection, intimacy, and trust. Unfortunately for women, men continue to struggle to adapt to what women want because they weren’t raised to be a sensitive, caring, and present partner. Relationships then become a battle between women asking for their needs to be met and men not responding with warmth, empathy, and validation. That’s because men are interpreting their partner’s needs as threats to their masculinity, which has been entrenched in gender role socialization since men were kids. It is not generally safe for these men to display emotions, sensitivity, or discuss the fear that their partner’s complaints trigger. Instead of acknowledging the fear, men display anger to protect that softer part of themselves, which again was reinforced since they were boys. Let’s also not pretend that this is just men. Women can display these emotionally dismissive messages too, and I’ve certainly seen couples where the female is the person who can’t access their emotions with their partner.
Remaining questions: What’s in chapter two and beyond? My sense is that Real will advocate for communication between partners about these relationship dynamics, teach assertiveness, and teach listening skills. We are not living in times where our relationships can be compared to our parent’s relationships? Whatever we learned from them may or may not be helpful as we try to form and sustain relationships as adults. Why are we expecting ourselves to just “know” how to have these kinds of relationships without learning about them and developing helpful skills? Don’t assume that “if the relationship is meant to be it will work.” All relationships require learning skills continuously. We can no longer rest on the fact that we have a job and a nice house. Relationships require much more.
Let me know your thoughts.
The 24th World Congress of Sexual Health issued a "Declaration of Sexual Pleasure" on October 15, 2019. The purpose of this blog is to help to contextualize this declaration. Part of my interpretation of the context is that there has been a shift by professionals towards emphasizing sexual pleasure as an important component of sexual health, which is evident by this declaration at this time. That’s interesting because the emphasis in the past was more on sexual function, which is why Masters and Johnson’s model of human sexual response similarly emphasized functioning and gave rise to DSM diagnoses. With the growing emphasis on pleasure, it makes me curious about why. Is that where we “should” be going in terms of emphasis? Or is it just a part of the acceptance of “other” reasons to have sex, finally.
On one hand, pleasure is absolutely an important part of sexual health but why are we only now recognizing pleasure as central to sexual experience? Pleasure shouldn’t be a new concept when it comes to sex. It’s a built-in part of the human sexual experience for as long as sex has existed – after all, pleasure and reproduction have been paired by evolution to promote the survival of the species. Is the study of human sexuality that far behind the experience of individuals? Yes, it is. It took until the early 2000s for sexual health professionals to finally recognize that sexual distress was an important concept when diagnosing sexual disorders! Until then, you could have been diagnosed with a sexual disorder based solely on how your sexual responses (desire, arousal, action, orgasm, and refractory period) aligned with Masters and Johnson’s model. Even if your sexual responses did not cause you distress, it didn’t matter, sexual health professionals with influence had decided that there was still something wrong with you that indicated attempts to change. That ridiculousness should sufficiently demonstrate the degree to which sexual function was positioned as THE most important part of sex in the past.
So, on the other hand, might the emphasis on pleasure nowadays merely be a reflection of what society believes is most important about sex? Have we shifted from a belief that sex is about reproduction to a belief that sex is about pleasure? And does that also reflect our changing beliefs about how we make meaning out of our lives? Abrahamic religions have typically emphasized guidelines that reinforce the belief that sex is more about reproduction than hedonistic pleasure. Without these religious beliefs shaping as many individuals’ sexual beliefs, it appears that society has developed a more individualistic and egocentric view of sexuality (and an understanding of those factors would be crucial to understanding the reasons for that shift over the last few hundred years, which for the purposes of this blog, I am merely referencing the fact that less individuals turn to religion to answer the questions they have posed about life). I imagine that one’s opinion on whether this shift is positive or negative is dependent on one’s beliefs about religion. However, that’s not the topic I’m interested in for the purposes of this blog. I’m interested in thinking about the context in which this declaration of sexual pleasure was made. Sexual pleasure is pretty obviously an important element of sexuality when individuals are having sex because they want to feel good either through the pleasure gained by connecting to a partner(s) which may or may not include orgasm, or through the pleasure gained via the 5 senses which likely includes orgasm. But, I also regularly see clients who are primarily interested in the functionality of sex for reproduction. They want to have a baby so they are focused on what they believe is the function of their sexual encounter – male orgasm via penetration. And that’s not something that is just a given for all couples. Research has shown that couples who are sexually satisfied in their relationship do not meet their sexual goals in about 15% of their sexual encounters. That’s a number that couples need to know because it is very normal for even couples with happy sex lives to not always get the sex they want, and those couples still consider their sex lives to be happy.
