Tag Archives: self esteem

Life after traumatic brain injury: Lessons from a support group

By Judy A. Schmidt October 8, 2018

Support groups are wonderful opportunities for people with similar life experiences to meet each other, share their stories and encourage one another. Group members benefit from learning coping strategies and everyday tips for dealing with various experiences. For people with traumatic brain injury (TBI), support groups offer informal opportunities for understanding a shared experience that greatly changed their lives, often within a few seconds’ or minutes’ time. They are left with physical, cognitive and emotional outcomes that impact their relationships, work and independence, often leading to loneliness and isolation.

As noted by the Brain Injury Association of America, more than 2.5 million adults and children experience a TBI in the United States each year, and support groups play a vital role in their continued recovery and re-entry to everyday life. A TBI dramatically interrupts life for these individuals and their families. Extended hospitalizations for physical recovery and long-term cognitive training for rewiring the brain alter all aspects of life, with treatment continuing for up to a year after the incident.

 

Effects of TBI

The effects of TBI are varied and highly individualized. The extent of the physical and psychosocial impacts depends on the type of injury (closed, open or acquired) and the severity of the injury. Thus, depending on the area of injury, people with TBI may deal with deficits in memory, executive functioning issues and poor judgment.

Frontal lobe injuries may lead to changes in mood and personality, difficulty making decisions and difficulty with expressive language, all of which are executive functions.

Injuries to the parietal lobe, which helps with perceptual abilities, may lead to difficulties naming words (anomia), finding words (agraphia) or reading (alexia), as well as problems with perceptual abilities that integrate sensory information. The ability to distinguish right from left may also be affected.

Damage to the temporal lobe may involve hearing loss, Wernicke’s aphasia (difficulty grasping the meaning of spoken language), problems categorizing information such as objects and short-term memory problems.

Brain injuries to the occipital lobe, which controls our vision, may lead to visual field problems, distorted perception and difficulty with reading, writing and word recognition.

Injury to the base of the skull at the site of the cerebellum creates difficulties with balance, equilibrium and coordination, as well as slurred speech.

Acute and long-term rehabilitation from TBI involves physical, occupational and speech therapy, as well as cognitive neuropsychological evaluations. As individuals recover from the physical damage, it is important for counselors to be a part of the rehabilitation team to manage adjustment to the physical injuries, acute stress and cognitive disability. In addition, the psychosocial aspects of TBI are very disruptive. They can be long-lasting as these individuals and their families begin to adapt to everyday life. Counselors are needed to provide individual and family counseling, as well as psychoeducation about TBI and recovery.

 

Psychosocial aspects of TBI

The psychosocial aspects of TBI are also related to the area of brain damage. People with frontal lobe damage may have difficulty making decisions, maintaining attention to tasks and controlling impulsive behaviors.

When the parietal lobe is damaged, difficulties occur with eye-hand coordination, reading, math and writing.

Temporal lobe damage interferes with communication skills, learning and memory. Learning difficulties due to recognition and visual field problems may result from occipital lobe damage.

In assisting people with TBI and their families, it is important to understand how psychosocial areas of life are affected and how these areas impact the potential return to daily living. For example, an individual may not return to his or her pre-injury abilities and can experience problems returning to work or school. Difficulties with problem-solving, understanding others’ emotions and social cues, or just being able to carry on a conversation may isolate the person with the TBI and increase his or her feelings of loss. Other areas of life that may be affected include the ability to drive, participate in sports and exercise, which can create deficits in the person’s social life. Problems with executive functioning can lead to challenges making sound decisions. Because safety is a major concern, the individual with a TBI may need to be monitored consistently by family, which can lead to tensions and other problems.

These are all skills that most of us take for granted or complete without much planning and forethought. But for individuals with TBI, family and personal relationships can grow strained, and the ability to build new relationships is impacted. The person’s independence and self-esteem suffer greatly.

 

Lessons learned

As a rehabilitation counselor for an acute inpatient rehabilitation program, I work with individuals who have TBIs, as well as their families, to provide counseling for stabilization, adjustment to disability and assistance with developing coping strategies. Providing support to these patients and their families as they begin realizing the extent of the brain damage and start dealing with feelings of loss is a crucial part of recovery.

For three years, I facilitated a monthly outpatient support group for people with TBI and found the experience fascinating. Hearing stories of people having car accidents, motorcycle accidents, work accidents, anoxia (deprivation of oxygen) and other unexpected accidents was difficult and often heart-wrenching. Yet these shared experiences forged a bond among group members that was undeniable and very moving.

They shared what it was like to not remember exactly what had happened to cause their brain injury. They shared what it was like to lose track of time and details and to have to trust the information told to them by health care providers, family members and friends. The fact that they each had “lost a period of time” from their lives and hadn’t been the same since seemed to build a sense of trust and caring among the group.

I soon learned that as a rehabilitation counselor, I could understand the medical, cognitive, vocational and emotional results of their injuries, but I couldn’t fully appreciate the daily psychosocial impact that their injuries had taken and continued to take on their lives.

The time since being injured varied among the support group members — anywhere from two years to 18 years. Regardless, the psychosocial effects they experienced were extensive. They talked about their school and work being interrupted, about having to settle for less challenging options or not being able to pursue their goals at all. Some shared tales of broken marriages and relationships, of losing custody of their children.

Others talked about losing their sense of independence because they had to rely on their families for almost everything. Some could no longer live at home due to the need for constant supervision, so they had to learn to live in group homes. Pursuing sports or other recreation choices was hard because of physical limitations. Another significant loss was no longer being able to drive and depending on others for transportation. The lack of money for “extras” was particularly difficult for those group members with children.

Holidays posed another challenge for these support group members because of sensory issues with noise, lights and too many people talking at once. Others discussed experiencing the stigma of having a TBI and being considered “different now” by family members and friends. This was felt particularly strongly at social gatherings, where family and friends made infrequent contact with them. Isolation and loneliness were prevalent themes in their stories. Depression, anxiety and low self-esteem made daily life a struggle.

