Tag Archives: Sexual Wellness

Sex-positive counseling

By Lindsey Phillips May 24, 2022

Sexuality is a core aspect of the human experience, yet it is often a topic clouded in shame and secrecy. Some people can’t even bring themselves to say the word “sex” out loud, resorting instead to euphemisms such as “the birds and the bees,” “the horizontal tango” or “getting to know someone in the biblical sense.” 

Mental health professionals who consider themselves sex-positive providers are hoping to change the way that people — including other helping professionals — think and talk about sex. In a recent Healthline article, sex educator Goody Howard defined sex positivity as “the idea that people should have space to embody, explore and learn about their sexuality and gender without judgment or shame.” 

Counseling already provides clients with that safe, nonjudgmental space. So, why aren’t more professional counselors talking about sex? 

Steve Ratcliff, a licensed professional clinical counselor in New Mexico and a licensed professional counselor (LPC) in Oregon, believes that too often clinicians avoid discussing sexuality and sexual wellness with clients out of their own fear or shame around the topic. Sometimes counselors incorrectly assume that sex is a topic reserved only for sex therapists, Ratcliff says. Although sex therapy does involve talking about sex, it’s much more than that. As he explains, sex therapists are trained to treat sexual disorders and concerns such as vaginismus (i.e., the involuntary tensing or contracting of the vaginal muscles out of fear of vaginal penetration) or erectile disappointment. 

“Some counselors consider talking about sex as tantamount to having sex with the client,” continues Ratcliff, a member of the American Counseling Association. “There’s this fear that if I talk about it, I’m running a risk ethically or in terms of liability. But if there is a significant clinical issue that we’re not addressing because of our own discomfort that might raise a larger liability and malpractice issue — are we not treating a client’s shame just because it’s sexual?”

Clinicians don’t have to specialize in sex therapy to broach the topic of sexual wellness with their clients. “Sexual issues and mental health go hand in hand, and they influence each other in very distinct ways,” says Angela Schubert, an LPC at Brightside Counseling Services in Greenwood Village, Colorado. For example, growing up in a household where homophobia is present could cause stress, especially if one of the family members is attracted to people of the same sex. And someone who lost their partner of 35 years may be depressed at the thought that they will no longer be able to have sex with this person. But as Schubert points out, clinicians don’t often ask or consider how sexuality may play a role in a person’s mental health. 

Clinical sex education (or a lack thereof) 

Ratcliff is a private practice therapist at Liberated Counseling and a sexual diversity researcher at The Alternative Sexualities Health Research Alliance (TASHRA). He says broaching sexuality is a skill that all counselors should have, yet most clinicians receive little to no training on the topic in graduate school.

“It is unethical how we approach sexuality in the field of counseling right now,” argues Schubert, an associate professor and director of online learning for the clinical counseling program at Central Methodist University in Fayette, Missouri. Only two states — Florida and California — require counselors to take a human sexuality course to be licensed. And human sexuality is mentioned in just two CACREP standards (rehabilitation counseling and marriage, couple and family counseling), she adds. 

On top of that, sex education varies widely in state public schools in the United States, with many providing inadequate information. As of April 2022, the Guttmacher Institute reported that 26 states and Washington, D.C., mandate both sex education and HIV education, and only 18 states require these education programs to be medically accurate. 

“You’re born and raised into an environment where there’s no formal sex education,” Schubert says. “So, you come into the counseling field as a master’s student already with your arm behind your back in terms of your knowledge and understanding of sexuality in a formal way. [However,] what you [do] have … are all these biases, values and assumptions related to sexuality. … And then you have a counseling program that does not require you to take a human sexuality course and may not even address human sexuality. How does this reality align with our ethical obligation to do no harm? We can do much better.”

Ratcliff would like to see CACREP add at least one required course on human sexuality to its standards. “One three-unit course in human sexuality in graduate school is not enough to become a sex therapist,” he says. “But it might be enough to provide a little bit of education, a little bit of exposure to different sexualities and a chance to work on our own stuff [biases] … and give us a chance to grow as well.”

Until that happens, the onus of finding training is placed on the counselor. Ratcliff and Lily Gonzalez, an LPC and sex therapist who is the co-founder of Moving Mosaic Therapy & Counseling in Chicago, suggest that counselors look for trainings through sex-positive associations such as the Association of Counseling Sexology & Sexual Wellness (ACSSW), which is an organizational affiliate of ACA, and the American Association of Sexuality Educators, Counselors and Therapists (AASECT). In particular, they both recommend attending a sexual attitude reassessment class, which involves process-oriented trainings that challenge attendees to evaluate their own beliefs and values toward sexuality and sex-related topics. These trainings provide clinicians with an opportunity to learn more about sexuality, explore any potential biases or conflicts, and practice their ability to self-regulate when exposed to things outside of their comfort level, Ratcliff explains. 

“You will be triggered” during these classes, Gonzalez says. “But you need to be because you need to know what’s going to trigger you [in session]. You need to understand what your limits and discomforts are and work through those. If we’re not comfortable with our own sexuality, we’re going to be really uncomfortable helping someone navigate theirs.”  

Giving and getting permission 

Consent is a crucial part of not only sex but also sex therapy. Clinicians can underscore the importance of consent by first asking and obtaining the client’s permission to discuss sexuality and sexual behavior, Gonzalez notes. She says that can be as simple as stating, “I’ve noticed you struggling with this problem related to sex. Can we go there?”

Counselors can also broach the topic of sexuality even before meeting clients, says Schubert, co-founder and president of ACSSW. This can be done in how they introduce themselves or through the language they include on their paperwork and intake forms, she explains. For instance, a clinician could note that they are a “sex-positive counselor” on their website. 

Cheryl Walker, an associate professional counselor and sex therapist at GlobeCoRe in Atlanta, creates a safe, welcoming environment in her clinical practice by forgoing binary systems of classification on her intake forms. “Folks who struggle with sexual wellness are [often] fighting these labels that are placed on them,” she observes. She includes blank spaces so clients can fill in how they want to be identified rather than forcing them to check a box, and she makes a point to ask about pronouns.

By engaging in binary thinking (“Are you this or that?”) or making assumptions, “counselors censor and close off conversations that the client either wants to have or needs to have,” says Walker, moderator of the ACA Sexual Wellness in Counseling interest network. “As clinicians, we can make sure we have this open space, this ambiguous space, so that the client can fill in the blanks.” 

Ratcliff, a member of AASECT, often works with sexually and racially diverse populations. He makes it known on his website and clinical paperwork that he is an LGBTQ+, kink-, polyamory- and consensual nonmonogamy-affirming provider and a sex-positive counselor. Using inclusive, affirming language and asking questions about sexuality on intake paperwork will cue clients that the counseling office is a safe place to discuss sex and sexuality, he says. 

Even if counselors are cautious in how they broach conversations around sex and sexuality, mistakes can happen. When they do, Ratcliff advises counselors to take ownership and apologize for their misstep. 

Barriers to sexual wellness

Sexuality is a significant part of who we are as human beings, but it is something that “we’ve been taught to hide, to be ashamed of and to not bring into the room,” Gonzalez notes. She says much of her clinical work involves providing psychoeducation related to the human body, culture and the origins of one’s sexual knowledge. Because counselors are often helping clients navigate something internal and hidden, it is helpful to have a trauma-informed background when doing sex therapy, she adds. 

Ratcliff notes that many people learn about sex from their peers or through the internet or television, and this inadequate education frequently leads to common misconceptions. People may incorrectly assume that older people or people with disabilities don’t enjoy or have sex, for example. 

Any sexual desire or preference that does not align with society’s accepted “norms” often results in feelings of shame, Ratcliff continues. Men may be embarrassed if they enjoy prostate massages because they have been conditioned to believe that the penis is the major sexual organ. And women might not feel the freedom to enjoy their sexuality because, as Ratcliff notes, female sexuality is highly pathologized in American culture. He says it is common for women to report not having an orgasm until much later in life when some of that shame has been dispelled. 

Religion often influences how people view sexuality. Gonzalez finds that it sometimes results in the overlap of sexual shame and self-shame. If someone is taught that being good involves being a “clean,” moral person, then that spills into their perception of their sexual self, she says. As a result, enjoying sex or being aroused by pornography may make them feel like a “bad” person. 

Walker, who is part of the University of Michigan’s sexual health certificate program 2022 cohort, also works with clients who are conflicted about sexuality because of their religious beliefs. Some are taught that touching themselves sexually makes them bad people, so they never learn what feels good to them physically, she says. 

One’s understanding of sexuality is also shaped by media — in this case, referring to all movies, TV shows and social media, not just pornography. Walker points out that television often perpetuates the fallacy that all people are equally desirable and that the path to love is simple — it just requires dinner and flowers, she jokes. So, when people experience in real life that love and sex aren’t simple and straightforward, they often wonder what is wrong with them. 

Counselors will often need to help clients realize how these external and internal factors affect their understanding of sexuality. “People do not often talk about sex,” Schubert observes, “yet it narrates a lot of our worldview, whether it’s something we are conscious of or not.” 

Schubert often has her counseling students and clients explore their sexual scripts — the narratives they have formed about sex based on embedded cultural beliefs, social messaging, biology, personal experiences, and formal or informal education about sexuality. She says counselors can begin to unpack these internalized messages by asking clients questions such as “What messages about sex did you receive as a child? Did anyone say, ‘I love you’? What did you learn about gender roles growing up?” 

Schubert often introduces the concept of a sexual script by having clients visualize it as an umbrella. Sexuality is the tip of the umbrella, and the parts of the umbrella connected to the tip all form one’s sexual script. The umbrella panels represent one’s identities and experiences; the ribs running along these panels are the beliefs, biases and assumptions; and the shorter ribs that hold the umbrella open are one’s values, she explains. 

Schubert, co-editor of the forthcoming Handbook for Human Sexuality Counseling: A Sex Positive Approach, published by ACA, provides a hypothetical example of working with a male client who struggles to say the word “masturbation.” Instead, he repeatedly says “that thing we do” rather than using the word in front of the clinician because he fears they would think less of him if he verbalized it. In this scenario, Schubert would prompt this client to explore the possible reasons behind his hesitation to say sexual words by using the sexual script exercise. She would ask him questions such as “Where did you first learn it wasn’t OK to say masturbation? Did your caregivers ever talk about sex with you? What did your religion or culture say about masturbation?” 