My point is that what individuals consider important about sex is unique and cannot be assumed. We must be respectful of the differences that exist about what is important about sex because what is important is in the eye of the beholder. Sex for reproductive purposes is just as valid as sex for pleasure purposes. We may be witnessing a shift in society’s beliefs about what is important in sexuality, but maybe this shift merely reflects some increased acceptance and advocacy for sexual pleasure as a contrast to society’s previous emphasis on sexual function. Let’s listen to each other to understand what is important to all of us about sex, and put it all on an equally valid level. For now, this declaration celebrates sexual pleasure, so consider it as one of the reasons for your sexuality, but remember that there are many, many, many reasons to have sex and one person’s reasons are not better than others (unless we start talking about sexual offending, which I am not trying to discuss here).
The participants of the Congress of the World Association for Sexual Health in Mexico City declared that they:
Sexual pleasure is the physical and/or psychological satisfaction and enjoyment derived from shared or solitary erotic experiences, including thoughts, fantasies, dreams, emotions, and feelings.
Self-determination, consent, safety, privacy, confidence and the ability to communicate and negotiate sexual relations are key enabling factors for pleasure to contribute to sexual health and well-being. Sexual pleasure should be exercised within the context of sexual rights, particularly the rights to equality and non-discrimination, autonomy and bodily integrity, the right to the highest attainable standard of health and freedom of expression. The experiences of human sexual pleasure are diverse and sexual rights ensure that pleasure is a positive experience for all concerned and not obtained by violating other people’s human rights and well-being.
1. The possibility of having pleasurable and safe sexual experiences free of discrimination, coercion, and violence is a fundamental part of sexual health and well-being for all;
2. Access to sources of sexual pleasure is part of human experience and subjective well-being;
3. Sexual pleasure is a fundamental part of sexual rights as a matter of human rights;
4. Sexual pleasure includes the possibility of diverse sexual experiences;
5. Sexual pleasure shall be integrated into education, health promotion and service delivery, research and advocacy in all parts of the world;
6. The programmatic inclusion of sexual pleasure to meet individuals’ needs, aspirations, and realities ultimately contributes to global health and sustainable development and it should require comprehensive, immediate and sustainable action.
URGE all governments, international intergovernmental and non-governmental organizations, academic institutions, health and education authorities, the media, private sector actors, and society at large, and particularly, all member organizations of the World Association for Sexual Health to:
A. Promote sexual pleasure in law and policy as a fundamental part of sexual health and well-being, grounded in the principles of sexual rights as human rights, including self-determination, non-discrimination, privacy, bodily integrity, and equality;
B. Ensure that comprehensive sexuality education addresses sexual pleasure in an inclusive, evidence-informed and rights-based manner tailored to people’s diverse capacities and needs across the life span, in order to allow experiences of informed, self-determined, respectful, and safe sexual pleasure;
C. Guarantee that sexual pleasure is integral to sexual health care services provision, and that sexual health services are accessible, affordable, acceptable, and free from stigma, discrimination, and prosecution;
D. Enhance the development of rights-based, evidence-informed knowledge of the benefits of sexual pleasure as part of well-being, including rights-based funding resources, research methodologies, and dissemination of knowledge to address the role of sexual pleasure in individual and public health;
E. Reaffirm the global, national, community, interpersonal, and individual commitments to recognition of the diversity in sexual pleasure experiences respecting human rights of all people and supported by consistent, evidence-informed policy and practices, interpersonal behavior, and collective action.
I’m going to invest some time in blogging each week so I hope you will enjoy the new format and the content to follow.
Intended audience: More towards professionals but also those interested in translating couples research into practical action
Reference: McNulty, J. K., Maxwell, J. A., Meltzer, A. L., & Baumeister, R. F. (2019). Sex‑Differentiated Changes in Sexual Desire Predict Marital Dissatisfaction. Archives of Sexual Behavior, 48, 2473–2489.