Research conducted by Jesse Fann and colleagues in 2009 and by Annemieke Scholten and colleagues in 2016 and subsequently published in the Journal of Neurotrauma shows that the rate of depression during the first year after a TBI is 50 percent. The rate is close to 60 percent within seven years after the TBI. So, it is crucial for counselors to have this awareness of serious mental health issues in people with TBI to properly assist them and their families in seeking appropriate treatment.

Members of the support group I facilitated discussed that being on medication was difficult due to the side effects and to the cost of the medication if they had little or no insurance. They felt that cognitive retraining programs and daily psychosocial programs modeled after those for people with serious and persistent mental illness helped tremendously. The aspects of these programs that they reported helping most were receiving cognitive behavior therapy and continuing to learn more about TBI. The psychosocial programs were highly regarded because of the increase in social activities, access to vocational rehabilitation and supported employment services, and integration back into the community.

At times, the support group was difficult to manage because of the cognitive and emotional deficits with which the individuals dealt. However, the members had their unique ways of helping each other and redirecting the conversations. It was very clear that they respected one another.

Our time together as a support group transformed us into a unique family, particularly because the group remained fairly constant in its membership. The members trusted each other and understood the struggles being discussed. However, they also felt safe in correcting each other and being bluntly honest (which people with TBI are). We did have some new members join along the way. They were welcomed with open arms, and veteran members exhibited an unabashed eagerness to help. It was always interesting to hear about the creative accommodations that our members developed to live life each day and how the professionals in their lives assisted them.

As the group grew stronger, the members felt it was important for me to record what they wanted others to know about TBI and people with TBI. Their primary messages were:

  • “Conversation and expressing one’s self can be difficult.”
  • “People with TBI may not like the same things as they previously did, so don’t force us.”
  • “Tasks may take longer for people with TBI, so wait for us.”
  • “Social situations can overload people with TBI.”
  • “TBI affects everyone around the person.”
  • “Those with TBI are still the same people they were before.”

During my time with the support group, I learned many lessons. First of all, I learned that life after a TBI requires constant adjustments that must be made each day to be productive and involved. I also came to understand that time does offer healing when abundant respect and empathy are present. But most important, I learned about living life as it happens from a wonderful group of resilient individuals.

 

 

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Judy A. Schmidt is a clinical assistant professor in the clinical rehabilitation and mental health counseling program in the Department of Allied Health Sciences, and an adjunct clinical assistant professor in the Department of Physical Medicine and Rehabilitation, School of Medicine, at the University of North Carolina (UNC) at Chapel Hill. She is the rehabilitation counselor for the acute inpatient rehabilitation unit for UNC Hospital, where she provides counseling services to patients and their families after traumatic brain injury, stroke, spinal cord injury and other neurological trauma. Contact her at judy_schmidt@med.unc.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Spinoza was right: Four steps to recovery from addiction

By James Rose August 21, 2018

The 17th-century Dutch philosopher Benedict Spinoza wrote that “when a man is a prey to his emotions, he is not his own master, but lies at the mercy of fortune.” He named this condition “human bondage.”

In my view, there is no greater form of human bondage among us now than drug addiction. Addiction is a form of self-imposed bondage that binds people as firmly as if they were held in chains. People who are addicted are being held in a form of bondage that is rooted in their own emotions.

In my three years of working with people in recovery from addiction, I have seen a clear pattern emerge. Individuals who begin recovery by detoxifying from their drug of choice soon feel a rush of hard emotions. These hard emotions are the ones they have been suppressing with their drug use.

From there, successful recovery follows a few distinct steps:

1) Patients name the emotions they are feeling.

2) They identify the story they have been telling themselves about the people, events or circumstances that are at the root of those hard emotions.

3) They examine the meaning of the story they have been telling themselves and consciously challenge that meaning.

4) They find a way to change the meaning of their story.

Because emotions flow from the stories we tell ourselves, patients in addiction recovery can then begin to change the emotions they feel, including the hard emotions that led to their drug use.

Let’s examine these four steps to recovery in detail.

1) Identify the hard emotions that arise. People vary significantly in their ability to discuss emotions. In general, women tend to be better at expressing their emotions than are men. Among people who abuse substances, both men and women typically struggle with expressing emotions. Not knowing how to handle strong emotions, and needing to numb them out, is often at the root of their use.

I often begin group counseling sessions by asking patients to name various emotions. It is a warm-up exercise to get them thinking about the range of emotions that exist and whether they are feeling them at that moment. Among the emotions frequently listed are loneliness, sadness, abandonment, depression, anger and hurt. Often, I will fill a chalkboard with their emotion words and then ask the participants to pick out a few words that apply to them. By giving patients a broad panoply of emotion words to choose from, they often find it easier to name their own emotions.

2) Identify the people, events or circumstances from which those hard feelings arose. For one young man, it was seeing his father, whom he considered his “rock,” suffer from diabetes and have his foot and part of his leg amputated. This was followed two years later by his father’s death. For a young woman, it was the death of her mother and the simultaneous abandonment by her boyfriend. For another young man, it was the emotional coldness of his father, which compelled him to threaten to commit suicide to get his father’s attention.

A sense of abandonment — and, in particular, abandonment in one form or another by a parent — plays a large part in many people’s addictions. A parent might be physically absent, either through death or divorce, or a parent might be physically present but emotionally absent. This can be the result of a parent who is simply emotionally distant by nature or a parent who is emotionally absent because they are involved in some form of addiction to drugs, alcohol, work, sex, gambling, pornography or other things.

Children by nature model themselves after their parents. Sometimes children are unaware of this modeling behavior. One client hated that his father struggled with alcoholism. So much so that this client had promised himself he would never drink alcohol, and he kept his promise. Instead, he used heroin. He had simply replaced one addiction with another, becoming as emotionally unavailable to others as his father had been to him. One common element among all addictions is that they make a person emotionally unavailable to others around them.

Sometimes I use the analogy of fun-house mirrors — those mirrors they sometimes have at carnivals that distort people’s images. As children, we try to get a clear picture of who we are by the image we see reflected in the eyes of our parents. If a child is fortunate enough to have mature, healthy parents, that child is more likely to gain a reasonably accurate self-image from their parents and have a secure emotional foundation from which to face life.

But if a child’s parents are unhealthy or immature, then the self-image the child receives from those parents is more likely to be distorted or flawed. These children may go through life with the unsettled sense that there is something wrong with them. The grown child then lacks a basis for determining what his or her self-image should be.