Gonzalez finds the bio-psycho-social model beneficial in helping clients understand the way that their life experiences affect sexual wellness. She explains that clinicians can explore any physical limitations or illness that might be hampering the client’s sexual wellness (biological), the client’s emotional reactions to sexuality such as past traumas or current stressors that affect it (psychological), and societal influences and expectations around sexuality such as the client’s religious views and the gendered roles they were taught as a child (social). 

For example, Gonzalez describes how a Latin American woman who is born into a religious and patriarchal environment may have certain expectations around sex. This woman may feel the need to be chaste in the way she presents herself to society yet also be sexually pleasing to her husband (what is referred to in psychoanalytic literature as “the Madonna-whore complex”). This woman wasn’t taught how to enjoy sex but instead views it as a service or act that she must perform, Gonzalez explains. Applying the bio-psycho-social model would help the client process this internalized messaging around sexuality and allow her to start working on her own sexual wellness, Gonzalez says. 

She finds this model particularly helpful when she’s working with partners who come from different cultures or religions. Counselors can use it to discuss each person’s cultural upbringing and models of love and how this affects what they expect and want sexually from each other, Gonzalez says. 

Reconnecting to our bodies 

One key aspect in helping clients achieve sexual satisfaction is broadening the definition of what sexual wellness means. “Our society has done a really good job of making us think outside our body instead of inside our body,” Gonzalez says. “And we’ve been taught to be performative. We’ve been taught to think, ‘Do I look cute in this [sexual] position? Do I look cute in this outfit?’ and not necessarily [think about] what feels good” and pleasurable. 

Body mapping is a technique Gonzalez uses to get clients out of their heads and back into their bodies. She may ask clients to explore their bodies without sexual intent to really learn themselves better. For example, the next time a client takes a shower, they could be mindful and notice how it feels when the water hits different parts of their body and where they enjoy the sensation more. This could progress to the counselor recommending that they masturbate at home with the same sense of exploration — and without the goal of having an orgasm. The touch doesn’t even have to involve a sexual organ; it could be the simple act of sensually touching their thigh, Gonzalez adds. 

Sometimes counselors must first help clients consider their own emotions, traumas and triggers around sexual pleasure. The body is capable of not only providing pleasure but also holding on to trauma, Gonzalez notes, which can cause certain parts of the body to trigger an emotional response. These bodily responses operate as the body’s “brakes and accelerators of sex,” a phrase Gonzalez credits to Emily Nagoski’s Come as You Are: The Surprising New Science That Will Transform Your Sex Life. Environmental factors such as location, music and aromas can also affect how someone responds to sex, she adds. 

“Body mapping can help the person understand where their bodily accelerators … and brakes are,” Gonzalez explains. “We want to avoid the brakes so that they don’t get in the way … and pay more attention to the accelerators, but you can’t do that without knowing your body.”  

Walker says mindfulness and meditation techniques are also great tools to help clients be fully engaged in the present moment rather than focused on life stressors or their own anxieties and insecurities around sexual performance. 

If a woman, for example, is anxious about sexual penetration because of a past sexual trauma or a religious belief that sex is “bad,” then her body may tighten and tense whenever she engages in sexual acts. This action restricts blood flow to the area, Walker says, which will cause further stress and displeasure. A counselor could use mindfulness techniques such as engaging the five senses (what she sees, hears, smells, etc.) to help the client learn to ground herself in the present moment and relax her pelvic area. 

Pathologizing sexuality

Many clients feel particularly vulnerable discussing sexuality, which means it can be easy to hurt or offend them if the counselor’s biases or opinions enter the session. Several clients have told Gonzalez about negative experiences they had when disclosing their sexual practices to other therapists, including one client who was devastated when a clinician stated “You must hate yourself” after learning they were into bondage, discipline, dominance and submission (BDSM). Gonzalez says part of her clinical work involves first healing the trauma caused by such negative or biased comments. 

If a client mentions a sexual practice such as BDSM, then Gonzalez may ask, “What does BDSM mean for you? How does that fit into your life? How do you receive pleasure from it? Is this experience consensual, and do you have a contract that defines the power exchange?” But she never assumes that this sexual experience has anything to do with the client’s reason for coming to counseling.

We have to differentiate between what the client sees as their problem and what we think the problem is,” Gonzalez stresses. 

Unfortunately, value impositions are common when discussing sexuality, Ratcliff says. After all, sex is a topic that often evokes strong reactions — positive or negative — from people. If someone enjoys something that makes the counselor uncomfortable or is outside of their accepted sexual norms, then it may become easier for the counselor to insert their own opinions and thoughts onto the situation, he notes. For example, Ratcliff says, if a clinician is bothered by the thought of a client who says they enjoy being tied up with rope, the clinician may be more likely to infer that the client’s preferred sexual activities underlie why they struggle with assertiveness or why they are depressed. 

Sex positivity requires clinicians to maintain an open mind and be inclusive of all types of sexual expression — even those that shock them. “It’s OK for counselors to have things that ‘ick’ us out,” Ratcliff says. “Our challenge as professionals is to be able to work with people who enjoy those things and regulate ourselves.”

Biases about sex are sometimes written into the theories, approaches and assessments that counselors use. Ratcliff finds that he often needs to tweak or translate his approaches and interventions to fit the needs of his clients. He sometimes uses online relationship psychological assessments such as the Gottman Relationship Checkup, but these are often based on cisgender, heterosexual couples, so they use terms such as “affair” — a word that doesn’t fit or work for clients in a consensual nonmonogamous relationship. In fact, putting forward the concept of having an affair or cheating runs the risk of pathologizing this type of relationship, he says, so he asks clients to replace the word “affair” with “relationship betrayal,” which is a more appropriate and inclusive description. 

Walker advises clinicians to look over their clinical forms, exercises and handouts with a discerning eye to ensure they contain gender-expansive and sex-positive language. This may involve making simple changes such as including examples with the pronoun “they” or using the word “partner(s)” instead of “couple,” she says. 

Readjusting one’s language can also help counselors and clients to shift their mindset and reconsider potential stigmas associated with certain terms. Schubert often chooses to say “sexually explicit material,” for instance, instead of “pornography” because she finds this phrasing helps to remove negative connotations around it and allows clients to discuss — without shame — what materials they are using and how that might be influencing their sexual wellness. 

Boundaries and transference

Establishing clear, healthy boundaries is important in any therapeutic relationship, but it becomes crucial when addressing a topic that many people consider sensitive or taboo. Gonzalez says that clients sometimes ask questions about her sexual life and preferences, such as if she’s queer or polyamorous. She turns this back to the client and asks, “What about that is interesting to you?” This question allows her to gauge if the client is asking out of curiosity, if there is any possible issue of transference at play or if they need to know that she understands them on a deeper level.

Counselors need to be careful in self-disclosing about their own sexuality in counseling, Ratcliff says. He suggests discussing sexuality in a broader, more general sense. For example, the clinician could tell the client, “Some people enjoy this sexual activity” rather than saying, “I enjoy this sexual activity.”   

Ratcliff cautions that counselors should also be mindful of potential power impositions and harm that self-disclosure can cause. For example, a therapist disclosing that they are interested in a particular type of kink to a client who is also into kink can create an implicit power dynamic, he notes. 

Walker acknowledges that it is relatively common for transference to occur when discussing intimate topics but not necessarily for the reason people might assume. It isn’t because sex therapy is filled with salacious talk, she says, but because the counselor is a nonjudgmental person who is affirming all of the client’s strengths and qualities, which may not be acknowledged by others in the client’s life. 

Schubert once had a client admit that they were struggling because they thought that they might be developing romantic feelings for her. Schubert didn’t shy away from the discussion; instead, she asked the client to explain what they were feeling. The client told her that she was the only woman they were able to talk with about such intimate things, and they weren’t sure why they couldn’t say the same things to their partner. Schubert said, “It seems to me that this is the first time — that you’re aware of — where you’ve been able to be fully yourself and be heard. That’s powerful because it shows how courageous you are in your ability to be vulnerable with another person, and specifically another woman.” 

This response helped shift the conversation away from any possible transference or attraction, Schubert says, and placed it back into the therapeutic realm. Then, together they explored what it was like for this client to be heard and whether it was time for him and his partner to go to couples counseling so they could figure out why he was having trouble discussing intimate topics.

By embracing a sex-positive attitude, counselors can help begin to break the silence, shame and stigma surrounding sexuality. Clinicians are “taught so well to meet people where they are in their journey,” Gonzalez says, and sexuality “is just another part of the client’s journey, another part of who they are.

Song_about_summer/Shutterstock.com

 

Sex counseling versus sex therapy

Although the terms sex counseling and sex therapy are often used interchangeably, some mental health professionals note a distinction between the two. “A sex therapist can do more in-depth psychotherapeutic work with a client,” explains Lily Gonzalez, a licensed professional counselor and sex therapist in Chicago, “whereas a sex counselor is more high-level counseling and psychoeducation, but not the deeper psychotherapy, and their work is usually limited in time.”

The Association of Counseling Sexology & Sexual Wellness (ACSSW), an organizational affiliate of ACA that promotes sexuality as a central aspect of being human, defines sexuality counseling as a professional relationship that aims to do the following: 

  • Help people increase their comfort and awareness of sexuality and sexual experiences
  • Validate sexuality as a core aspect of the human experience
  • Provide evidence-based education regarding sexual health concerns 
  • Support clients as they navigate various influences on their sexuality 
  • Empower clients to express their sexuality while also respecting their own and other’s sexual rights 
  • Promote sexual wellness 

(See ACSSW’s website counselingsexology.com for more on sexuality counseling and sexual wellness.)

The American Association of Sexuality Educators, Counselors and Therapists (AASECT) distinguishes between AASECT-certified sexuality counselors and therapists. AASECT notes that sexuality counselors come from a variety of professions, including counselors, nurses and clergy, and they help clients resolve sexual-related concerns through problem-solving techniques and psychoeducation. Sexuality counseling is typically short-term care and focuses on the immediate concern or problem. 

AASECT-certified sexuality therapists, on the other hand, are licensed mental health professionals who provide in-depth psychotherapy and have specialized training in treating clients with sexual issues and concerns. They are capable of both treating simple sexual concerns and offering more comprehensive, intensive psychotherapy if needed. 