Problem identified by authors: Since couples regularly come to see me because of sexual desire differences, I’m regularly trying to better understand how couples can best manage this issue. This article that I’m discussing today appears to partly address this problem that heterosexual couples often experience. It causes people to question whether they can stay together, whether the seeming incompatibility in sex drives is tolerable or stifling, and whether they can compartmentalize this problem and just grin and bear it while they try to raise their kids. What are the factors that drive sexual desire issues with heterosexual couples? And what does that mean for a couple’s relationship satisfaction?
Context and previous research: I’ve always remembered a story that my PSCYO 105 prof told the class about how the Coolidge Effect got its name. Turns out that US president Calvin Coolidge and his wife were visiting a chicken farm and Mrs. Coolidge remarked that the rooster must have remarkable sexual stamina to reproduce so often, as there was only one rooster for the entire farm. Mr. Coolidge responded by saying, “I’d like to remind Mrs. Coolidge that the rooster’s remarkable stamina was owed in large part to the fact that the rooster had a variety of partners and was not stuck with the same partner, which would result in Mrs. Coolidge’s dissatisfaction.” Or something like that, I’m paraphrasing from my memory. But it was an important contextualization, albeit during a time of misogyny and patriarchal repression of female sexuality. Regardless of its origins or the politics of it, the Coolidge Effect suggests that novelty is more important to sexual desire for men than women. It may be interesting to further understand the possibility of how the Coolidge Effect merely represented an adherence to gender roles.
That’s the second contextual factor I’d like to speak to before we get into examining what the article found. Is it really biology that drives the differences between genders? (apologies for not using a non-binary research study, I will try to include articles that are more inclusive). Could testosterone explain the changes in sexual desire over time? Research has indicated that men’s testosterone levels decline over time after full maturity but women’s testosterone levels also drop after menopause. Could the cultural expectations of our society be the larger influence? Meaning that if men and women are expected to behave in certain ways, they will conform unconsciously to fit in. And we already know how problematic gender roles have been for sex positivity and freedom of expression. How many people do you know where it is the man who wants more sex and how many people do you know where it is the woman who wants more sex? My clients are about 50-50 when they come to see me. Have you ever asked anyone else? Or do you assume that you know what must be happening in their sexual dynamic? Does that make you feel shameful? Even though you don’t really know?
Research has demonstrated that child-birth and child-rearing still impact women more than men and stress appears to impact women’s sexual desire more than for men. Research also has demonstrated that women are twice as likely to be “responsive” in terms of sexual desire, rather than “spontaneous,” which is twice as likely for men. Again, it is unclear if this is due to biological differences or gender role expectations. So, it’s a real thing that women seem to more often bear the stress of child-rearing, and that this stress is likely to impact their sexual desire while men are less likely to undergo such changes.
Another contextual factor to think about is Helen Fisher’s research on the 3 stages of love that she identified by observing different brain processes in response to a relationship partner over time. At first, lust is the driver as our brains are stimulated by dopamine and adrenaline, evolution’s trick to try and get us to reproduce, accidentally or not. The dopamine-release habituates to that partner after between 6 and 18 months, and that’s when those relationships end. In order to continue, Fisher says that the brain must rely on the serotonin neurotransmitter to perpetuate the pair-bond. She calls this the love stage and it is also temporary, up to about 4 years into the relationship, long enough for evolution to get us to raise a child together to an age it can survive more independently. To stay together after year 4 requires attachment, yes that same thing I’ve talked about lots. Only with attachment do we stay together. And only when we can repair our attachment injuries can we tolerate the waves of being in a relationship for a long time. But wait, does this mean that we are predestined to shift from a sex-heavy courtship to a more secure and loving (which isn’t that sexy) long term bond? Maybe.
Some researchers pin the blame on women, saying that women use enhanced sexual desire and activity to attract a man, but as security increases over time, they have less reason to behave sexually to keep him. This narration makes it sound as if women have a plan to trap a man by giving them lots of sex as a way to ensnare him, which is followed quickly by a sexless and unsatisfying marriage. This stereotype is unfair and hurtful to women, just as is the stereotype that men are horn-dogs and don’t need to be courted into getting turned on too. Maybe there are some evolutionary or biological factors involved in female courtship, but those factors are conflated by women bearing more of the stress of child-rearing, so if male participation could unburden mothers and make it more equal, maybe women wouldn’t lose so much sexual desire after having a child. Do they also have to deal with the extra burden of household responsibilities too? Is that still a bit of an expectation from many men?