That sense of not being able to see oneself clearly can create a lasting pain in a child’s heart, and addictive behaviors are more likely to develop in an effort to numb out that pain. As counselors, our work can involve “reparenting” our clients by providing a clear self-reflection of who they truly are — an image these clients might never have received from their actual parents.

There is also a hidden stigma involved in situations in which children have the opportunity to become better than their parents. Sometimes this stigma is called invisible loyalty. For example, if a child comes from a family where drinking is normal behavior, the child risks breaking a family norm — and thus becoming “better” than his or her parents — by not drinking. That is a step toward independence that not everyone is willing to take.

3) Challenge the story you are telling yourself. Often, the event or circumstance involved in the triggering event creates a terrible blow to the person’s self-esteem. For example, the client whose father walked out on the family when the client was 5 was taught in the most unmistakable terms that he was worthless. The woman whose mother died and whose boyfriend left her shortly thereafter simultaneously suffered both grief and abandonment — abandonment at a moment in her life when she most needed someone she could turn to and trust to help her deal with her grief. The young man who lost his father to diabetes felt cast adrift without the man who had represented stability in his life.

Our emotions follow our narrative. If the stories we tell ourselves are ones of loss, abandonment and aimlessness, our feelings will be ones of worthlessness. It is that feeling of worthlessness at the core of our being that is often at the root of addiction. Addiction is a way of trying to numb out those unbearable feelings. If our narrative tells us that all is lost, then there is nothing much to do but to numb out our pain and drag ourselves through life as best we can.

Our feelings are predictions of what to expect, based on our past experience. If our past experience has been full of sorrow and loss, we will come to expect more sorrow and loss in our lives. We will approach the potential of something joyful happening in our lives with dread, lacing it with the expectation that, sooner or later, things will turn out badly. If close relationships turn into abandonment and loss, we might create self-fulfilling expectations by not entering into new relationships with openness.

And yet, it is human nature to want to have close relationships. One young man with whom I worked desperately wanted to feel some sort of emotional connection with his father. To all appearances, his father was a good man and a good father, but he was incapable of showing warmth and caring to his son on an emotional level. The son’s drug use was an attempt to self-medicate the pain he felt at the lack of that important connection in his life.

It reached a point where the son called his father and said he had a knife in his hands and was ready to slit his wrists because he was so desperate for his father to show some level of care and concern for him. The father responded; the son did not commit suicide. He told his father of his drug use, and the son agreed to go into recovery. The son had received a message of worthlessness from his father, and he found that message too painful to live with. He forced his father’s hand to show caring.

In recovery, the young man gained an understanding of how deeply he felt the sense of emotional abandonment by his father. Once he gained an understanding of that emotion, he was ready to pursue the fourth step.

4) Change the way you tell your story. For that young man, recovery meant telling his story differently. Instead of telling himself that his father’s coldness meant he was worthless, he came to understand that his father’s coldness was his father’s nature — the product of his father’s own difficult upbringing. The son learned that he was capable of finding the sort of emotional connection he craved with his mother, his siblings, his friends and his new companions in Alcoholics Anonymous (AA).

He came to accept that he would never change his father, but he learned that he could change himself so that he could find the emotional gratification he longed for from others. He had previously believed that he needed to be like his father — cold and emotionless. Once he changed his story and gave himself permission to truly feel the emotions he was experiencing, he could share those feelings with others and find the sort of emotional connections that he craved. Once those emotional longings were satisfied, his need to numb out his more painful emotions evaporated.

Changing one’s story is fundamentally an act of building self-esteem. Self-esteem is built in a number of ways. It comes from allowing oneself to feel one’s emotions, from avoiding all-or-nothing thinking and from recognizing that life events most often consist of shades of gray. Finding the strength to express one’s true self among others, and to experience that self as different from other people and to develop enough detachment to become comfortable with those differences, is also essential.

For some people, and particularly those who had difficulty with their parents while growing up, spirituality may provide the context for seeing themselves differently. This is the concept behind the step in AA to surrender to a higher power, however that higher power may be understood. Seeing oneself as a child of God may provide a corrective lens for those who grew up with the fun-house mirrors and were never able to gain a true picture of themselves through the eyes of their parents.

I once spoke at a Christian-based recovery center where I offered that sort of corrective vision to the patients by slightly changing the word order of a familiar Scripture reading. I told the audience, “If you want to know who you are, consider these words from the Gospel of Matthew. ‘You are blessed, you who are poor in spirit, because yours is the kingdom of heaven. You are blessed who mourn, for you shall be comforted. You are blessed who are meek, for you shall inherit the earth,’” and so on through the remaining Beatitudes. And then I said, “You are a child of God, because why else would Jesus have taught us to pray to God as ‘Our Father?’”

Learning to see oneself differently, and changing one’s story in a way that builds self-esteem, is the fundamental act of recovery. Guiding patients through the growth of creating a healthy sense of self-esteem is at the core of my work as a counselor. People are not only recovering from the habit of substance abuse. They are recovering their lost selves.

Spinoza wrote, “The more clearly you understand yourself and your emotions, the more you become a lover of what is.” Examining emotions with patients and helping them to see themselves as they truly are is the royal road to helping those in recovery. It is the path that leads them to self-knowledge and self-esteem. Ultimately, it is the path out of the trap of human bondage.

 

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James Rose, a national certified counselor and graduate professional counselor, is a recent graduate of Loyola University Maryland and works in addictions treatment at Ashley Addiction Services. Contact him at jrrose@loyola.edu.

 

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Read more by James Rose, from the Counseling Today archives: “Stepping into recovery

 

Related reading, also from Counseling Today: “Grief, loss and substance abuse

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Canine companions

By Laurie Meyers May 4, 2018

Having kids and young adults train rescue dogs isn’t technically animal assisted therapy, but for the kids—and dogs—involved in the Teacher’s Pet program, the result has definitely been therapeutic.

The youth —with the help of professional animal trainers— use positive reward-based training to increase local rescue dogs’ chances of being adopted. In return, working with the dogs helps the students develop patience, empathy, perseverance and hope, says Amy Johnson, the creator and executive director of Teacher’s Pet, a Detroit-area non-profit program.