(For more on the differences between AASECT’s certifications, see aasect.org/certification-types-distinguishing-sexuality-educators-counselors-and-therapists.)

 

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Resources on sexual health and wellness 

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@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.

Building a foundation in premarital counseling

By Bethany Bray January 31, 2022

For many people, the phrase “premarital counseling” may conjure the image of a young, starry-eyed couple doing short-term work with a counselor or religious leader to discuss issues such as whether they’d like to have children or who will be responsible for cooking and taking out the trash.

While that scenario can and does still happen, more U.S. adults are delaying marriage. According to the U.S. Census Bureau, the median age for first-time marriage was 28.6 for women and 30.4 for men in early 2021. In 2000 and 1980, those statistics were 25.1 and 22 years for women and 26.8 and 24.7 years for men, respectively.

In addition, fewer American adults are choosing to say “I do” at all. The Pew Research Center estimates that roughly half (53%) of all U.S. adults are married, which is down from 58% in 1995 and 72% in 1960. Between 1995 and 2019, the number of unmarried Americans who were cohabiting rose from 3% to 7%.

These gradual but notable changes have led professional counselors to evolve their approaches to meet the needs of today’s premarital couples, regardless of whether they have a wedding date marked on the calendar. For Stacy Notaras Murphy, a licensed professional counselor (LPC) with a private practice in the Georgetown section of Washington, D.C., premarital counseling includes the couples on her caseload who are planning a wedding as well as those who are in unmarried yet long-term relationships.

In the two decades that Murphy has done premarital counseling, she has shifted from a top-down, topic-focused approach to a bottom-up approach that addresses attachment style and other deeper issues. This is not only because couples’ needs have shifted over the years, Murphy says, but also because recent research indicates the meaningful role that attachment plays in human relationships across the life span.

It is still important to prompt couples to talk through “big-ticket items” such as their expectations about finances, children, sex and intimacy, and the role that family and extended family will play in their lives, Murphy says. But premarital counseling should also build a foundation for couples to engage in these types of deep discussions — and navigate conflict when it inevitably arises — on their own in a healthy way, she stresses.

“All of these topics are grist for the mill,” says Murphy, an American Counseling Association member. “At the end of the day, couples want to understand themselves more deeply, and you don’t get there on your own by talking about what your goals are for retirement [and other topics]. … More so, it’s focusing on the steps that partners take to get their needs met and how those conflict and dovetail. It can be a beautiful dance.”

Getting started

Murphy thinks that in many ways, premarital counseling is couples counseling and uses similar tools and approaches. Premarital counseling has a more preventive focus, however, whereas couples counseling with married clients is often focused on repair work and undoing unhealthy patterns.

Tyler Rogers, an LPC and licensed marriage and family therapist who owns a private practice in Chattanooga, Tennessee, begins work with premarital couples by asking some straightforward questions: “Why do you want to do this?” and “What are you hoping to gain by getting married?”

Hearing couples’ perspectives on the why can help a practitioner understand more about the two partners, their relationship and their expectations, he says. If their answers tend to be more surface level, such as “this person makes me happy,” it opens the door to ask other questions and explore deeper with the couple, including offering psychoeducation about how attraction and liking someone are not the same as being “relationally competent,” Rogers notes. These discussions sometimes involve talking through why and how marriage requires “an entirely different skill set” than dating or living together, he says.

This work is still beneficial for couples who are getting married later in life or who have been living together for a while. Counselors will just need to tailor their approach to meet the couple’s experience.

“Sometimes counselors will need to help [more established] couples have a merger marriage, like the merging of two companies,” says Rogers, an associate professor of counseling at Richmont Graduate University. “Older couples [who are getting married] have less idealistic issues clouding what they think is coming [or] are more aware of each other’s problems. They might say, ‘We are really not good at talking about X’ or ‘This is how our conflicts go.’ … It’s a hybrid place of doing some marriage counseling along with premarital work. Couples may already have patterns or habits that aren’t great, but not to a breaking point.”

Practitioners may also work with couples where one or both partners have been divorced or experienced a painful breakup previously, and they come to therapy wanting to “get it right this time,” Murphy says. “These couples know a lot about themselves but also [know that they] need this partner to be very different than the one who hurt them in the prior relationship. We do a lot of unpacking what their needs are. I also acknowledge that it can be triggering for the other partner to hear a lot about someone’s ex.”

Beatriz Lloret, an LPC with a couples counseling private practice in College Station, Texas, takes a two-pronged approach to premarital counseling: One part involves psychoeducation on the components of a healthy relationship, and the other part explores the couple’s attachment style and patterns. In psychoeducation discussions with couples, particularly those who don’t have a healthy example to follow from their parents or family of origin, she often pulls from the Gottman method’s “sound relationship house theory,” including its components of trust and commitment.

“Couples often feel hopeful because they’re about to get married but sometimes mixed and apprehensive about periods of disagreement. The premarital [counseling] becomes couples therapy a little bit to address those issues,” says Lloret, an ACA member. “The beauty of it is that when [clients] are willing to come and dive into it a little, things [improvements] happen fast, especially because the issues are fresh and there is not too much rigidity built up yet.”

In addition to psychoeducation, Rogers and Lloret both say that initial work with premarital couples includes weaving in questions to cover necessary topics such as family of origin, finances and money management, children, and the roles they expect to have within the relationship.

Lloret says some of the clients who seek her out for premarital counseling do so as an alternative or in addition to premarital programs in their faith communities. These couples sometimes want to discuss issues — often those that have connotations of shame, such as sexuality — that they aren’t comfortable discussing with a religious leader or in programs that use a group setting. 

Although Lloret typically sees premarital couples together for the initial intake session, she splits the couple up for the second session to work with each person individually. This helps her get to know and build rapport and trust with each partner, as well as screen for domestic violence, she says. However, beyond issues such as abuse that require sensitivity, she has a “no secrets” policy for these sessions. Clients sometimes reveal that they haven’t told their partner about a chronic illness, a financial problem or a past affair; Lloret stresses the importance of disclosing and working through these issues with their future spouse.

Ellen Schrier, an LPC with a solo private practice in North Wales, Pennsylvania, has several assessment tools she uses to begin work with premarital couples. She says underlying distress — often involving frequent conflict, trust issues, personality clashes or infidelity — is revealed through this process in roughly 90% of the couples she sees. With distressed couples, it is often the case that one partner is pursuing the other, and the other partner is pulling away, withdrawing or avoiding conflict, she notes.

Schrier considers premarital counseling to include all of the unmarried couples she counsels, including those who aren’t engaged or looking to get married. She estimates this work is 30% of her caseload. Like Lloret, Schrier often sees premarital couples individually for a session early on to get to know them and help tailor her work to their needs.

“Often the case is they come in to strengthen the relationship, but there’s more to it,” Schrier says. “As you begin to talk, you realize there are deeper issues or past infidelity. They come in looking for a little boost but actually are struggling with a big problem.”

Addressing attachment

Initial assessment and discussion about content topics (finances, children, sexuality, etc.) in premarital counseling serve a couple of different purposes. One, they provide the practitioner with information about a couple’s personalities and background and, two, they open the door for deeper discussions and work on challenges that underlie those topics, including addressing attachment, repairing broken trust or breaking cycles of conflict and blame.

“The big-ticket-item conversations have to happen, and they can be very triggering, so it’s good to have them in couples therapy,” Murphy says. “My role is to let them talk about that content but then put it into the context of how they’re talking about it. … It’s absolutely critical to teach them about their own attachment style and how that interacts with their partner’s. Across the board, teaching them how to have healthy disagreements is my main agenda. We have such stereotypes that a ‘good marriage’ is one where you don’t have any conflicts, but that is so untrue. Demystifying that process is my job more than anything else.”

Murphy and Lloret use emotionally focused therapy (EFT) with premarital couples and find it useful for helping clients explore and dig into patterns and attachment issues. Throughout this work, the counselor guides the couple as they talk through deep issues that they wouldn’t necessarily recognize or know how to address on their own. Lloret says some premarital couples choose to work with her because she specializes in EFT and attachment.

“The counselor is a moderator to prompt deeper exploration, diving into what’s really inside of you and what’s really inside the other person,” Lloret says. “I don’t give solutions — what do I know [about what] they should do? — but they do.”

Having couples talk about their family of origin and the examples of marriage and relationships they’ve seen in their lives can be a good starting point for attachment-focused work with couples. Research shows that attachment patterns that humans form in early life repeat in romantic relationships, Lloret notes.

Murphy says, “I repeat over and over: ‘I’m not asking questions about your childhood to vilify your parents. They did the best they could. [And] it’s actually a good sign that you’re asking for help. But it’s important to talk through what you have experienced and what you believe.’ We want to get very clear about those expectations and desires and how to talk about them.”

Rogers believes it is important to relay a message to premarital clients who haven’t had healthy or stable examples of relationships in their life that “it’s not your fault; you didn’t choose that.” A counselor can help couples focus on the fact that they don’t have to repeat those experiences in the family they create.

Couples can also seek out other couples that they would like to emulate. Rogers sometimes asks clients to think of people they know whose relationships they admire and then to connect with them as “marriage mentors.”

“Ask them to have dinner with you, and pick their brain and learn from them,” suggests Rogers, an ACA member who previously worked as a Protestant pastor.

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At its core, premarital counseling should help clients explore and learn about themselves and “the process of couplehood,” Murphy says. Relationship education is some of the most important ground to cover, she emphasizes. The crux, Murphy says, is helping clients understand that human attachment draws us to want connection and support from others. Counselors can then help teach clients how to give and receive that with a partner in a healthy way.

“At the end of the day, [couples] need to really know each other deeply and take care of each other. … It all comes down to ‘is there someone in this world that has my back?’ That’s the basis of attachment: to be secure, to know that there is someone in this world who thinks we are special, a home base,” Murphy says. “Premarital couples don’t always have a lived experience of worrying about that, and my job is to establish that that’s why we’re here or [to] remind experienced couples [of that]. At the end of the day, it’s the same lecture [both in premarital counseling and couples counseling] about the role of attachment in our lives.”

But sometimes partners can become too attached. Some couples who are in the early stages of their relationship have an attachment that Lloret describes as two hands with interlaced fingers. It’s very hard to move one hand independently when the fingers are so tightly interwoven, she explains.