Research findings: “Results of this study demonstrated that women’s sexual desire declined more steeply over time than did men’s sexual desire, which did not decline on average. Further, childbirth accentuated this sex difference by partially, though not completely, accounting for declines in women’s sexual desire but not men’s. Finally, declines in women’s but not men’s sexual desire predicted declines in both partners’ marital satisfaction. These effects held controlling depressive symptoms and stress, including stress from parenthood. In sum, compared to their husbands, wives demonstrated lower levels of initial sexual desire that (1) declined more steeply over time, (2) were partially, but not completely, attributable to the birth of children, even after controlling stress, including stress associated with parenthood, as well as depressive symptoms, and (3) ultimately predicted changes in marital satisfaction for both members of the couple (though somewhat less reliably for husbands) and thus lower levels of marital satisfaction at the end of the of the study for both members of the couple… Changes in wives’ sexual desire predicted changes in both partners’ marital satisfaction, not because they predicted change in couples’ sexual frequency, but because they predicted changes in their sexual satisfaction. Our findings might reassure some couples that the emerging mismatch in marital sexual desire is normal and typical.”
Interesting results. I read it to say that women have lower sex drives than men generally (which could be biology or adherence to gender norms), and that women’s sexual desire goes down steeply over time while men’s sexual desire remains unchanged (even though testosterone levels go down over time). Some of the changes in sexual desire could be attributed to child rearing but not all (so maybe changes in testosterone or changes in gender norms due to increasing age whereby older adults are expected and considered to be less sexual than younger adults). And when women’s sexual desire levels went down, satisfaction in their relationship also went down for both partners. Interestingly, the dissatisfied couples appeared to have the same amount of sex as satisfied ones, but when women had less desire both partners experienced less sexual satisfaction. The lesson – women’s sexual desire matters in relationships. My take – how couples manage these sexual desire issues is what matters. Is this true – if men can satisfy and nurture their partner’s sexual desire throughout the years, both partners will be happy.
Remaining questions: Does testosterone have any impact? Or is it only when testosterone changes to outside the normal range that it becomes an issue? Why doesn’t men’s sexual desire drop more as they get older? Are women’s sexual desire levels supposed to drop because of evolution, biology, and reproductive success? Or is that a bunch of bullshit that has been fed to us in order to control our sexuality? I’ve met too many clients who experience a sexual awakening after a 20-year marriage ends to believe that we are hamstrung to outdated notions of heteronormativity, ageism, and an emphasis on the differences between men and women, as if in an attempt to reinforce an unconscious bias towards a binary understanding of gender. And those sexual awakenings are maintained well beyond what could be explained by the “lust phase” of relationships. Provide a context for your partner to be sexual, and not just based on what you think it should be, and it appears your relationship is more likely to stay strong throughout the years.
Let me know your thoughts.
I found this article I wrote a while ago and thought it might be useful for people interested in sex therapy.
A Timeline of Modern Sex Therapy
Sex therapy, the treatment of sexual problems, has positively evolved since Kinsey and Masters and Johnson, the pioneers of modern sex therapy (Weeks, Gambescia, & Hertelin, 2015). Technological advancements have helped many people effectively deal with sexual issues while debate and controversy has expanded our understanding of human sexuality, helping many more in education and therapy. Let’s take a look at a partial timeline of sex therapy, noting the positive evolution of the field due to technology and challenges to previous understanding.
1948: Alfred Kinsey published Sexual Behavior in the Human Male, sparking interest in both the public and in researchers about human sexuality. Five years later, he published Sexual Behavior in the Human Female. The focus of the burgeoning field of sex therapy is on sexual behavior at this time since it is a taboo topic in Western society (Ridley, 2015).
1954: William Masters begins his research on sex, joined by Virginia Masters in 1957. They attempt to understand the human sexual response with an emphasis on physiology and behavior, sparking the field of sex therapy (Hyde & Delamater, 2011).
1960: The Pill is invented to help women decide if they wish to pursue sexual activity for pleasure by preventing pregnancy. This technological advancement is credited as a major part of the Sexual Revolution, sparking curiosity in the Western culture as to their enjoyment and satisfaction with sex (Leiblum, 2007).
1967: The American Association of Sex Educators, Counselors, and Therapists is founded by Patricia Schiller. This organization became the credentialing body for sex therapists, helping to promote higher standards and effective practice in the field (Haeberle, n.d.).