The idea for the program was born when Johnson, a former public school teacher, was working as a dog training instructor at the Michigan Humane Society. Johnson, an American Counseling Association member, wasn’t sure what the training would look like at first — she simply knew

Images courtesy of Teacher’s Pet. Identifying features of (human) participants have been blurred for confidentiality.

she wanted an intervention that would help both kids and dogs. Johnson contacted every group she could find in the United States and Canada that worked with both youth and dogs to learn more about how their programs worked. Her intent was to work with kids who — like their canine counterparts — were behaviorally challenged and often unwanted. So, not only did Johnson contact school counselors and psychologists for their input, she decided to become a professional counselor herself.

The end result was a program that is 10 weeks long and meets twice a week for two hours. Teacher’s Pet currently works with teens from an alternative high school and three detention facilities and young adults, aged 18-24 at a homeless shelter, says Johnson, a licensed professional counselor. At each facility (except for the homeless shelter), the training takes place on site. Participants from the homeless shelter are brought to an animal shelter to complete the program.

The program’s group facilitators are all professional trainers and they choose only dogs with good temperaments to participate, says Johnson, who is also the special projects coordinator and director of the online animal assisted therapy certificate program at Oakland University in southeast Michigan. Before the participants begin working with the dogs, the facilitators give them some safety training.

“We spend the first day going over body language and stress signals,” Johnson says. “They meet the dogs on day two, after one more hour of dog body language education.”

Other safety measures include limiting the number of dogs — five or six per class of 10 students — and keeping the dogs on long tethers placed 10 feet apart so that they can’t interact with each other, she says. There are also always at least four trainers in the room and the dogs are closely monitored. If a dog gets overexcited, is struggling to get off the tether or barking at another dog, a trainer will remove it from the room, Johnson says.

At the beginning of each session, the lead facilitator goes over the goals for the session, such as teaching the commands “sit,” “stay” or “down,” learning to walk on a leash or not jump for the food bowl. The individual trainers explain how to teach the commands and let the teens or young adults do the actual training as they supervise. The dogs are never forced to participate—if an individual dog is nervous or reluctant, the goal for the day is to establish trust and confidence, she says.

Johnson says that sometimes dogs that come off the streets have specific problems like trembling when people walk by. In that case, the students will sit with the dog until it becomes more comfortable and then start with small steps like going for a brief walk outside.

As participants are teaching the dogs new behavior, often their own behavior changes, she says.

In particular, a lot of the teens and young adults who participate have poor communication skills, Johnson says. For instance, some are so shy that they don’t project their voices and the dogs don’t respond to their commands. The participants have to learn to speak firmly and assertively, and to demonstrate a sense of command by standing up straight. One boy told Johnson that he decided to test the tone of voice and body language he used with the dogs on his peers to see what would happen. Imitating the behavior he used with the dogs gave the boy more confidence and he found it easier to interact with his peers, she says.

Johnson describes another boy who was very angry, had little patience and low impulse control. He had a soft heart and would choose dogs that were struggling, which told Johnson that he was projecting his anger.

“Inside he was like the dogs [scared],” she says. So the trainers paired the boy with a dog that was afraid of men. His job was to make the dog like him, Johnson explains. The boy had to be patient and sit with the dog. As the dog got calmer and more confident, the boy would gently encourage it to move closer and closer. By the end of the program, the dog was joyfully playing with boy.

Johnson says that the program facilitators coordinate with the participants’ counselors when possible, so that if they are struggling with particular problems — such as patience or impulse control — training sessions can include activities that help address those difficulties.

The teens and young adults also learn from each other. The first hour of each session is devoted to training and the second to journaling and “debriefing” — talking as a group about what worked and what didn’t.

Johnson believes that even just the oxytocin release that comes from spending time with the dogs is highly beneficial. The program participants are often deprived of loving human touch and the dogs will lick and hug and make them laugh — reducing their anger and anxiety.

As the program draws to end, saying goodbye isn’t easy, but that in itself can be a lesson learned, Johnson says. The students start to detach from the dogs a little bit, and they’ll talk about how that is a normal part of processing grief and loss, she says. The kids also write letters to potential adopters  touting the dogs’ accomplishments.

When the program is over, the teens and young adults say goodbye to the dogs and learn that they can say goodbye and not have it be the end of the world, says Johnson. The participants also get lots of pictures of themselves with the dogs and a certificate for the wall. Many former students have told Johnson that they keep a picture of themselves and the dog they trained on their dressers.

“I had a youth email me seven years later and ask me for another copy of his certificate because his was in a storage unit that was auctioned off,” she says.

Many graduates want to volunteer with Teacher’s Pet for adoption and other events, Johnson says. The organization also remains a resource for the students — they can get letters of recommendation or basic things like clothes for school or school supplies if needed.

Johnson says that Teacher’s Pet is also currently working with the American Society for the Prevention of Cruelty to Animals (ASPCA) on a longitudinal study to determine if the program produces behavioral changes in the kids, and if so, for how long.

 

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For more information about Teacher’s Pet, visit the website at teacherspetmi.org or email Amy Johnson at amy.johnson@teacherspetmi.org.

Related reading, on therapeutic power of the human-animal bond, from the Counseling Today archives: “The people whisperers

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor:ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

The role of value in adult self-esteem and life satisfaction

By Harvey Hyman December 19, 2017

While reflecting on my clinical experiences with adult clients during my postgraduate internship, I discerned a common thread. The thread was that the feeling of being valueless was at the root of my clients’ depression, anxiety, anger and substance abuse, as well as the violence and verbal abuse experienced within couples.

Although the immediate cause of the perception of being valueless varied (e.g., pervasive childhood neglect or specific episodes of childhood physical, sexual or emotional abuse), the consequences were the same in each case — chronic dysphoria of one kind or another. It is simply not possible to esteem oneself, to be vulnerable with others, to feel able to positively impact the lives of others through relationships or achievements, or to expect an enjoyable and meaningful future when one is convinced that she or he lacks value.