“They need to [learn to] feel comfortable with a certain amount of emotional distance. They need to find patterns of interaction that are healthy while feeling supported, but also maintaining their own independence,” Lloret says. “It’s common to see these issues in premarital counseling, including communication issues, arguing and misunderstanding. They often label it as a communication issue, but it’s really trying to differentiate while maintaining a bond [and] feeling seen and heard and understood while keeping connection.”

Bridging differences

The number of Americans marrying someone with a different cultural background than their own is increasing with each generation. In 1967, 3% of married U.S. adults had a spouse who was a different race or ethnicity. That number has since grown to 11% of adults being intermarried in 2019, and the percentage is even higher (19%) among newlywed couples, according to the Pew Research Center.

Murphy says discussions about culture and cultural differences between a couple — and the friction, misunderstandings or other challenges that may arise from these differences — can fit naturally into conversations about family of origin and relationship expectations. Here, as with other topics, it’s important for counselors to dig into why clients feel the way they do.

“The goal has to be to keep it curious instead of feeling that your partner’s family does it ‘weird’ or ‘wrong,’” Murphy notes.

Prompting premarital clients to share about how their family celebrates holidays can be a good way to introduce these topics, delve into client expectations and uncover potential sticking points that the couple hasn’t addressed yet, Rogers says. It can also be an opportunity to talk with the couple about how holidays — and other aspects of marriage and long-term relationships — can involve a blend of preferences from the two partners instead of being all one way or the other.

Another important aspect of these discussions involves asking couples how they think their partner views their culture, adds Rogers, who leads trainings on premarital counseling through the Prepare/Enrich program. He sometimes prompts clients by asking, “What aspects of your culture are important to you? What would you like your partner to embrace a little more or understand a little more?” 

“Generally, it’s a conversation they’ve had already without realizing they were having it, in the form of disagreements about things such as family, money or traditions, [and] without realizing that it’s tied to their identity and feeling that their partner’s objection to their stance is a rejection of their culture,” he says. 

Culture ties into how people express love and relate to those they love in many ways, Lloret notes. This includes everything from expectations about gender roles in marriage to a person’s comfort level around discussing sex or displaying affection in public. For example, in Latin American culture, a male partner may be taught that showing possessive behavior and jealousy can be a way to express care and love. But a female partner from an American background might find these expressions overly controlling.

A counselor’s role is to guide clients as they break down the meaning behind feelings and behaviors and explore why aspects of their culture and traditions are important to them, Lloret says.

“When they take the time to clarify what the expectation means, break it down and explore how they make sense of it, and then find ways to compromise and give and take [with their partner], that’s when the beauty comes,” she says. “It’s either explaining, ‘I can’t give this thing up, but it doesn’t mean that I don’t love you,’ or ‘I will compromise because I love you.’ It’s deeper conversations that create connection rather than getting stuck on the differences.”

Building a firm foundation

Premarital counseling should always aim to provide couples with the tools they need to navigate future disagreements and differences on their own. This includes learning to compromise and respond to each other in ways that are not reactive, judgmental or assumptive, Rogers says.

For example, perhaps one partner wants to live close to their parents and have them involved in the couple’s life, whereas the other partner would prefer to maintain some distance from the in-laws. A counselor can serve as a moderator as the couple talks through why they are in favor of or opposed to something and what compromises they are willing to make. Rogers suggests having clients identify specific solutions such as not allowing the in-laws to have a key to the couple’s home or agreeing to limit dinners at the in-laws’ home to twice per month. That approach is more tangible, he says, than one partner saying something vague such as “Don’t worry, my parents won’t be over all the time.” 

“In premarital counseling, I’m trying to help them learn the process of being a patient, curious person to find out why their partner doesn’t think the way that they think when they don’t agree,” Rogers explains. “A lot of that is teaching them how to communicate why they have the position that they do and encouraging them to do some digging without judgment. … Whatever the issue is, there is a deep why, a reason why they hold these feelings close. The counselor’s role is to help them understand their own why and explain it to their partner, while at the same time being open and accepting [of] their partner’s why.”

Schrier says that couples in premarital counseling often need to learn how to fully listen and acknowledge their partner. “A lot of people don’t have that important skill of listening to someone without reacting … [and] understanding each other’s position and validating it, valuing it, without escalating, getting overwhelmed or angry,” Schrier says.

“Sometimes they need to learn how to have one person speaking at a time without the other person interrupting or adding on to what the partner is saying,” she says.

Schrier uses various activities to help couples practice these skills, including one that has the partners take turns being the “speaker” and the “listener” as they respond to prompts such as:

  • Name three strengths and three challenges in your relationship.
  • What would you like to have more of and less of in your relationship?

Schrier says these conversations help clients with skill building and help her identify things to focus on with the couple. In the process, couples often find things they agree on such as needing to work on communication or making time to have fun together, she adds.

Equipping couples with an expanded emotional vocabulary can help in this realm as well. Clients often fail to realize or fully describe their feelings when in conflict with their partner, Schrier notes. For example, a client who wants more connection from their partner may express that as blame: “You don’t spend enough time with me.”

Schrier has a detailed list of “feeling words” that she gives clients to help prompt more constructive and respectful dialogue. She also sometimes suggests that during disagreements, clients ask their partner (using a nonaggressive tone), “Can you say that in a different way?”

Perhaps a towel left on the bathroom floor triggers an argument between a couple. Initially, the person who discovers the towel may feel intense anger toward their partner, who dropped the towel. But skills learned in counseling can help the person realize what they are feeling beyond anger, she explains.

“Saying ‘I feel disrespected or devalued’ is a better way to talk about it and less reactive. It’s more empowering to say that than to say, ‘You make me angry.’ It gives their partner more to understand and change,” Schrier says. “It’s a way to slow the conversation down a little bit so they can better understand their partner instead of assuming they know what [their partner is] feeling.”

Couples who aren’t able to do this sometimes get “stuck on a hamster wheel” of arguing over the content (in this case, a dropped towel) rather than the feelings of a disagreement, she adds. When this happens repeatedly over time, it can lead to contempt, resentment and distance in relationships.

“It’s so much easier to work on problems when you’re coming in [to premarital counseling] with a spirit of friendship, instead of years later coming in as adversaries with years of misunderstandings and hurt feelings,” Schrier says. “It’s better to do it on the front end and be preventive.”

Premarital counseling can also open the door for couples who need deeper long-term work, Murphy notes. Premarital clients who are not able to fully resolve challenges before their wedding date may need to return for further counseling after they are married or when a life change, such as having a child, upsets the couple’s equilibrium.

“Premarital counseling can be the appetizer to a later full meal of deep couples work that is needed, sometimes years later or with a different clinician,” Murphy says. “It’s important [for counselors] to normalize getting input from different sources throughout the life span.”

Preventive care

Although premarital counseling often covers some of the same ground as couples counseling, there is one major difference: clients’ attitudes. The counselors interviewed for this article said that premarital work is rewarding because most clients are optimistic, enthusiastic and willing to strive to make changes to strengthen their relationship. In addition, growth and improvement often occur quickly.

“Premarital counseling is preventive care in a lot of ways,” Rogers says. “It can be some of the most rewarding, fun work to do with couples. … So many other mental health issues could be helped if we can help people have healthy relationships. We can be instrumental in pushing the ball forward to start marriage off on the right foot rather than addressing things only when they’re in a bad situation.”

 

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Let’s talk about sex

One of the most important “musts” to discuss with couples in premarital counseling is sexuality. This is an area that couples who are older or who have lived together for a while may think they have figured out and don’t need to cover, says licensed professional counselor (LPC) Tyler Rogers.

Rogers sometimes jokes with premarital couples, saying, “John Lennon was wrong. Love is not all you need.”

Couples may have “the basics” of sexual intimacy mastered but need psychoeducation about how a healthy sex life will need to evolve and change over the course of a marriage. There will be times in life when sex isn’t easy and effort has to be made to foster intimacy, Rogers says. It’s important for practitioners to ask premarital couples about their sexual history and expectations regarding sex and, if they are sexually active together, to ask questions to ascertain their level of sexual wellness. Manipulative behavior such as withholding sex can indicate an area that needs more attention in therapy. Factors such as past sexual trauma or pornography use can complicate this issue, Rogers notes, especially when it is undisclosed between partners.

“There can be feelings of shame or guilt, especially if things are not disclosed until after they are married,” he says.

Tensions or misunderstandings regarding sex can cause distress that spills into other areas of the relationship for couples who otherwise have healthy connection, notes Beatriz Lloret, an LPC with a couples counseling practice in Texas.

Lloret says that where she lives, many premarital couples choose to delay sexual experiences — and important related discussions — until after marriage. Clients who fall into this category, many of whom are in their 20s and come from conservative, Christian backgrounds, often explore feelings and judgments regarding sexuality, she says. For some, discovering that their partner has certain sexual preferences or expectations carries a negative meaning or assumption for them. As with learning how to handle conflict in premarital counseling, practitioners may need to equip clients with tools to listen and respond to their partner about intimacy without being reactive or accusatory, Lloret says.

“For couples who don’t get to explore their sexuality until they’re married, once they open the door to this whole universe of sexuality, there’s a chance for a huge mismatch. Sometimes people have very different ways of expressing themselves and relating to pleasure, and it can create a big disconnection,” Lloret says. “They often need to explore judgment in a way to open their heart to the human being they’re in love with and the wiring that is sexual pleasure for that person. [It’s] getting judgment out of the way. There’s no one technique or easy way to do that, but the focus should be on being open and nonjudgmental.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@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.

Bringing pornography use out of the shadows

By Bethany Bray November 30, 2021

Dana Kirkpatrick, a licensed professional counselor (LPC) and certified sex therapist (CST) and supervisor in Pennsylvania, is only half joking when she says she “specializes in talking about really uncomfortable things — and business is booming.”

She often supports clients as they delve into what is and isn’t working in their sex lives and how that intertwines with mental health, relationships and other aspects of life. Those discussions frequently include open and honest conversations about pornography, Kirkpatrick says.

Pornography use, like many other topics related to sexuality, can tie into other concerns that individuals and couples bring to counseling. Clients’ attitudes and beliefs regarding pornography are typically internalized based on social, cultural and moral influences. It is up to practitioners to raise the topic and create a nonjudgmental space for clients to explore the role pornography might play in their own sexuality and relationships, says Kirkpatrick, an American Counseling Association member and owner of the counseling practice Calm Pittsburgh.