1970: Masters and Johnson publish Human Sexual Inadequacy, the first modern book on treating sexual problems (Hyde & Delamater, 2011).
1973: The Diagnostic and Statistics Manual (DSM) of Mental Disorders removes homosexuality as an illness, promoting equality and informing sex therapy practice (Ridley, 2015).
1974: Helen Singer Kaplan publishes The New Sex Therapy, building upon Master’s and Johnson’s behavioral model by adding an emphasis on desire, sexual satisfaction, and couples’ dynamics (Weeks, Gambescia, & Hertlein, 2015).
1982: Ladas, Whipple, and Perry publish The G Spot – and Other Recent Discoveries about Human Sexuality. Female researchers begin to emphasize the differences between male and female sexuality, where previously it was viewed from one dominant lens (male) (Leiblum, 2007).
1987: The DSM-III-R is published, which removes nymphomania and Don Juanism as illnesses, and makes a reference to sex addiction, igniting a fervent debate over the nature of compulsive, impulsive, hyperactive, or out of control consensual sexual behavior. This discussion spurns research and attempts at articulating how to understand and treat this behavior (AASECT, 2017).
1989: Gerald Weeks describes a theoretical underpinning of sex therapy using his Intersystems Approach, which uses a systemic lens, signalling a change in approach from a behavioral focus to a more holistic perspective (Weeks, Gambescia, & Hertlein, 2015).
1998: Viagra is approved by the FDA, the first effective oral medication to treat erectile dysfunction. This medical intervention shifted focus to a more medicalized treatment of sexual disorders, which has had both positive impacts and significant discussion of the role biology and medicine play in sex therapy and understanding human sexuality (Leiblum, 2007).
1998: The American Psychiatric Association releases a statement opposing conversion therapy (attempts to change sexual orientation from homosexual to heterosexual). The nature of how we define illness and the boundaries of therapy continues to evolve (Hyde & Delamater, 2011).
2002: Rosemary Basson presents the female sexual response cycle, distinguishing the female complexity of sexuality with the more linear model for men, helping sex therapists understand how to better assist females seeking sex therapy (Leiblum, 2007).
2007: Facebook and the iPhone spearhead social media networking, which changes how people relate to each other. Sexual contact also changes with hook-up apps, while niche sexual interests form online communities. Pornography is also exploding in popularity at this time, and our society’s ability to adapt to these technologies creates debate while clinicians adapt to new issues in therapy (“porn addiction,” infidelity and technology, and exploring fetishes and alternative forms of sexuality) (Weeks, Gambescia, & Hertlein, 2015).
2013: The DSM-5 is published and debate rages on about the nature of diagnosing sexual problems, enriching the field with an important conversation about the nature of sex therapy (Ridley, 2015). Some argue that sexual problems are reflections of a sex negative culture while others attempt to pathologize to meet the needs of insurance companies (Donaghue, 2015).
The current state of sex therapy is that it remains in its relative infancy of development. Debate rages on regarding the importance of the medical model in sex therapy, the differences between male and female sexuality, how to define sexual problems/ disorders, the best ways to understand the factors involved in sexuality, and how to understand sexuality when it presents differently than most (Weeks, Gambescia, & Hertlein, 2015). These conversations and debates are important so that we can push ourselves to find better models, theories, and interventions to help clients. Sex therapy is for the curious, for those who want to explore issues without having definitive answers (Ridley, 2015). If we all embrace this culture of curiosity and not shying away from debate, we can keep moving forward in our understanding of human sexuality and our important goal of helping more people. Sex therapy, as I understand it currently, necessitates consistently learning and integrating new findings.
AASECT. (2017). AASECT’s 50th anniversary timeline. Retrieved from
Donaghue, C. (2015). Sex Outside the Lines. Dallas, TX: BenBella Books.
Haeberle, E. J. (n.d.). Chronology of sex research. Retrieved from
Hyde, J. S. & Delamater, J. D. (2011) Understanding Human Sexuality (11th ed.). New York:
Leiblum, S. R. (2007). Sex therapy today: Current issues and future perspectives. In S. R.
Leiblum (Ed.). Principles and Practice of Sex Therapy (4th ed.). New York, NY, US: The
Ridley, J. (2015). What every sex therapist needs to know. In K. M. Hertlein, G. R. Weeks, & N.