During the past few months, I have been learning about and practicing a technique involving mindful self-compassion designed to increase my sense of personal value, and I have been working with willing clients to teach them the same technique. I have written this article to voice my perspective on how self-perceived valuelessness is the major factor in transdiagnostic client suffering and to share a technique for building belief in your clients that they possess value as human beings.

 

The meaning of value and valuelessness in human life

In common parlance, the word “value” signifies having such positive qualities as worth, goodness, merit, effectiveness, usefulness, importance, attractiveness and desirability. People who perceive themselves as possessing value are much more likely to have self-esteem, self-efficacy and life satisfaction than are people who appraise themselves as lacking value. Believing oneself to be valuable is associated with resiliency and posttraumatic growth because external hardships and adversities do not destroy value but, rather, reveal it.

To lack value means that one is not lovable, desirable or worthy of mattering to and belonging with others. There are few, if any, sources of emotional pain greater than believing that you lack value. I believe that clients who are convinced that they lack value are the ones most likely to suffer from depression and to engage in self-destructive behaviors such as alcohol or drug abuse, the self-sabotage of relationships, cutting, burning, eating disorders and suicide attempts. When you are certain you lack value, it is equally certain you will hate yourself and will consider or perpetrate acts of self-harm. You may even want to end yourself to stop the pain of living with this certainty and being your own worst enemy instead of your own best friend.

I understand that genetic abnormalities that cause bad brain neurochemistry, especially during times of stress, can trigger self-hate, depression and self-destructive behavior. However, I am convinced that most of the time distorted thinking about the self (as being bad, incompetent or certain to fail at everything) and maladaptive coping behaviors arise from our clients’ belief that they are valueless.

Believing that you are valuable but constantly berating yourself for being a piece of crap or sitting in a squalid room injecting heroin into your veins with a used needle are totally inconsistent. Believing that you are valueless also rears its ugly head in interpersonal relationships. People who know they are valuable can shrug off the unfair accusations, attacking comments, insults and rejecting behaviors of others by recognizing that they come from ignorance, mistaken assumptions, implicit biases, defensiveness or fear. On the other hand, people who see themselves as valueless will perceive dire threat and react with fight, flight or freeze when exposed to these things because they confirm their inner sense of valuelessness.

 

The association between value and triggering

A very common bit of psychological jargon that I hear today is the word “trigger.” It is used in the sense that some statement, action or inaction of one person set off an intense, immediate and automatic emotional reaction in another person who felt unsafe. This person responds with crying, threats of violence, actual violence, emotional contraction, fleeing the scene and the like.

When one spouse says “Shut the hell up” to the other, strikes the other or gets in the car and drives off to parts unknown following a dispute, we can say that he or she was triggered, but what really happened? I think what happened is that the spouse who acted out had a thin, fragile scab over his or her self-perception of being valueless and something the other spouse said tore it off.

Whether we remind ourselves that we are valueless through our own inner critic (the usual way) or someone else reminds us by their statements or conduct, it hurts just as much. And when that pain sets in, our self-esteem plummets from whatever shaky height we had lifted it up to. We then temporarily lose our effectiveness as people because we turn away from the world to soothe ourselves with substances or punish ourselves with self-attacking words or deeds.

 

Intrinsic versus extrinsic value

According to sources as diverse as the Judeo-Christian Scriptures, the philosophers Immanuel Kant and Martin Buber, and the Declaration of Independence, human beings have intrinsic value. Theologists may see intrinsic value as coming from people being created by a perfect Creator, whereas philosophers might see intrinsic value as coming from our possession of rationality and our capacity to act ethically by choosing the good.

To believe in the intrinsic value of the individual is to believe that our value is not contingent upon externals such as one’s most recent successes, the current size of one’s bank account or the current level of one’s physical attractiveness. For Viktor Frankl, value becomes evident when a person establishes an authentic meaning for his or her life. For Abraham Maslow, it is when a person self-actualizes his or her potential.

Despite so many sacred and secular voices in favor of intrinsic value, virtually none of the people I have met buy it. Rather, they engage in constant self-evaluation in relation to internal standards of achievement and attractiveness, as well as external comparisons with family members, friends, co-workers, professional colleagues and even star athletes, movie actors and celebrities.

Freud described this long ago as checking one’s self-evaluation in the mirror of one’s ego ideal and getting judged harshly by one’s superego for every discrepancy. Today we talk about the voice of the inner critic instead of the superego, but the process and consequences are the same. There is a constant need to reassure oneself of one’s value, and a failed attempt to do so is followed by self-attack, ego deflation and suffering. Kristin Neff, who has done pioneering research on self-compassion, has pointed out that self-attack is accompanied on a somatic level by release of cortisol and adrenalin, which make us feel sick.

 

Value and secure attachment

Why is it that a handful of people seem certain that they possess value while everyone else sees their value as questionable, fluctuating or even absent? The work of John Bowlby on attachment helps to shed light on this phenomenon.

Bowlby said that how infants and toddlers were treated by their parents, especially their mothers, had a huge impact on their sense of self. Infants and toddlers who received a consistent flow of love, caring, warmth, gentle touch, soothing vocalization and affirmation would develop what Bowlby called a “secure attachment” composed of feeling welcomed, loved, valued and wanted. The secure attachment was the germ of self-acceptance and self-confidence that fueled these children’s exploration of their environment and their ability to self-soothe when they experienced fear, physical pain or other adverse consequences.

In Bowlby’s framework, infants and toddlers who received love, warmth and caring in an unstable, episodic and inconsistent manner would develop an insecure or approach-avoid attachment style associated with a reduced sense of personal value and trust in others. The most damaged infants and toddlers were the victims of pervasive abuse or neglect who received the message that their caregivers hated them or did not care about them. These children developed an avoidant attachment style in which they reacted to others by distancing themselves emotionally and physically.

 

Therapeutic approaches to correcting self-perceived valuelessness

If secure attachment is the foundation of the self-perception that one has value, then the most effective therapy for clients who doubt their value or regard themselves as valueless should be some form of reparenting that has the effect of strengthening a weak attachment to others. Unfortunately, this type of therapy is demanding, prolonged and expensive, and is by no means guaranteed to work.