This is unexplored territory for most clients, she points out, especially for couples, many of whom have never spoken out loud to each other about their use of or views on pornography. It is a complicated topic that can involve feelings of shame, hurt or embarrassment, and individuals often don’t know how to begin to talk about it.

“The important thing is [for counselors] to prompt that dialogue,” notes Robert Zeglin, a licensed mental health counselor and CST in Florida who is the founding editor of the Journal of Counseling Sexology & Sexual Wellness. “[A client] may think their partner is watching porn for one reason, but they may be wrong, entirely wrong — and they need to talk that through. … It’s a very powerful thing when people are openly allowed to talk through these things: Why am I so opposed to porn? Or why am I drawn to it? It’s really powerful to facilitate and be a part of that [exploration].”

Unrealistic expectations and assumptions

Kirkpatrick says pornography can shape a person’s sexuality much like romantic comedies do. Both set people up with unrealistic expectations concerning sex, attraction and romance, she explains.

“If [the film] Pretty Woman was your first view of romance, then that’s what you see as romance,” Kirkpatrick says. “It’s the same for porn or 50 Shades of Grey. If that’s what you see first, it’s an expectation. Both scenarios create delusions of grandeur that set you up for failure.”

“Just as with romantic comedies, we know they’re actors, but [pornography] can still lead to unrealistic expectations,” she notes. 

Pornography use can have negative effects on clients’ sexual wellness when it is used as a substitute for or an addition to sex education during a client’s formative years or when it is consumed without the intentional mindset that pornography is fictitious, with actors who are performing in scenes and stories that are created, curated and edited by a full crew of professionals.

Zeglin, an associate professor and program director for clinical mental health counseling at the University of North Florida in Jacksonville, refers to this tendency to view pornography as factual or real as “bad porn literacy.” Clients who have this mindset can struggle with body image issues and negative thought patterns as they compare their bodies to the above average (and often augmented) bodies they see portrayed in pornography, he explains.

“Body shame is a common theme when talking about pornography [with clients],” Zeglin says. “Just as not everyone looks like the cast of [the TV drama] Grey’s Anatomy, we need to emphasize that [pornography] is entertainment. There are so many bad expectations that can leak into sex and body expectation.”

Similarly, clients can harbor unrealistic expectations about what sex is or should be, Kirkpatrick adds. This can especially be true for people who started viewing pornography at a young age. Young adults may expect their partners to do certain things and respond in the same way that they’ve witnessed on screen, she notes.

Aydrelle Collins, an LPC who specializes in Black sexuality at her Dallas practice, Melanin Sex Therapy, says that pornography is where many of her clients first learned about sex or saw other people be sexual. In addition to body image issues, this can lead to a narrow or incomplete understanding of sexuality, she says.

In pornography, “the focus is on the orgasm, and if there’s not one [in real life], it can lead to disappointment,” Collins says. “That robs people of being in the moment of sex, the full experience, and can lead to the assumption that they have to have performance-type sex.”

Pornography use can also lead to misconceptions about what a partner may want in sexual situations. For example, a pizza delivery person in a pornography scene may knock on the door ready and willing to have sex with the resident, but is that realistic or accurate? Of course not, Kirkpatrick says. Counselors can help clients talk through and clear up any assumptions they’ve internalized that may be leading to frustrations or challenges in their relationships or sexual wellness.

Zeglin, an ACA member, also emphasizes that counselors can offer psychoeducation for clients who harbor unhealthy expectations or assumptions gleaned from pornography. One important message, he says, is the reality that sex is often just OK, with some really great and really disappointing experiences thrown into the mix.

Clients’ lives and relationships can also be negatively affected by pornography when it is used compulsively. If a counselor hears a client talk about their pornography usage with language that might indicate a dependence or addiction — including viewing it at inappropriate times, such as when they’re at work or school — further assessment or specialized treatment may be needed. (For more on the nuances of helping clients who use pornography compulsively, see the articles “Six steps for addressing behavioral addictions in clinical work” and “Addicted to sex?”)

Broaching and breaking unhealthy cycles 

Laura Morse, an LPC and CST in private practice in Lancaster, Pennsylvania, says her clients bring up the topic of pornography almost daily, most frequently through questions related to the theme of “Am I normal?” Clients often wonder if what they are watching and the amount of time they spend watching is “OK” or “normal”; others question whether they should be watching it at all, Morse says.

“As clinicians, we work with clients who may be struggling with unpacking the messages they receive about sex — messages which can have negative impacts on their own sexuality and their relationships,” says Morse, an ACA member and Gottman-trained couples therapist. “It’s essential that we use evidence-based tools to evaluate what role pornography serves in our clients’ lives and assess what concerns they may have about their usage. Is it impacting time away from work? [Causing them to] spend too much money? [Resulting in] loss of interest in sexual desire with their partner? All of these assessment questions help inform treatment planning.”

Morse and Collins both recommend the PLISSIT model (developed by Jack Annon in the 1970s) for prompting discussions to assess clients’ thoughts on and relationship with pornography. The model’s acronym represents its four intervention levels: permission, limited information, specific suggestions and intensive therapy. Breaking discussion into these ascending levels helps practitioners decide whether they need to continue or intensify conversations with a client and match the individual(s) with an intervention that meets their level of need. 

The model’s first level can help broach sexuality-related subjects in an open way, as the practitioner invites and gives the client(s) permission to talk about and explore issues they might have previously considered taboo, including pornography, Morse says.

Feelings of shame regarding pornography use — either self-described in individual clients or shaming language used toward a partner in couples counseling — can also indicate that a counselor needs to facilitate discussion about the topic, Zeglin says. This can include the need to unpack the assumption that because one partner views pornography, it means they don’t find their partner attractive anymore, he notes. When left unprocessed, these emotions can lead to an unhealthy cycle.

“Because of that shame, they start to hide the porn use, [and] secret-keeping and hiding things is never good for relationships,” Zeglin says. “It creates a cycle, and it’s a pretty common manifestation within couples [where one or both partners] have an overall values system that porn is taboo.”

In addition to feelings of blame, shame and embarrassment, Collins says that pornography use can lead to a disconnect between couples. This is especially so for couples who have never talked about the subject together.

“It can create a disconnect in the relationship, in multiple layers. It’s not just the porn, but everything surrounding it and the shame that can come up,” says Collins, who is fully trained but not yet certified as a CST. “It can show up as resentment, lack of sex and connection, or arguments. It can be a spiral where one person is caught watching porn and they’re not having [frequent] sex already, and then that person is shamed [by their partner]. It causes them to retreat and furthers the lack of intimacy.”

Hurt feelings surrounding pornography use are often magnified when a couple isn’t having sex regularly or as frequently as one or both partners would like, Collins adds. Blame can become intensified if one partner feels the other is choosing pornography over sex within their relationship.

In these cases, a counselor can help clients talk through not only their feelings regarding pornography but also the many complicated layers that can accompany those feelings. This can include trust issues, Collins notes.

“You don’t trust [your partner] if you feel like you’ve been misled or lied to or shamed or ridiculed for something that you feel is normal and natural and everyone does it. Once that trust gets broken, there comes a disconnect,” Collins says. “We all bring our own messages that we’ve received about sex and sexuality into relationships, and that’s the biggest underlying thing. Sex brings up a lot of feelings of uncomfortableness if you haven’t had a chance to explore your own feelings about sexuality. … We all have attitudes and biases, including around porn. We all have different feelings about what’s healthy and not healthy, whether it’s OK to watch, and how much is OK to watch.”

Collins has worked with couples who have differing views on the consumption of pornography and admits that it can be a sensitive subject to broach. She emphasizes that practitioners should validate each partner’s views about pornography and focus on repairing the disconnect between partners by helping them process their underlying emotions.

To foster discussion in sessions, Collins often creates a “sexual health plan” with couples to outline what they’d like their sex life to look like together and the role that pornography will or will not play in it.

“In cases like these, I explore clients’ views on porn watching and what that means for their relationship,” Collins says. “These conversations can be difficult to facilitate, and working with this dynamic [when partners have differing views on pornography] can be a tender topic for couples. My advice to counselors working with couples is [to] focus on the underlying emotional hurt that is there. What are their goals for their relationship? The best thing a counselor can do to facilitate these discussions is to check their own views and bias around porn in order not to take sides.”

Unpacking the complicated layers that can surround clients’ pornography use may also include talking or asking about physical problems that are affecting clients’ sex lives and debunking misunderstandings or assumptions they may have regarding their or their partner’s sexual challenges.

Collins emphasizes there is no confirmed connection between the consumption of pornography and physical problems such as delayed ejaculation or erectile dysfunction. However, client assumptions regarding this topic can lead to an unhealthy cycle, she notes.

“Many people have the misconception that masturbating or watching too much pornography can desensitize people and cause them to not be able to perform or get an erection for sex,” Collins explains. “And those assumptions can exacerbate the problem if you have those [physical] problems already.”

The counselor’s role 

Kirkpatrick notes that when working with couples who are processing their feelings regarding pornography and its effects on their relationship, a helpful first step is to invite both partners to describe what they feel pornography is. Each person will have a different definition, and couples will benefit from understanding each other’s boundaries, she says. Is it acceptable to look at Playboy magazine? Browse the website Pornhub? Watch the TV show Game of Thrones? Visit interactive mediums where the user communicates with another person (such as virtual reality or video chat)?

“Help the partners define what their beliefs are [regarding] pornography use — good or bad — and what feelings they are having presently related to [their] pornography use. The key is finding the partners’ definition of their feelings and validating those feelings,” Kirkpatrick explains. “Then [counselors] can help them work on where their views come from and if they are being kind to themselves. Do they feel betrayed? Confused? Left out? Jealous? Once we can identify what that feeling is, then we can address it.”

Kirkpatrick also suggests that counselors include a range of questions about client sexuality, including pornography use and masturbation habits, during intake. This information will provide the practitioner with more context, and it lets the client know that the counselor is interested in and open to discussing these often-taboo subjects.

The counselors interviewed for this article agree that when unpacking the topic of pornography (both with individual clients and couples), a practitioner’s role is to serve as a neutral facilitator, prompting clients to explore the values, emotions and thoughts they hold regarding its use. With couples, this includes making equal time for each partner to explain their likes, dislikes and range of feelings.