Gambescia (Eds.). Systemic sex therapy (2nd ed.). (pp. 3-16). New York, NY, US:
Routledge/Taylor & Francis Group.
Weeks, G. R., Gambescia, N., & Hertlein, K. M. (2015). Sex therapy: A panoramic view. In K.
M. Hertlein, G. R. Weeks, & N. Gambescia (Eds.). Systemic sex therapy (2nd ed.). (pp.
276-298). New York, NY, US: Routledge/Taylor & Francis Group.
I watched this TED talk by Brene Brown after I read her latest book "Braving the Wilderness." I decided to write this blog for other clinicians, but it can really be applicable to everyone. Let me know what you think. Is this stuff the answer? Part of the answer? Too fluffy?
One of the wonderfully scary aspects of being a mental health professional is that our work is intimately tied to our personal lives. If we are talking to clients about relationships, we can’t escape the fact that we have experiences, joy, and sadness in relationships as well. We’ve all had to confront whether it is safe for us to be vulnerable and authentic in a relationship and we’ve all wrestled with the fear of being rejected if we do so. Brene Brown’s (2010) research demonstrates that this vulnerability and authenticity is essential to growth and meaning in our lives. But, it’s not as easy as just doing what we know we should do. And it’s not like we can just tell our clients what they should do. So, how can we wrestle with these topics that are so universal and help others?
First, we need to recognize that our need for human connection and safety is hard-wired into our brains (Johnson, 2004). It is not a matter of some people needing to connect while others don’t have that need – all mammals have this because it has been a part of our evolutionary process. Working together with others in tribes and societies has separated humanity from other mammals and animals and has been behind our ability to form culture, technology, and growth. Of course, there are some mammals, including humans, who may have neurological impairments that limit this drive for connection, and those clients may need to be approached differently (autism spectrum, organic brain damage, severe trauma, etc.). But for most individuals, connection, whether they acknowledge it or not, is a key part of their pursuit of meaning and purpose because it is a biological imperative.
When connection is disrupted, that necessarily means that meaning and purpose is also disrupted. So where does this disconnection come from? Brown (2010) has identified shame as the key culprit that limits connection and comes from a person’s belief that they are lacking in some way as they are, not good enough, or don’t deserve love and belonging. According to Brown (2010), shame unravels connection because it prevents us from being authentic. We are too scared of disconnection to risk being vulnerable about who we are with others. This fear is why we can’t just tell clients (or ourselves) to just behave authentically. Fear of not connecting with others can lead individuals to numb themselves with substances (drugs, alcohol, etc.) or behaviors (eating, avoiding people, etc.) to escape this shame and fear. Individuals do this because it works – it helps them temporarily not feel shame, fear, and vulnerability. But, this avoidance is only temporary and requires more numbing to persist. We can also try to move towards certainty instead of ambiguity to lessen these fears, and try to perfect ourselves superficially. Unfortunately, that means that we are pretending, not being authentic, and only willing to present to others what we perceive they will accept. This form of “putting on a mask” ultimately prevents true connection as one can never be confident that they are accepted if they are only letting others see a certain version of themselves, not the real thing. Additionally, masking our true selves also prevents full expression of other feelings, limiting our ability to feel joy, gratitude, and safety.
I agree with Brown (2010) when she stated that connection requires ourselves to be fully seen. In order to do so, we have to be willing to show others who we are, faults and all. We must be vulnerable and courageous enough to take the risk that others may react with disconnection. To do this, we would need to recognize that we are still safe if someone doesn’t respond to us with connection and compassion. We would have to be compassionate with ourselves and have the strength to not take others’ reactions personally. In short, as Brown (2010) stated, we must believe that we are worthy of love and belonging for who we are, not who we think others want us to be. Shame is the fear that we are not worthy of love and belonging, and these fears must be validated with clients (and ourselves). We may have had experiences of disconnection, conditional love, and heartbreak in the past where our brain went into protection mode saying, “this won’t happen again, it was too painful, I must protect myself from this hurt.” Individuals come to these beliefs earnestly and without choice. They needed to protect themselves often because their environment wasn’t safe. If they had been vulnerable, perhaps their parents, friends, or partners would have attacked them and reinforced the idea that they are not worthy of love when they are authentic. This validation goes a long way for clients since they may have never been told that it is understandable that they needed to develop ways to protect themselves from hurt.