Cognitive behavior therapy is great at showing the falsity of automatic, negative thoughts about the self, but until the deep-seated conviction (the core belief) that one is valueless is gone, these thoughts will continue to arise. Trauma therapies work to desensitize, contextualize and reinterpret memories of adverse childhood experiences, but the conviction that one is valueless, resulting from pervasive abuse or neglect, is very tenacious. This conviction can represent the foundation of personality and self-identity and the form the ego took from parental shaping in childhood.

If it is not possible to remove and replace the psychological foundation of self-image, what can be done to solve this problem? My hunch is that behind the conveyance of a sense of value to the infant/toddler through parental holding, touching, warmth and affirmation is a programming of the brain (“I know I am loved”) and the heart (“I feel that I am loved”). Abuse, neglect or inconsistent parenting can confuse the brain of the infant/toddler (“I’m not sure I’m loved and lovable”) or program it to believe that “I am neither loved nor lovable.” These things can make the child’s heart feel the same message.

So, how can clients in therapy reprogram their brains to know and their hearts to feel that they have value? At this point in my investigation, I have only anecdotal evidence and nothing like the kind of systematically collected empirical evidence developed in the course of a randomized, controlled clinical trial based on an experimental design. Thus, my proposal is based on isolated experiences in the therapy office and is nothing like the sort of evidence-based protocol that an insurance company would want to see. On the other hand, positive clinical experiences can be the germ of subsequent studies to confirm or deny a hypothesis about those experiences.

The method I have been trying out on myself and some of my clients derives in part from what Kristin Neff and Christopher Germer call “mindful self-compassion.” The basic practice is to combine deep, slow, meditative breathing with eyes closed; an attitude of genuine compassion toward the self; the tender placement of hands upon one’s body (e.g., placing one open hand over your heart); and the inward repetition of chosen affirmations in a soothing voice.

I have tried out such affirmations as “I am worthy,” “I am valuable,” “I matter,” “I know my own goodness,” “I feel loved and included,” “I love and include,” “I am connected with all other beings and they with me,” “I trust that the universe supports me” and “the universe is unfolding in and through me, and I have an important role to play.” Individuals using this practice can create and try out different mantras until they have found some that resonate in a deep and profound way with them.

The meditative breathing serves to produce a trancelike, mildly euphoric state in which the parasympathetic nervous system is activated, the voice of the inner critic is switched off and there is a sense of warmth and expansive possibilities. The role of tender self-touch is to provide mammalian comfort and reassurance — to put oneself in a place of safety and trust.

The combination of meditative breathing with eyes closed and self-touch enables clients to become attuned to themselves in a way that could not happen in the therapy office with the distraction of glances, conversation, pauses and concern over the counselor’s opinion. When imbibed in this atmosphere of self-compassion and self-attunement, the self-affirming mantras take on the ring of truth, not New Age phoniness. Doing this exercise with sincerity is a form of self-reparenting that features the three elements that Dacher Keltner considers essential in loving mammalian connection: warmth, gentle touch and soothing vocalizations.

At this point, I have no evidence that this particular practice by itself can convert individuals who are convinced that they are valueless to people who know and feel they possess value. However, I am observing in myself and my clients that combining this practice with another therapy has a powerful, synergistic healing effect and that this practice has clinical promise.

 

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After 25 years of law practice, Harvey Hyman retired, studied Buddhism and world religions, and entered graduate school to obtain a master’s degree in mental health counseling. He graduated this past October and is now registering for a counseling internship in the Sacramento, California, area. He hopes to work in the field of trauma psychology. Contact him at harveyhyman56@gmail.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Helping female clients reclaim sexual desire

By Alicia Muñoz October 2, 2017

If you see women in your counseling practice, it will be hard to ignore the issue of female sexual desire in your work together, even if the focus of treatment is something that appears unrelated to sexuality. In fact, a woman’s relationship with her own experience of sexual desire is often inextricably linked to her sense of identity, self-esteem, personal agency, energy levels, self-care habits and interpersonal relationships. Her desire issues and how she feels about them will weave their way, often implicitly, into your sessions.

The more that counselors can increase their awareness of the nuanced issues related to female sexual desire, the easier it will be to create a space in which clients can explore these issues safely and productively. Working with women more explicitly on understanding, experiencing and sustaining sexual desire can empower them to proactively regulate their moods, reduce stress levels and decrease symptoms of anxiety and depression. Furthermore, reconnecting with the motivation to feel sexual desire has the potential to help transition trauma survivors from “survival to revival” (in the words of couples therapist Esther Perel) as they access the enlivening energy of their own erotic life force.

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), female sexual interest/arousal disorder is characterized by a lack of sexual interest or sexual arousal for at least six months. Whether a woman is upset or distressed by her lack of interest or arousal is a crucial criterion for the diagnosis. The disturbance can be moderate, mild or severe, lifelong or acquired, generalized or situational. Furthermore, according to the DSM-5, “Women in relationships of longer duration are more likely to report engaging in sex despite no obvious feelings of sexual desire at the outset of a sexual encounter compared with women in shorter-duration relationships.”

Rosemary Basson, director of the University of British Columbia’s sexual medicine program, has noted that other than in the early stages of a new relationship, women’s arousal doesn’t always follow the traditional model of spontaneous sexual desire. Rather, women’s desire tends to be more responsive, with a deliberate choice to experience sexual stimulation required before an actual experience of arousal.

Estimates on how many women suffer from female sexual interest/arousal disorder vary widely, in part because there is so much complexity, variability and subjectivity to how sexual desire issues and arousal problems are measured and experienced. According to an article by Sharon J. Parish and Steven R. Hahn in the April 2016 issue of Sexual Medicine Reviews, issues with sexual desire or arousal are present in 8.9 percent of women ages 18 to 44, 12.3 percent of women ages 45 to 64 and 7.4 percent of women 65 and older. These percentages translate into a significant portion of the female population. It is hard not to wonder what sociocultural circumstances are contributing to making problems with desire so pervasive and systemic for women.

In Standard E.5.c. of the 2014 ACA Code of Ethics, counselors are reminded to “recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and strive to become aware of and address such biases in themselves or others.” This ethical consideration comes into play when counselors treat women with desire issues.