Counselors should remain neutral — “without putting their thumb on either side of the scale” — while facilitating these conversations, Zeglin stresses. This mediator role includes the exploration of differences between couples and the differences that individuals hold within themselves on the topic.

“Have frank conversations about [the client’s] comfort levels and interest, [saying,] ‘Tell me a little bit about your values about sexual stimuli and porn. Is there anything that would get in the way of enjoying that?’ It’s the same as [addressing] anything that would put them outside of their comfort zone,” Zeglin says. “We need to give time and space to all voices, all the complex and dynamic parts of the people in the room.”

If pornography has led to conflict, feelings of betrayal or other hurtful emotions between partners, it may be appropriate to have them agree to temporarily pause their pornography consumption while they unpack their feelings and thoughts during this phase of therapy, Kirkpatrick says.

Because pornography consumption is an intense subject, clients may feel more comfortable talking about it if the counselor offers to look in another direction or turn their camera off in sessions held via telebehavioral health, she adds.

Inviting clients to frame their conversations about pornography through the lens of “this is what I’m into” empowers clients and allows them to present their thoughts in an open, positive way, Kirkpatrick says. In couples counseling, this approach can also spark questions, further dialogue between partners and, in some cases, reveal that the couple shares similar interests.

Kirkpatrick advises counselors to create an open and safe place for clients to talk about pornography use because it helps take away the power of shame that often accompanies the topic. She sometimes uses a “yes, no, maybe” chart that lists a variety of sexual interests, including different types of intercourse, use of vibrators, pornography and other preferences, to encourage open discussion between couples. Each partner fills out their own chart, selecting “yes,” “no” or “maybe” for each item. Afterward, couples have an avenue to talk about things honestly with each other (both inside and outside of counseling sessions). This tool can also help with overcoming shyness, Kirkpatrick says, and reveal sexual interests that both partners share, including ones they may not have known about or considered previously.

Kirkpatrick also sometimes suggests that clients use the app MojoUpgrade, which has a similar quiz to help couples explore and spark discussion about sexual interests and desires. The app shows only items for which both partners have responded “yes,” which can also help with overcoming shyness, Kirkpatrick says. 

In couples counseling, the clinician should ensure that conversations about pornography remain respectful and refrain from assigning blame or shame toward either partner, Collins says. Society often views pornography in black-and-white terms of either all good or all bad, but it’s more complex than that. A counselor can help clients understand that it’s natural to have multifaceted feelings on the topic.

“The truth is you can put up boundaries for what you want, but you need to get there without shaming your partner,” Collins says. “Have clients really flesh out what their narrative is around sex. If they feel like porn is not the best thing for their partner to watch, explore why that is without shaming their partner. [Prompt] conversation about what they are getting out of watching porn: Is it fantasy or being curious, etc.? Everyone is allowed to have their own feelings about what is healthy and boundaries on what they want out of sexuality.”

Collins notes that using a narrative focus can be helpful in this realm. Prompting clients to explore their sexual narrative frames the conversation in an empowering way and allows them to talk through and reject stereotypes and internalized messages that they no longer feel are helpful or accurate, Collins says.

An important aspect of this work includes asking clients questions about their sexual history. Collins does a sexual genogram with clients to find out where they first learned about sex, who they have discussed sexual issues with and other details. Asking questions about when and how they began to view pornography can also give the counselor and client(s) more context on factors that influence how they feel about and interact with pornography currently.

“I go line by line, unpacking everything they’ve ever taken in about sex, and assess how that impacts how they view sex now and how they view themselves as a sexual being,” Collins says. “[This allows them to] leave the things that no longer suit them and find the things that help them define their sexuality. … Our role as therapists is to help clients [find] their own narrative — not what they’ve been told or our narrative, but what works for them.”

Allowing clients to “be present and accept that they are sexual creatures” leads to empowerment and stronger confidence and decision-making, she adds.

Back to basics 

Zeglin advises practitioners who are helping clients process their feelings and thoughts on pornography to “take the sex out of it.” Instead, counselors should draw upon the same toolbox of methods they would use to help a client who is wrestling with a nonsexual dilemma.

“Anything that distracts from the relationship can impact it negatively; it’s not the porn per se,” Zeglin says. “It’s just like anything — it’s really the use of it and not the thing itself that can cause problems.”

In fact, research has shown that the level of dopamine released by the brain when a person watches pornography is the same as when a person does other things they enjoy or find pleasurable, he adds.

pio3/Shutterstock.com

Zeglin finds that Gestalt theory is a helpful lens to use as he prompts clients to explore and “give voice” to the parts of themselves that are in competition. For example, perhaps a client is conflicted because they want their partner to be happy, but they also feel that their partner must think they are ugly because their partner chooses to watch pornography. Or maybe a client is drawn to pornography because it entertains them or brings them pleasure, but they also feel guilt and shame for watching it. 

“If you take the sex out of it, it becomes a counseling 101 values conflict,” Zeglin says.

Perhaps a counselor is working with a couple experiencing a common scenario: One person is watching pornography and is compelled to hide it, and the other partner finds out and is hurt. By taking the sex out of it, Zeglin says, counselors can flip this conversation and ask, what if the person had set a goal to lose weight and the partner found them sneaking Oreo cookies? In both scenarios, the practitioner and clients would need to explore the couple’s lack of communication, the sense of broken trust, and other thoughts and feelings related to the behavior, he explains.

“Don’t make the problem the porn. Focus on the relationship. Sex is so moralized that we get distracted by that sometimes,” says Zeglin, a co-founder and past president of the Association of Counseling Sexology and Sexual Wellness, an organizational affiliate of ACA. “Counselors already have the tools to address it, but it just feels different because sex is involved.”

When it’s a good thing

Adult couples who have talked through their feelings and preferences and are accepting of pornography may find that viewing certain things together can enhance their sexual relationship. The counselors interviewed for this article noted that some clients (consenting adults) on their caseloads have benefited from incorporating pornography into their sex lives as a way to explore new things together. This can happen organically, such as when couples come up with the idea on their own, or when a counselor suggests it (when appropriate) as a bonding exercise for a couple outside of session.

“First, you have to make sure it’s accepted by the couple and culturally appropriate,” says Kirkpatrick, who co-presented a session, “Sex Positivity: Increasing Competencies in Addressing Sexuality Issues in Counseling” at the 2021 ACA Virtual Conference Experience. “There are body-positive sites, or sites with [instructional-style videos on] things to try. It’s using it as a tool, not a replacement. It should be something to enhance your sex life, not replace your sex life.”

Kirkpatrick has a list of sex-positive websites she offers to clients who express an interest in watching pornography together. It can be a means to grow together and learn what each partner does and does not like, she says. It can also be a way for couples who have a low sex drive or sexual desire to begin thinking about sex before becoming intimate together. Depending on a couple’s interests and comfort level, Kirkpatrick’s sex-positive recommendations can include pornography that involves writing (such as erotic fiction), photographs or images, or videos.

Collins agrees that pornography can be a helpful tool for some clients. Couples who have trouble with physical issues, such as erectile dysfunction, can use it to find and explore other avenues of sexuality that may work better for them, she notes.

“A lot of people figure out what turns them on by watching porn,” Collins says. “It can be a way to educate, watch together and … explore fantasy, broaden your sexuality or get out of a rut. It can give people options, room to explore, and open up dialogue and conversation around sex.”

It can also be a way for couples to bond and even laugh, Zeglin adds. “Couples need to explore both mentally and physically, and things change over the life span. Desires change, bodies change as we age. Just like anything, porn can serve as an opportunity to see what strikes your fancy,” he says. “Or you can giggle together about how unrealistic it is [and] how bad the dialogue is.”

Counselor competency

Professional counselors must always assume a nonjudgmental lens when working with clients, especially ones who are wrestling with thoughts and feelings about the complex and sometimes uncomfortable topic of pornography. The professionals interviewed for this article agree that counselors have a responsibility not only to leave their personal feelings out of the equation but also to seek training, continuing education or consultation when they don’t understand or know how to best treat a client’s questions or conflicts regarding pornography.

“We [counselors] are licensed as health providers, and we have to remember that what is and isn’t healthy is different than what is or isn’t personally important to us,” Zeglin says.

Collins agrees, noting that the last thing she wants to do is add another voice to a client’s understanding of a topic that is already heavily influenced by cultural, societal and other factors.

“I want them to find their own voice,” Collins says. “We [counselors] need to be checking our own biases and our own narratives around sex so that we are not imposing what we feel about sex and porn [on clients]. When our stuff comes into a session, it takes away from the work that we are doing with the client. Sometimes, with sex, [practitioners] tend to forget that.”

Practitioners also shouldn’t make assumptions about clients’ views on pornography. For example, clients who come from conservative religious or cultural backgrounds may not automatically be opposed to pornography use, whereas clients who come from more liberal backgrounds won’t necessarily embrace it, Kirkpatrick points out. In addition, clients will have a range of feelings about pornography that won’t necessarily fall into binary categories of “pro-pornography” or “anti-pornography,” she says.

Kirkpatrick urges counselors not to feel that they should refer a client whenever sexual wellness issues arise in counseling work. Instead, she encourages counselors to seek training, supervision or consultation with a local sex therapist. Counselors and CSTs can also co-treat clients, when appropriate, she notes. (Find a local CST and continuing education offerings at the American Association of Sexuality Educators, Counselors and Therapists website, aasect.org.)

Counselors who find they are interested in facilitating dialogues about pornography should consider seeking certification as a sex therapist, she adds.

“Don’t automatically refer. We need more people to be able to talk about this comfortably,” Kirkpatrick stresses. “Also, ask the client. I learn more from my clients than anyone else. … They are the experts in their sexuality because it’s so complicated. They are the experts on themselves.”

 

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Pornography use during the COVID-19 pandemic

As the COVID-19 pandemic began to stretch across the globe, causing millions of people to stay home, many individuals and organizations predicted or assumed that the isolation, loneliness and boredom would result in an increase in pornography consumption. 

In spring 2020, Pornhub announced that the online platform’s “premium” content would temporarily be free to users who were on lockdown because of COVID-19. As a result, the company reported a 38%-61% increase in web traffic from regions that had lockdowns and restrictive stay-at-home orders. This usage was above and beyond the more than 1 million daily unique web visits that Pornhub reported in 2019.