What does that mean specifically for helping clients (and even ourselves)? First, we must accept that our fears and shame are not reflections of our unworthiness. It is okay to feel scared to open up to others. It is actually sometimes the first step in vulnerability to acknowledge, with compassion, that we have this fear (Johnson, 2004). You can remind clients that humans are born to struggle in these ways and we are all imperfect. Second, our goal is to help clients find the courage to take risks with their partners when it is safe. We can help clients identify tolerable risks that they can take with their partner and show them, in session, how to accomplish it so that is goes well for both partners. Sometimes we need to “slice the risk thinner” (Johnson, 2002), meaning that some clients will need to start with just acknowledging to their partner that they are vulnerable without describing this vulnerability. Some clients are closer to being ready for deeper sharing of vulnerability, but their partner may not be ready to receive it yet or respond with empathy and compassion. Therefore, it is crucial for clinicians to assess the readiness of clients for this kind of work and pace it appropriately. This statement is especially true when it comes to trauma survivors as their highly reactive nervous system is easily overwhelmed (Johnson, 2002). Third, we can help clients strengthen their ability to take risks by helping them learn to practice gratitude and positive affirmations. This aspect is important because research tells us that numbing vulnerability also numbs gratitude and joy (Brown, 2010). You can have clients practice gratitude most simply using the methods developed by Hanson (2013). His research is grounded in neuroscience and brain changes and suggests that we need to practice gratitude or compassion six times per day for at least 30 seconds each time for brain changes to occur. Gratitude or compassion doesn’t have to be restricted to certain things though, since it is more about the process of gratitude that matters, not necessarily the content. I tell clients that even appreciating a morning cup of coffee or getting to work on time is enough to focus on to make brain changes. These activities, which you can tailor to suit your own, and the client’s, language will help client’s feel more worthy of love and belonging, the antidote to their feelings of shame that prevent vulnerability and connection. Perhaps it is best to simultaneously work on the second and third steps I have proposed here depending on where your clients are at.
These proposed interventions are aimed at helping clients to feel worthy of love and less scared to present their authentic selves. We know that when clients feel worthy and can be vulnerable with others, then they have a better chance of reinforcing those feelings of worth. It is important to remember though, that sometimes it isn’t safe for a client to be vulnerable, either because the client isn’t ready to deal with a negative outcome, or the person receiving the vulnerability cannot respond with compassion. Your job as a clinician is to educate your client about the research on vulnerability, validate their fears in reaching out, and work with the couple to take appropriately-timed and vulnerable risks with each other. Remember, being vulnerable isn’t easy, but it is associated with feeling connected and worthy of love, an essential element of our humanity.
Brown, B. (2010). The power of vulnerability [Video file]. TEDTalk.
Hanson, R. (2013). Hardwiring Happiness: The New Brain Science of Contentment, Calm, and
Confidence. New York, NY: Harmony Publishing.
Johnson, S. M. (2002). Emotionally Focused Couple Therapy with Trauma Survivors:
Strengthening Attachment Bonds. New York, NY: Guilford Publications.
Johnson, S. M. (2004). The practice of Emotionally Focused Couple Therapy: Creating
connection (2nd ed.). New York, NY: Brunner-Routledge.
How much social media or screen time is recommended for kids? This is one of the most frequent questions I get when working with parents and kids. It seems that most people usually do one or two hours per day as the limit, but rather than rigid rules, research suggests that it's more important to engage your children in dialogue. Instead of focusing on a number of hours allowed, it's better to focus on talking with your kids about social media and screen time, seeing what they think, and collaboratively come up with some guidelines for use in the home. In short, focus on the process of teaching your kids how to critically think about use social media and screens. Talk to them about the benefits and risks and make sure you acknowledge the benefits. Kids are smart enough to know that there are both sides to the discussion so talk honestly with them. In addition to these discussions, you have to model healthy social media and screen time behaviors for them. You can't tell them to get off their phone when you spend all night on it. So, even before you have these discussions, consider talking about your own social media habits with a partner or friend. Check out the policy statement on social media use in kids from the American Academy of Pediatrics.
And if you're interested in creating a personalized family media use plan, check out this link: www.healthychildren.org/English/media/Pages/default.aspx
Dr. Joan Kelly is one of the foremost experts on high-conflict separation. She created this handout on the top ten ways parents can protect children during separation. I think it gives parents some great tips.