With the work of Helen Singer Kaplan’s triphasic sexual response cycle and an ever-expanding body of nuanced research on women’s sexuality, studies have come a long way from the male-centric, Freudian view of women’s sexual and psychological functioning and even from Masters and Johnson’s linear model of spontaneous sexual response. Researchers today strive to be more objective and aware of the physiological and psychological reality of women.

Even so, systemic prejudices related to gender and gender identity continue to saturate every area of girls’ and women’s lives, creating unique challenges in female clients in the areas of desire and sex. Fostering the safety and trust necessary to explore your clients’ desire issues can move issues of female sexuality and desire from an implicit undercurrent in your work to an explicit focus of therapy. This can help clients separate the wheat of their erotic potential from the chaff of limiting, destructive or shame-based gender and sexual conditioning.

Take Louisa, a 30-year-old client who has been married for two years. (Note: Louisa isn’t an actual client; however, her situation illustrates common sexual desire issues experienced by clients who seek counseling.) Although Louisa initially seeks treatment for depression and anxiety, a few sessions into treatment she begins referring in passing to life stressors that are “TMI” (too much information). Following these TMI comments, Louisa deflects the conversation to other topics with a shrug and a laugh.

Counselors can be attuned to these “throwaway” comments and to dismissive humor, gently inviting clients to elaborate by expressing interest in the information the client is editing out. When the counselor gently points out Louisa’s “TMI” reference and explores what she thinks might be too much information for the therapist, the issue of Louisa’s sex life begins to surface. Counselors may need to reassure clients who experience shame around sexual desire and sexuality that it can be of great benefit to focus on and explore heretofore off-limit topics and the memories, beliefs, thoughts and feelings connected to those topics.

Interventions

The following interventions may provide springboards for exploring desire issues in counseling sessions with female clients.

1) Provide psychoeducation on the connection between relaxation and sexual arousal, and work with your client to identify ways she can relax. Maureen Ryan, a sexual health coach in Amherst, New York, says, “The first step to a great sexual experience is to relax. Pleasurable touch helps facilitate this process. The body becomes aroused, and then the desire follows. For most women, sexual intimacy precedes desire.”

Explore the thoughts, fears and behavioral patterns that inhibit relaxation. Work on helping your client identify how she might create an external environment that would facilitate her transition into a sexually receptive or erotically engaged state. This might include activities that allow her to feel present or “in the flow” or connect more with pleasurable sensory input (tastes, sounds, smells, visual stimuli, touch).

2) Invite your client to create a body map. Sex therapist Aline Zoldbrod suggests using this technique with couples to facilitate a dialogue about current preferences. However, it can also be used one-on-one with female clients who may struggle with shame issues related to their bodies and their experiences of sexual desire.

Your client draws a body shape, back and front, and then uses red, yellow and green crayons to color the shapes in. Green means “I like to be touched here always,” yellow means “I like to be touched here sometimes,” and red means “I never like to be touched here.” This map can serve as one starting point for a deeper exploration of a client’s relationship to her body and her history with touch.

3) Introduce the “prop” of a velvet vulva into your arsenal of psychoeducational tools and use it to help clients understand the anatomy of the vulva, the clitoris and what movements and sensations typically stimulate arousal. This prop can also be used to instruct women on arousal as counselors model a clear, sex-positive language for expressing needs and preferences to a partner.

4) Introduce your client to the concept of “sexual blueprints.” You may want to provide a client with a handout summarizing sexologist Jaiya’s five erotic blueprints: energetic, sensual, sexual, kinky and shapeshifter. Reading about and discussing these blueprints can reduce shame, normalize a client’s experience of her own sexual predilections and help her consider new possibilities. Jaiya’s website (missjaiya.com) has a quiz to help women and men identify their blueprints.

5) Explore the meaning of pleasure for your client. What turns her on? What charges her up and connects her to her own sense of flow or aliveness? A counselor can coach a client to say, “I feed my own desire when …” and then complete the sentence with different activities, thoughts and behaviors that enliven her. Encourage your client to begin developing a running list of whatever it is she can proactively do to power herself up, delight herself and revitalize herself.

Also be sure to have an extensive list of your own desire-feeding activities. This will help you menu ideas for your clients.

6) Help clients develop awareness about the sex-negative and body-negative influences that have shaped how they see and experience themselves and their bodies. Encourage them to limit the sex- and body-negative influences in their lives. This may mean avoiding certain magazines, being mindful about television shows and choosing not to watch certain movies or videos. It may mean setting clearer boundaries with select people in their lives.

Also help clients explore ways that they can take in more sex- and body-positive messages, either through reading different magazines, limiting their exposure to narrow standards of beauty, increasing their vigilance of the kinds of advertising or body imagery they expose themselves to, or regularly and intentionally appreciating their own bodies through pleasurable body rituals and experiences.

A shift in attitude

Over time, Louisa begins to understand that the lack of sex in her marriage underlies her anxiety and depressive symptoms. She fears it means that she and her husband are on their way to divorce and that it’s “all her fault.” Here, the counselor helps Louisa increase her awareness of this critical inner voice and develop greater self-compassion.

Louisa’s husband has become more vocal about their sexual problems and grown increasingly more irritable and withdrawn in their day-to-day life. As a result, Louisa is no longer able to continue pretending the problem is just situational, temporary or unimportant.

In therapy, she examines her sexual misconceptions and beliefs and the influence of her family’s cultural and gender-based expectations of her. To her surprise, she realizes she has limited awareness of her actual bodily sensations. She often “lives in her head” and ignores the signals her body sends her. As a result, she has never really tuned in to what she feels leading up a to sexual encounter. Her low sexual desire is just the tip of an iceberg of denial related to sensations and emotions.

Part of Louisa’s work in therapy becomes learning how to “listen” to her body. She practices doing this in session and also sets aside time outside of sessions to sit quietly and observe her own sensory experience.

In the past, when Louisa lost her motivation to have sex with one of her boyfriends and couldn’t recreate the feeling of strong, active arousal with him, she would interpret it as “falling out of love” or the boyfriend “not being right for her.” It wasn’t until Louisa married her husband that she was faced with the stark truth of her own sexual experience: She had a hard time experiencing spontaneous, robust arousal once the novelty of a relationship wore off. Mostly, later in a relationship, she simply responded to her partner’s desire for her.

This insight signaled a shift in Louisa’s attitude toward sex and herself. She started to mourn her lack of erotic engagement with her past partners and current husband and to commit to cultivating a relationship with her own erotic experience. She began recognizing her own inhibitions, her lack of erotic accountability and the expectation she had always carried that her partner should know what pleased her without her assistance, guidance or willingness to explore the ways that their needs and desires met or diverged.

Because Louisa loved her partner and wanted to make their marriage work, she committed to learning how to experience her own desire and arousal more regularly. Her motivation to feel desire for her own pleasure and sense of wholeness shifted her approach to the sexual disconnection in her marriage from that of a burdensome problem to an adventure.

Untapped potential

When it comes to working effectively with female sexuality and desire, remaining neutral about larger cultural biases can stall your work as a counselor. In a culture saturated with narrow and distorted models and templates of beauty, it is nearly impossible for human beings who emerge from their mothers as female babies to grow up free of misconceptions about their core selves, their bodies, their sensuality and their eroticism.

Some women may manage to stay intuitively connected to their erotic core throughout childhood and adolescence despite the social, relational and societal risks involved, perhaps even making it into adulthood relishing the full range of their sexual experiences on their own terms. A great number of women, however, wouldn’t have survived physically, much less psychically, without shutting off their sexual circuit boards.

Usually, this shutdown isn’t a conscious choice. It is something that girls learn to do within the context of their relationships as a way of maintaining caregivers’ and others’ love and approval. Even for girls growing up in progressive, supportive families, fitting in with peer groups or feeling socially rooted can sometimes cost them some important piece of connection to their core sexual selves. Girls may grow up lacking erotically vibrant, powerful female role models. Sometimes their families and circumstances don’t allow them the luxury of maintaining a strong, healthy, intact relationship with their bodies.

When girls suppress aspects of their deepest erotic impulses and experiences, layers of judgment and shame encase not only what and how they feel, but also who they are. Like a seed trapped in amber, a woman’s erotic potential can remain untapped even as she develops and grows in other areas. It waits for the right conditions to emerge.

Counselors can provide those conditions in therapy. Here are some key ways that counselors can help women reclaim their erotic selves.

1) Take continuing education courses on sexuality.

2) Read progressive, inclusive books on women’s sexuality and women’s sexual empowerment, such as Getting the Sex You Want by Tammy Nelson, She Comes First by Ian Kerner, Mating in Captivity by Esther Perel, Woman on Fire by Amy Jo Goddard, Pussy: A Reclamation by Regena Thomashauer, Come as You Are by Emily Nagoski and Women’s Anatomy of Arousal by Sheri Winston.

3) Familiarize yourself with the facts regarding the unique challenges that women continue to face today locally, nationally and globally, particularly as they relate to physical safety, fiscal equality, political representation and reproductive issues and rights.

4) Learn to talk about all of the parts of women’s bodies with ease. Practice with your children, spouses, colleagues and friends. Learn the exact locations of women’s body parts, study how they interact and learn to identify a woman’s body parts by their correct names (e.g., distinguishing between a woman’s visible genitals — her vulva — and the internal, muscular tube that leads from her vaginal opening to her cervix — her vagina). Learn to discuss sex, sexuality and sexual acts correctly and comfortably.

5) When you pick up on a client’s reactivity, defensiveness, shame or self-consciousness related to a sexual topic, bring warmth and compassion to the moment through attuned interventions. For example: “I noticed that you covered your eyes just now as you mentioned having sex with your boyfriend. Can we be curious about what just came up for you?”

It is important to keep in mind that low desire and lack of sexual interest are issues that many women won’t openly admit to, even when these experiences are their daily reality. There is a lot at stake. Just as a man’s sexual identity and sense of competence can get tied up with his ability to pleasure his partner to orgasm or to maintain an erection, a woman’s sense of sexual self-worth can be intricately connected with her ability to both stimulate and quench her partner’s sexual desire.

When the impetus or the drive to engage in sex with her partner or spouse wanes, a woman’s sense of sexual self-confidence can waver. It can feel as if she is failing at an essential aspect of her being: loving and being loved sexually. It can also inspire terror. Will she lose connection to this person she depends on and loves? How will this affect her family relationships? Is this a prelude to something worse? What changes lie around the corner as a result of her inability to match her partner’s sexual needs with her own authentic responses and initiatives?

Counselors are in a privileged and important position with their female clients at this particular historical juncture. Women are feeling pulled to take up leadership positions and exert influence in spheres of power previously dominated by men, from political offices to corporate headquarters to influencing the ecological trajectory of the planet. To experience the fullness of their emotional range, the force of their uniquely feminine values, priorities and principles, and the vitality of their full aliveness, many women need help developing a healthier relationship with their erotic selves. Because many women have adapted and suppressed aspects of themselves to function in a world that prioritizes the more traditionally masculine values of strength, dominance, competition and self-protection, they need to find ways to access the more traditionally feminine priorities of sustainability, vulnerability, connection and empathy to feel truly like themselves again.

Counselors can safely, warmly and sincerely support the exploration of women’s low sexual desire or inhibited arousal by first prioritizing a woman’s desire as an essential energy source in her life. They can help their female clients navigate the unique, nuanced challenges of low desire and the ways it manifests in a woman’s relationship to her own self, her body and those she loves. Once this issue is prioritized in treatment, it can be made explicit and explored. From there, it becomes easier to disentangle the negative beliefs that women harbor about their bodies and themselves from their inalienable, noncontingent worth as women.

Because many women have come to experience their own desire as beyond their control, they may fear that they are the problem — outliers on the graph of normative human sexual desire doomed to disappoint and frustrate the people they love and need most. Helping women take control of their own experience of sexual desire through explicit counseling interventions has the potential to shift clients’ views of what’s possible for them erotically and, in so doing, what’s possible for them as vibrant, entitled human beings with desires that matter. This shift is seismic and can transform all aspects of women’s lives.

 

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Alicia Muñoz is a licensed marriage counselor and desire expert in private practice in Falls Church, Virginia. She is also a speaker, author, blogger and frequent contributor to various print and online publications. Visit marriedtodesire.com for more of her writing on desire, or sign up for her weekly Relational Growth Challenge at aliciamunoz.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.