However, a study published recently in the Archives of Sexual Behavior polled more than 2,000 men and women in February, May, August and October 2020 and found that pornography consumption among American adults decreased overall in 2020.

In May, immediately following the United States’ first wave of pandemic-related restrictions, there was a small increase in the number of people who said they had viewed pornography in the past month, but less so than in the baseline data, which indicated that 38% of participants — 59% of men and 21% of women — reported using pornography at least once per month.

“Among those who reported use in May 2020, only 14% reported increases in use since the start of the pandemic, and their use returned to levels similar to all other users by August 2020,” wrote the study’s co-authors. “In general, pornography use trended downward over the pandemic, for both men and women. Problematic [compulsive or uncontrolled] pornography use trended downward for men and remained low and unchanged in women. Collectively, these results suggest that many fears about pornography use during pandemic-related lockdowns were largely not supported by available data.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@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.

Addressing sexual violence among teens

By Leontyne Evans October 13, 2021

Intimate partner violence is increasing at an overwhelming rate among teens and young adults. Because of this, sexual violence is also increasing. Due to the lack of education and awareness in this area, it often goes unreported to authorities.

To better understand the topic, we first have to define it. Sexual violence involves forcing or attempting to force a partner to take part in a sex act or sexual touching when the partner does not or cannot consent. It also includes nonphysical sexual behaviors such as posting or sharing sexual pictures of a partner without their consent or sexting someone without their consent.

While facilitating groups and programs with young people in Omaha, Nebraska, I found that 3 of 10 participants were victims of sexual assault by a partner and didn’t know it. They were unaware that the actions of their partner were classified as abuse.

This has been consistent with all groups, classes and programs that I have facilitated. It is important to bring awareness to how under-reported this issue is among youth. In many cases, it’s not only those who have been victimized who are unaware they have experienced sexual violence. Believe it or not, the perpetrators of such abuse can lack awareness that they are using abusive tactics such as manipulation and coercion.

The need to talk about sex

A lack of education in this area exists in part because it is typically seen as taboo to talk about sex and consent with youth. Among those who are victims of sexual violence, physical violence or stalking by an intimate partner, 26% of women and 15% of men report that the abuse or other forms of violence took place before age 18.

Many parents think that talking about sex will encourage their children to engage in sexual activity before they are ready, despite there being no solid research to support this belief. So, because parents aren’t teaching it at home and because the sex education being taught in schools is pretty much limited to “have sex and you’ll get pregnant or catch a sexually transmitted infection,” many youth don’t have a proper understanding of what consent actually is.

Some victims believe they have to have sex with someone because it’s their “job” as a partner. The urban proverb of “what you won’t do, someone else will” reigns in the heads of our youth, making them believe they must have sex to keep a person’s interest. There are also young people who have not been taught to accept the word “no,” so when their partner says it, they don’t believe it or accept it. They either continue to try until their partner gives in or they become aggressive because they feel “disrespected.” This is the behavior we must bring attention to as counseling professionals. But to do that, we must figure out where it starts, how it starts and why.

Overall, youth who offend are more likely than youth who do not offend to have backgrounds involving fetal alcohol spectrum disorders, substance abuse, childhood victimization, academic difficulties or instability in the living environment. Studies performed on youth offenders show that youth who have been faced with adversity are at a higher risk to offend. These studies seem to be suggesting that these problems are rooted in familial dysfunction.

The message of entitlement

My work with youth has exposed several issues with parenting when it comes to young people understanding and accepting the word “no.” Many parent do not seem to grasp that every decision they make will have an impact on their children one way or another. Raising entitled children may not seem like such a big deal when they are younger, but those small, cute children have to grow up someday.

Not telling a child “no” to avoid hurting their feelings or hearing them cry is common. We want to protect our children from the harsh realities of the world and try to soften the blow by giving them the things that make them happy. But what happens when that child turns into a teenager and can’t accept the concept of “no” because they literally don’t know how. What happens when that sweet baby grows up learning that “no” doesn’t really mean no? That if they keep asking, become aggressive, act intimidating or annoy someone enough, that “no” can turn into a “yes”?

Kids who can’t accept no for an answer or perceive rejection as a form of disrespect take these behaviors into adulthood and are more likely to abuse. Once again, it may not be intentional. They may not even see themselves as abusers. This has simply become their norm, a learned behavior that has been accepted rather than corrected, leading them to believe that the person saying no is the one with the problem — not them.

Working together

In the counseling profession, we not only have the ability to work with youth victims and perpetrators; we can also offer support to the adults in their lives. We can speak to the importance of supporting the development of healthy, respectful and nonviolent relationships. It is critical that we take advantage of our access and give parents tips on how to navigate through these tough situations.

During the preteen and teen years, it is critical for youth to begin learning the skills needed to create and maintain healthy relationships. These skills include knowing how to manage feelings and how to communicate in a healthy way.

We can all work together to end the cycle of teen dating violence and teen sexual violence by encouraging adults to create safe and brave spaces for our youth. This involves creating spaces at home and school where youth feel safe to come to an adult to have open and honest conversations. It should be a place of trust and support, not judgment and anger.

Youth also need examples of healthy relationships. If children have been subjected to unhealthy relationships, parents should consider seeking professional help for their children to process their feelings toward what they have witnessed.

We often focus on making sure that adults involved in domestic violence situations are connected to programs and services, but we tend to forget about how children are affected by the abuse. As we encourage adults to seek counseling, we should encourage them to seek therapy for their children as well. Second-hand violence is just as impactful as firsthand violence.

Gaelle Marcel/Unsplash.com

Being willing to be uncomfortable

In working with youth, we need to get used to the idea of introducing the concept of consent and safe sex at an early age. Contrary to popular belief, this will not encourage youth to have sex. It will, however, ensure that they are properly educated and prepared when they do decide to engage in sexual activity.

We also have to start having the same conversations with boys and girls. We can’t teach our girls about consent and not our boys. We can’t see only our girls as having the potential to be victims and not our boys. All children should be provided with the same knowledge, skills and tools to combat abuse.

Finally, we must create the possibility for prevention. Sex education should include more than discussions about pregnancy and sexually transmitted infections. Safe sex should refer not only to using condoms and contraceptives but also to discussing actual safety. Safety includes consent, mental and emotional safety, physical safety, the environment, etc. Using a condom does not make sex safe.

I had a client say that she hadn’t been raped because she didn’t scream and he used protection. We must change the narrative of what rape looks like in our society. We have to educate our youth in all things concerning sex, not just the parts that are comfortable to discuss. Then and only then can we begin to end the cycle of teen dating violence and sexual violence.

 

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Leontyne Evans works as the survivor engagement specialist for Survivors Rising, where she helps to empower and uplift survivors by providing education and resources that encourage survivor voice and self-sufficiency. She is a published author of two books, Princeton Pike Road and Relationships, Friendships and Situationships: 90 Days of Inspiration to Keep Your Ships From Sinking, both of which support her mission of ending the cycle of unhealthy relationships. Contact her at leontynesurvivorsrising@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.

Six steps for addressing behavioral addictions in clinical work

By Amanda Giordano October 5, 2021

The first time I worked with a client who said he was addicted to internet pornography, I had no idea how to respond. I quickly tried to recall material from my master’s-level addictions course, but we had discussed only substance use disorders. I hadn’t learned anything about how to address addictive behaviors. Thankfully, one of my professors was a certified sex addiction therapist and supervised me as I worked with this client through internship.

Since then, I have dedicated myself to learning about behavioral addictions and conducting research in this area. In the process of writing a clinical reference book on the topic, I interviewed dozens of clinicians who specialize in behavioral addictions, as well as members of many 12-step programs, to learn more about the realities of behavioral addictions. What I heard from almost every clinician I interviewed is that they had to seek out their own training related to behavioral addictions. Whether through conference presentations, webinars, books or online training programs, they initially taught themselves how to address addictive behaviors because the topic was not covered in their counselor training programs. As a counselor educator, I fully understand that we cannot cover all important topics in depth in a two- or three-year training program, but it seemed as though the clinicians with whom I spoke would have benefited from at least an introduction to behavioral addictions during their graduate training. 

Since becoming a counselor educator, I have been intentional about infusing content related to behavioral addictions into my courses (e.g., human development, addictions counseling, clinical supervision). I also developed an elective solely dedicated to behavioral addictions. I frequently receive emails from former students that say something along the following lines: 

  • “Thank you for teaching me about internet gaming addiction. I am working with my first high school student with this type of addiction.”
  • “I am using the resources you mentioned in class about sex addiction because I have several clients who have lost control over their sexual activity.”
  • “When my client mentioned gambling, I wasn’t afraid to ask more about it because I had a framework for understanding behavioral addictions.”

An issue for all counselors

I monitor published statistics on the prevalence of behavioral addictions, but more than that, I hear firsthand from former students how frequently clients with addictive behaviors present to counseling. Therefore, my goal in writing this article is to present six steps that all counselors can take to better address behavioral addictions. Whether working in a school, college counseling center, community mental health agency, private practice, hospital, couple and family counseling practice, or another setting, we must be able to recognize and respond effectively to behavioral addictions.

1) We need to have a solid conceptualization of behavioral addictions

Researchers have proposed that addiction is one disorder with a variety of expressions — some that take the form of substance misuse and others that take the form of compulsive engagement in rewarding behaviors. Thus, much of what we know about chemical addiction is relevant to behavioral addictions. For example, both drugs of abuse and hedonic behaviors activate reward circuitry in the brain — specifically, the mesolimbic dopaminergic pathway. 

Although more neuroscience research is needed, it is proposed that highly rewarding behaviors (e.g., sex, gaming, gambling) trigger the release of neurotransmitters implicated in reward (e.g., dopamine, opioids). The activation of reward circuitry can cause pleasurable feelings and provide an escape from negative feelings, both of which serve to reinforce the behavior and increase the likelihood of repeating the activity in the future. For individuals with specific vulnerabilities (e.g., genetic predispositions, histories of adverse childhood experiences, mental health conditions, social learning related to specific behaviors as coping mechanisms), a rewarding behavior can become the primary means of regulating their emotions. Thus, it is the unique interaction between a vulnerable individual and the specific nature of the rewarding behavior that increases the risk of behavioral addictions.

Additionally, the chronic activation of one’s reward circuitry via compulsive engagement in rewarding behaviors may lead to neuroadaptations, or changes in the brain as a result of experience. The chronic overstimulation of the reward system due to behavioral addictions may cause the brain to adapt by decreasing the natural production of dopamine, decreasing the number of dopamine receptors or decreasing the number of dopamine transporters. This downregulation of the dopamine system can lessen an individual’s baseline experience of reward (e.g., at baseline, the individual may feel dysphoric), thereby triggering cravings for addictive behaviors to enhance one’s mood. In this way, the addictive behavior becomes part of a cycle of feeling dysphoric at baseline and then seeking engagement in the addictive behavior to induce positive feelings or ward off withdrawal. 

An understanding of behavioral addictions as a means of regulating emotions with potential neurobiological antecedents and consequences can help us cultivate accurate empathy for our clients and develop effective treatment plans.

2) We need to recognize behavioral addictions in our clinical work

There is a lot of shame around addiction in general and behavioral addictions specifically. Many clients may present with other issues (e.g., depression, anxiety, suicidal ideation, relational conflict, low self-esteem) rather than disclose an addiction to sex, gaming, gambling, food, shopping or another behavior. Therefore, it is imperative that counselors consistently ask clients about their engagement in potentially addictive behaviors in a nonevaluative way. For example, when a client discloses difficulty in their lives, a counselor might ask, “I am curious how you cope with these challenges. Some people turn to alcohol, some people escape through sex or pornography, and some people engage in internet gaming to feel better. How do you deal with your negative feelings?” 

Also, including items on one’s intake form related to addictive behaviors can normalize the experience for clients and invite them to disclose early in the course of treatment. As with chemical addiction, it is impossible to recognize a behavioral addiction simply by looking at a client — behavioral addictions occur among clients of all ages, racial and ethnic groups, genders, religious/spiritual affiliations, sexual orientations and socioeconomic statuses. Therefore, counselors need to be intentional and assess for behavioral addictions with all clients. 

Furthermore, it is important for counselors to accurately distinguish between high involvement in a behavior and a behavioral addiction. Definitions of addiction, diagnostic criteria and published research reveal “Four C’s” that can help counselors identify behavioral addictions: 

  • If the behavior is compulsive. 
  • If the individual has lost control over their behavior.
  • If the behavior continues despite negative consequences.
  • If the individual experiences cravings or mental preoccupation with the behavior when not engaging. 

A client who is very enthusiastic about a behavior or highly involved (e.g., a professional gamer) will not demonstrate the Four C’s of addiction (e.g., they can limit or control their engagement, they do not experience negative consequences). However, if the Four C’s are present, it should alert counselors to engage in further assessment for a behavioral addiction. There are many assessment instruments for behavioral addictions, including the Internet Gaming Disorder Scale, the Bergen Social Media Addiction Scale, the Sexual Addiction Screening Test-Revised and the South Oaks Gambling Screen.

3) We need to embrace our responsibility to address behavioral addictions

It is likely that counselors in all settings will encounter clients with behavioral addictions, and we should be prepared and willing to address these addictions. Rather than assuming this type of clinical work requires a brand-new set of skills, counselors need only to add to their previously established clinical skill set to address behavioral addictions. For instance, when working with clients with behavioral addictions, counselors will still rely on their basic counseling skills such as empathy, reflective listening, unconditional positive regard, immediacy, genuineness, open questions, multicultural competence and an understanding of theory. These elements are still necessary for developing rapport, setting goals and engaging in effective interventions with clients with behavioral addictions. 

In addition to these foundational skills, counselors should become informed about the specific nature of the addictive behavior (e.g., gambling, gaming, exercise, cybersex), including relevant neuroscience. This can also be helpful when providing psychoeducation to clients and their families. Counselors can gain addiction-specific knowledge through self-study, webinars, conference presentations, attendance at open 12-step meetings, consultation with seasoned professionals and pursuit of certification or relevant credentials. 

Along with gaining addiction-specific knowledge, counselors should apply interventions that have proved to be helpful with behavioral addictions (i.e., those that are evidence based). There is a wealth of research that outlines helpful strategies for working with behavioral addictions (e.g., group interventions, motivational interviewing, dialectical behavior therapy, cognitive behavior therapy, couples counseling interventions, mindfulness-based interventions). Several published studies and manuals exist to help inform and guide counselors who are working with a specific behavioral addiction for the first time. 

All counselors can become more equipped to address behavioral addictions by adding addiction-specific knowledge and evidence-based interventions to their clinical repertoire. There certainly will be times when a referral is in the best interest of the client (e.g., to a residential treatment facility for sex addiction or an intensive outpatient program for gaming addiction), but many times the best (or only) available option will be for counselors themselves to treat clients who have behavioral addictions. In these instances, counselors are encouraged to consult with other clinicians who have experience working with the specific behavioral addiction or to seek supervision. Rather than abdicating the responsibility of addressing behavioral addictions, all counselors should be willing to meet the needs of these clients.

4) We need to understand what abstinence entails for behavioral addictions

Abstinence as it relates to substance use disorders is fairly obvious — stop using drugs of abuse. Abstinence from behavioral addictions is less clear, however. Are clients expected to abstain from sex? Stop shopping? Never use the internet? No, abstinence in relation to behavioral addictions entails identifying and refraining from the out-of-control, compulsive behaviors that lead to negative consequences. 

Twelve-step programs use a variety of tools, such as the three circles technique or the development of bottom lines, middle lines and top lines, to aid in defining abstinence for clients with behavioral addictions. In both techniques, individuals and their sponsors engage in honest evaluation and identify all compulsive, harmful and out-of-control behaviors from which they will abstain (e.g., betting on fantasy sports, engaging in cybersex activities, binge eating when they are not hungry, checking social media while driving, playing or watching internet games). These activities are listed in the innermost of three concentric circles or constitute one’s bottom lines. Next, individuals and their sponsors identify behaviors that are warning signs, triggers or precipitating behaviors to those listed in the inner circle or bottom lines. These activities are then written in the middle circle or serve as one’s middle lines. Finally, behaviors that are encouraged, aspirational, align with the individual’s personal goals and values, and increase wellness are identified and listed in the outer circle or make up the top lines. 

In the realm of behavioral addictions, abstinence is defined by refraining from inner-circle activities or bottom lines. When a middle-circle or middle-line activity takes place, it is not considered a relapse, but rather serves as a warning sign that the individual is nearing the inner-circle (or bottom-line) activities and needs to take action (e.g., call a sponsor, go to a 12-step meeting, use a predetermined coping strategy). Thus, the process of recovery among those with behavioral addictions includes abstaining from inner-circle/bottom-line activities, minimizing middle-circle/middle-line activities and increasing outer-circle/top-line activities.

5) We need to be familiar with the 12-step programs in our area

Twelve-step programs can be extremely valuable (and affordable) resources for our clients with behavioral addictions. The number of 12-step groups dedicated to behavioral addictions (e.g., Computer Gaming Addicts Anonymous, Internet and Technology Addicts Anonymous, Sex Addicts Anonymous, Sexaholics Anonymous, Gamblers Anonymous, Overeaters Anonymous, Food Addicts in Recovery Anonymous, Workaholics Anonymous, Debtors Anonymous, Celebrate Recovery) further confirms their prevalence in society. 

Prior to referring clients to a 12-step program, counselors should be familiar with the programs in their area and able to provide details to their clients regarding how to access a meeting, what to expect during a meeting, the mission of the fellowship, and the traditions and common practices of 12-step programs. Many 12-step programs have brochures and literature specifically designed for counselors to help them make referrals to these programs. 

Additionally, in some instances, multiple 12-step programs exist for the same behavioral addiction (e.g., Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, Sexual Compulsives Anonymous; Food Addicts in Recovery Anonymous, Overeaters Anonymous). Counselors should be aware of the differences between the programs so that clients can make an informed decision about which fellowship might be the best fit for them. Almost all of the 12-step programs for behavioral addictions have comprehensive websites, a basic text (e.g., the Sex Addicts Anonymous Green Book) and literature that can help counselors become better informed. Again, counselors are encouraged to attend open meetings themselves to learn more about the programs in their area. 

6) We need to be willing to advocate for clients with behavioral addictions 

Behavioral addictions are not well understood among the general public and often are stigmatized to a greater degree than is chemical addiction (consider potential societal reactions to someone with sex addiction compared with someone with an alcohol use disorder). Counselors, by the nature of their professional identities, are advocates and serve to remove barriers to clients’ wellness. Several prominent barriers exist among those with behavioral addictions. These barriers include societal and internalized stigma, public misinformation and bias, lack of available (and affordable) treatment options, lack of insurance coverage, lack of trained clinicians, and the prominence of the moral model of addiction (i.e., addiction is the result of a moral failing) rather than the biopsychosocial model of addiction (i.e., addiction is influenced by one’s genetic makeup, psychological factors, personal experiences and environment). 

Practical means of advocating for individuals with behavioral addictions include: 

  • Ensuring that all counselors receive training (either during or after graduate school) to recognize and respond to behavioral addictions
  • Ensuring that all local communities have counselors who are equipped to address behavioral addictions (e.g., certified sex addiction therapists, credentialing from the International Gambling Counselor Certification Board)
  • Conducting research regarding behavioral addictions to support their inclusion in diagnostic manuals and to increase empirical evidence
  • Engaging in efforts to ensure insurance coverage for behavioral addictions treatment
  • Becoming involved in legislation related to the regulation of potentially addictive behaviors
  • Dispelling myths and raising public awareness about the realities of behavioral addictions
  • All counselors can engage at the individual, community or public level to advocate for clients with addictive behaviors. 

In sum, behavioral addictions are prevalent in today’s society and affect individuals across the life span. All counselors should be familiar with behavioral addictions so that they are able to recognize them among clients and respond appropriately (whether that means addressing the behavioral addiction themselves or referring clients to another level of care). 

As we become more informed and receive more training, we can best attend to the needs of clients with behavioral addictions and ensure that they receive competent, effective care. The steps detailed in this article are not the responsibility of a select group of clinicians but rather a responsibility for all counselors so that we can best support clients with behavioral addictions.

tommaso79/Shutterstock.com

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Amanda Giordano is a licensed professional counselor, an associate professor at the University of Georgia and the author of A Clinical Guide to Treating Behavioral Addictions: Conceptualizations, Assessments, and Clinical Strategies. Visit her author page at facebook.com/amandaleegiordano.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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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.