1. Talk to your children about your separation.
Studies-show-that only 5 percent of parents actually sit down, explain to their children when a marriage is breaking up, and encourage the kids to ask questions. Nearly one quarter of- parents say nothing, leaving their children in total confusion. Talk to your kids. Tell them, in very simple terms, what it all means to them and their lives. When parents do not explain what's happening to their children, the kids feel anxious, upset and lonely and find it much harder to cope with the separation.
2. Be discreet.
Recognize that your children love you both, and think of how to recognize things in a way that respects their relationship with both parents. Don't leave adversarial (legal) papers, filings and affidavits/declarations out on your kitchen counter for the children to read. Don't talk to your best friend, your mother, your lawyer on the phone about legal matters or your ex when the kids are in the next room. They may hear you. Sometimes kids creep up to the door to listen. Even though they're disturbed by conflict and meanness between their parents, kids are inevitably curious - and ill-equipped to understand these adult matters.
3. Act like grown-ups. Keep your conflict away from the kids.
Even parents with high levels of anger can "encapsulate" their conflict, creating a protective buffer for the children by saving arguments or fights for a mediator's office – or a scheduled meeting at a coffee shop. It may seem obvious but so many separating parents continue to fall down on this front. When parents put children in the middle of their conflict and use them as messengers, sounding-boards or spies, children often become depressed and angry and may develop behavioral problems.
4. Parents, stay in the picture.
Long-term studies show that the more involved both parents are after separation and divorce, the better. Develop a child-centered parenting plan that allows a continuing and meaningful relationship with both parents. Where a good parent-child relationship exists, kids grow into adolescence and young adulthood as well-adjusted as married-family children. High levels of appropriate parental involvement are linked to better academic functioning in kids as well as better adjustment overall. That's true at every age level and particularly in adolescents. Father, should you be the non-custodial parent, be more than a "fun" dad. Help with homework and projects, use appropriate discipline and be emotionally available to talk about problems.
5. Parents, deal with anger appropriately.
In their anger and pain, parents may actively try to keep the other parent out of the children's lives – even when they are good parents whom their children love. When you're hurting, it's easy to think you never want to see your ex again, and to convince yourself that’s also best for your kids. But children's needs during separation are very different from their parents. Research reports children consistently saying "Tell my dad I want to see him more. I want to see him for longer periods of time. Tell my mom to let me see my dad."
6. Be a good parent.
You can be forgiven for momentarily "losing it" in anger or grief, but not for long. Going through a separation is not a vacation from parenting – providing appropriate discipline, monitoring your children, maintaining your expectations about school, being emotionally available. Competent parenting has emerged as one of the most protective factors in terms of children’s positive adjustment to separation.
7. Manage your own mental health.
If feelings of depression, anxiety or anger continue to overwhelm you, seek help. Even a few sessions of therapy can be enormously useful. Remember, your own mental health has an impact on your children.
8. Keep the people your children care about in their lives.
Encourage your children to stay connected to your ex's family and important friends. If possible, use the same babysitters or child-care. This stable network strengthens a child's feeling that they are not alone in this world but have a deep and powerful support system - an important factor in becoming a psychologically healthy adult.
9. Be thoughtful about your future love-life:
Ask yourself, must your children meet everyone you date? Take time, a lot of time, before you remarry or cohabit again. Your children in particular form attachments to your potential-life partners and, if new relationships break up, loss after loss may lead to depression and lack of trust in children. And don't expect your older kids to instantly love someone you've chosen – this person will have to earn their respect and affection.
10. Pay your child support.
Even if you're angry or access to your children is withheld, pay child support regularly. Children whose parents separate or divorce face much more economic instability than their married counterparts, even when support is paid. Don't make the situation worse. In this as in all things, let your message to the kids be that you care so much about them that you will keep them separate, and safe, from any conflict. They will appreciate it as they get older.
I found this from the California Courts and thought it was pretty informative so I'm sharing it here.
Children going through divorce or separation have certain needs. Although there are no foolproof ways to raise young children before, during, and after a separation, you and the other parent can help your children cope better with the divorce or separation.
Most families are more calm and stable 2 years after the parents separate. However, your children need your help now to get used to the changes in their lives.
All types of families can give young children what they need. Parents do not have to be perfect. Even so, when parents live apart, young children need them to:
No matter where your children are, they need to be with adults who: