Tag Archives: Sexual Wellness

Bringing pornography use out of the shadows

By Bethany Bray November 30, 2021

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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.

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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

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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

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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.

Master conflict therapy as a critical component of couples and sex therapy

By Heather Davidson March 4, 2021

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“We just don’t communicate well,” Merle reported in our first session while her husband, Luke, nodded quietly in agreement. Like many couples presenting for couples counseling, Merle and Luke believed “communication issues” were causing much of their relationship distress.

As a couples therapist, I knew that “communication issues” could mean myriad things. As is the case with many couples I see, I found that Merle and Luke were actually communicating well with each other. The conflict seemed to have more to do with the fact that they did not like what the other was saying.

The distress that Merle and Luke were experiencing in their relationship was affecting their sexual relationship too. When it comes to couples, whatever issues are going on outside of the bedroom also play out in the bedroom. Recent research shows that 40% to 50% of women (Marita McCabe et al., publishing in The Journal of Sexual Medicine in 2016) and 31% of men (Cleveland Clinic, 2016) experience a sexual disorder. The research suggests that even if couples initially report a nonsexual problem such as communication issues, they are likely experiencing sexual difficulties as well.

Despite how common sexual issues are, many counselors are uncomfortable discussing sexual matters with their clients. Counselors who fail to ask about a couple’s sex life, even in cases in which couples are presenting with the generic complaint of communication issues, are neglecting important information that would help them develop a deeper understanding of the couple. The therapist who disregards the sexual aspect of the couple’s relationship will struggle to help the couple achieve a healthier level of functioning.

As both a couples therapist and certified sex therapist, I believe that a couple’s sexual dynamics can tell us a great deal about their nonsexual dynamics and vice versa. Master conflict therapy has provided me the skill set and ability to go deeper with couples who present with a wide variety of relational and sexual problems.

Identifying the master conflict

Master conflict therapy is an integrative approach to treating couples that combines Freudian psychoanalytic conflict theory and Bowen theory with basic principles and practices of sex therapy. We each have a master conflict and unconsciously choose a long-term partner with the same master conflict. The master conflict stays with us for life, regardless of whether we stay with our long-term partner. The goal of master conflict therapy is for couples to learn how to healthily balance and manage their master conflict, because it will never go away.

A couple typically has the same fight over and over again. While the content of the fight may change, the process of the fight looks the same. For instance, Merle and Luke fought often about how to spend their money, how to spend their free time and even how often they should visit their in-laws. But the process of their fighting was that of two partners vying for the other’s acceptance while simultaneously rejecting each other. The process of the fight can sometimes be a good indicator of what the master conflict is.

Counselors should familiarize themselves with several important facts about master conflicts. First, master conflicts are internalized in childhood by verbal and behavioral messages from one’s family of origin. The master conflict can be influenced by religion, culture, ethnicity or experiences of traumatic events in childhood. Commonly, clients are aware of one side of their conflict, but rarely are they aware of both. Clients might have multiple conflicts, but the master conflict is the most influential or most powerful. In addition, the master conflict is evident is many areas of the client’s life (work dynamics, career choices, friendships, hobbies, etc.). It is also important to note that neither side of the conflict is better than the other. Rather, both sides of the conflict have pros and cons.

Although master conflicts do not influence who we choose for short-term relationships or casual sexual encounters, they do determine the choice of a long-term partner. Long-term partners will share the same master conflict. Master conflicts are normal and exist in every relationship. However, when the conflict becomes unbalanced, the couple will find themselves in distress. Once the master conflict becomes unbalanced, it can be very difficult for the couple to manage. Ultimately, to balance the master conflict, both partners must agree on a strategy and work collaboratively to manage the master conflict.

Many events can unbalance a master conflict, including major career changes, financial changes, a new baby or even living with your partner in quarantine during a global pandemic. For Merle and Luke, problems had been brewing for some time, but the crisis of quarantine unbalanced their master conflict of acceptance vs. rejection. Those with an acceptance versus rejection conflict have one side of themselves that needs to be accepted and another side that needs to be rejected. Merle and Luke both desired to please others and had a strong desire to be accepted by the other. Paradoxically, those with this master conflict also unconsciously set themselves up to be rejected by others.

In our book Master Conflict Therapy: A New Model for Practicing Couples and Sex Therapy, published in 2018, Stephen Betchen and I outline 19 of the most common master conflicts we see in our clinical practices. In addition to acceptance vs. rejection, another very common master conflict that I see is commitment vs. freedom. Clients with this master conflict have one side that wants stability and the security of commitment, but the other side longs to be free of restraints. People who have a history of affairs or a pattern of quickly getting in and out of relationships may be likely to have this master conflict. Clients who witnessed their parents’ affairs or demonstrated lack of commitment to each other may also develop this master conflict. Those with this master conflict may have patterns of changing careers or jobs often, moving frequently or getting involved in many different hobbies or interests without pursuing any of them long term.

Counselors who work extensively with addictions should become familiar with the getting your needs met vs. caretaking master conflict. For this master conflict, one side of the client wants to meet their own personal needs, while the other side desires to be selfless and martyrlike. Clients who have this master conflict often were raised in families in which addiction was present or a parent or sibling had a disability or illness that required most of the family’s attention and resources. These clients often have specific life goals that they would like to achieve, but their martyrdom at work, in friendships, and with their families and significant other consumes most of their time and energy needed to meet these goals.

Another common master conflict is specialness vs. ordinariness. Clients with this master conflict have one side that needs to feel special or different, while the other side feels ordinary or even less than ordinary. The client who builds themselves up while simultaneously putting themselves down could have this conflict. People with this master conflict seek constant validation and pursue materialistic possessions or unique life experiences that they believe make them different. Those with this master conflict are at higher risk of engaging in affairs because affairs are an easy way to experience the high of being “special.” Despite the constant chasing to set themselves apart from the crowd, people with this master conflict continue to feel as though they are “less than” or just ordinary, often because what they have built their specialness up from is not authentic.

Counselors who work with high achievers, including those at the top of their professional fields, celebrities and elite athletes, should look out for success vs. sabotage. Clients with this master conflict want to be successful or big and often have achieved something major, but the other side of themselves desires to be small or to fail. With great success comes the risk of great failure. Individuals with this conflict will sabotage their own success, and because their partner shares the same master conflict, their partner will also sabotage them if they become too big or too successful. 

Assessment and development of relationship symptoms

The first three to five sessions should serve as the assessment phase of treatment. While I let couples start where they need to in the first session, during the next few sessions I collect a genogram and history for each partner. As I gather this information, I also pay attention to both the language they use to describe their presenting problems and to their nonverbal communication.

Merle often used the word “rejected” and described her position in the relationship as “unfair.” She tended to be the more vocal and active partner in couples therapy. Luke, on the other hand, presented as distant and seemed shut down or dismissive toward Merle. Luke reported that “Merle just does not like what I value,” and I observed resentment in many of the passive-aggressive comments he would make toward Merle in session.

The couple explained that they were seeking couples therapy because of “bad fighting and poor communication” since being quarantined with each other. Some of the fights were related to sharing household tasks and parenting while still trying to work. But the major source of conflict concerned whether now was an appropriate time to try having a second child. Luke believed the couple should delay or not even have a second child because of the economic instability associated with the global pandemic. Merle accused Luke of being “selfish” and concerned merely with having time to pursue his artistic interest (an interest with which he was experiencing success).

The couple reported meeting as young 20-somethings at work. They both described the dating and engagement phase of their relationship as positive. At the time, Merle was supportive of Luke pursuing art, and in turn he supported Merle going after her dream career even though it was in a low-paying field. Although the young couple had always planned on having a family eventually, they were surprised to learn a few months before their wedding that Merle was pregnant. They both cited the unplanned pregnancy as the beginning of their relationship’s demise, but they each had different beliefs as to why that was.

Merle came from a warm but intrusive family. She described having close relationships with her sisters. She had excelled in school and sports as a child and teen. Merle described herself as a “people pleaser,” and she often worried about disappointing her family and friends. When one of her sisters dropped out of college to pursue a different career path, Merle saw her parents struggle deeply with that decision. Merle’s father was a first-generation immigrant who had never had the opportunity to go to college. It was very important to him that all of his daughters complete college, and Merle believed that he never fully recovered from her sister’s decision to leave school.

When Merle discovered she was pregnant before her wedding, she was so terrified to disappoint her parents that she concealed the news until after the event was over, even though it was obvious that she had gained weight. As Merle explained, “I would rather deal with my parents’ disappointment about me getting fat than their disappointment in me getting pregnant before being married.”

Luke came from a disorganized and controlling family. Both of his parents came from working-class backgrounds and were religiously conservative. Although Luke had an interest in pursuing the arts, both of his parents prohibited him from getting involved in such an “impractical” interest and pushed him into activities that were “better for getting into college,” even though he had little interest in them. Luke was also deaf in one ear, which had created learning difficulties for him as a young child. This was another trait he felt made him “less than” his other siblings. While his siblings followed in the path of their religious parents, Luke showed little interest in organized religion and eventually left his parents’ faith as a young adult. This decision caused much conflict within the family.

As the third child of seven, Luke had often witnessed his mother being overwhelmed by their large family, especially given that her husband worked long hours to support them. Luke described feeling robbed of what he perceived to be normal childhood pleasures and experiences due to his parents’ inability to provide adequate attention and financial support to their children.

Luke had spent much of his 20s getting his professional day job to a place where he was secure and could devote more time to pursuing his artistic interests, which his parents continued to disapprove of from a distance. Although Merle tried to reassure Luke that their baby would not change his ability to engage in his artistic pursuits, he knew from his own childhood that this simply was not true. Luke described a period of depression during the pregnancy. Merle reported being excited about the pregnancy but also stressed about how to “make Luke be OK with it.”

During the assessment, I always take a sexual history. In this case, both partners denied experiencing any sexual trauma, and both reported having long-term relationship partners before they met each other. Luke acknowledged being less sexually experienced than Merle due to his upbringing. Despite this, the couple felt positive about their sexual relationship before having a child; they were both happy with the frequency and believed they shared mutually in pleasure. In recent years, however, their sexual frequency had declined. Luke attributed this to stress, whereas Merle worried that it was more personal.

Discussing a couple’s sexual development and history helps the counselor to recognize sexual patterns. It also helps the couple become more comfortable talking about sex. Merle eventually disclosed tearfully that she worried Luke was no longer attracted to her because he experienced delayed ejaculation. Luke claimed to be unsure about why he was experiencing this problem and denied that he was no longer attracted to Merle. Both reported that the delayed ejaculation began around the same time they were fighting over whether to have a second child.

In treatment, Luke eventually admitted feeling conflicted about having a second child and worried that the additional demands would take away from his pursuit of a side career as an artist. Merle dismissed his concerns as selfish and lashed out at him for “taking away” her dreams of a larger family. Living under quarantine caused Luke rarely to have time to do anything with his art. In fact, he spent most of his time balancing working from home and trying to parent. The result of these sexual experiences left both partners feeling rejected by the other: Merle by Luke’s delayed ejaculation and lack of desire for another child, and Luke by Merle’s reaction to his sexual difficulty and overly optimistic stance on having another child.   

Treatment and relapse prevention

Master conflict therapy consists of four treatment goals:

1) To help the couple uncover their shared master conflict

2) To help the couple determine the origin of their master conflict

3) To help the couple decide which side of the conflict to choose, or to integrate both sides of the conflict to a tolerable, balanced state

4) To alleviate the couple’s symptoms, both sexual and nonsexual

Couples should leave treatment knowing how to manage their master conflict, which will prevent a relapse when their conflict becomes unbalanced in the future. Their fighting should become less intense and less frequent, and they should have the skills to collaboratively manage their master conflict.

It takes many sessions to fully understand a couple and to gather enough data to support whatever master conflict a therapist might suspect. During this time, the therapist should be conducting a thorough assessment, providing the couple with relevant psychoeducation regarding their presenting problem, and providing the couple with behavioral strategies that can help them get out of crisis.

With Merle and Luke, I discussed psychoeducation regarding delayed ejaculation and sexual desire. I also helped the couple improve their basic communication skills. Because Luke did not have any medical risk factors that would have caused delayed ejaculation (we ruled these out with an extensive medical history, a visit to a urologist and routine bloodwork), I suspected most of the problem was psychological. I also explored with the couple the behaviors and emotional baggage that each of them brought to the relationship from their families of origin that not only informed their conflict style, but also colored the way each of them viewed this conflict.

Merle and Luke soon began to see the ways in which they were similar, including both never feeling fully accepted by their families and both fearing rejection by the other. They eventually recognized the ways that their own acceptance vs. rejection master conflict played out in other areas of their life unrelated to their romantic relationship. Merle had a long history of people pleasing and a yearning to be accepted by female friends; this often set her up for disappointment and rejection. Luke was a hard worker and longed to be acknowledged at work, but when he did receive praise, he would act out, leading his superiors to feel frustrated with him. Discovering how similar they were to each other helped Merle and Luke to build mutual empathy.

Once this couple gained a better understanding of their master conflict and the impact it had on their lives, we turned to the issue of having a second child. Merle felt conflicted between wanting to please Luke by limiting the family to one child and wanting to expand the family, even if this meant additional challenges for them and more tension between them. Luke saw Merle as willing to risk their relationship, their financial stability and the overall stability they had created for their first child just to have another child. He explained that he worked hard in a day job that he did not particularly like and put his artistic pursuits to the side for the sake of family stability. This had also enabled Merle to take her “dream job” even though it was low paying — something the couple agreed on during their engagement.

After much processing, Luke expressed that the only way he would agree to having a second child would be if Merle took a higher paying job or they found a way to move to a much more affordable area of the country. Faced with the idea of losing her career, Merle was better able to resonate with Luke’s position. Ultimately, the couple decided to shelve the decision to have another child for one year. Merle would explore other career opportunities that could provide the family with additional financial security, while Luke agreed to look for affordable places that the family could live and examine whether a more permanent work-from-home situation might ever be available to him.

Upon termination, the couple reported fighting much less frequently and with less intensity. They reached an understanding of their master conflict and could now easily predict where each of them might struggle or feel triggered by the other. As they had resolved their conflicts, gained more understanding over their pattern of fighting and mutually agreed not to have another child at this time, Luke’s delayed ejaculation subsided. Merle’s fears of not being attractive to Luke waned, and the couple both reported feeling more emotionally and sexually connected.

Master conflict therapy prepares couples to manage their differences and conflicts for the long term. By providing a framework for better understanding themselves and each other, the couple can better manage future conflicts — regardless of the content — as they see how the process is the same.

 

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Heather Davidson is a licensed professional counselor and the founder/owner of a boutique private practice in Bryn Mawr, Pennsylvania, called Better Being Main Line. She is both a certified sex therapist and a certified eye movement desensitization and reprocessing therapist and specializes in treating individuals and couples with sexual issues and those with traumatic experiences. She is the co-author of the book Master Conflict Therapy: A New Model for Practicing Couples and Sex Therapy (Routledge, 2018) and is an instructor for the Council for Relationships’ postgraduate certificate program in sex therapy. Contact her at heatherdavidsonlpc@gmail.com.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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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.

Life after cancer

By Laurie Meyers April 29, 2020

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To the uninitiated, a favorable cancer prognosis may appear to follow a challenging yet relatively linear path ending on an upward trajectory: diagnosis, treatment, elimination, champagne.

After all, what’s not to celebrate? Treatment is over! You’re cancer-free! Everything is great! You may now return to your regularly scheduled programming.

You are ecstatic, right?

For most people completing cancer treatment, the answer is: It’s complicated. And bewildering, because almost no one talks about the messy reality of “after.”

These are some of the unspoken truths about life after cancer:

  • The end of treatment is a cause for celebration and a time of uncertainty and fear.
  • The end of daily, weekly or monthly medical visits can leave patients feeling as though their safety net has been removed.
  • The emotional support that patients receive from those around them may shrink — sometimes dramatically — once their cancer is “gone.”
  • Surgery, chemotherapy and radiation may be over, but treatment is not; patients still require regular scans and, in some cases, pharmaceutical maintenance regimens.
  • Pain, neuropathy, fatigue, mental fogginess, physical restrictions and other side effects often last long after treatment is completed.
  • After months or years of focusing on cancer, survivors can struggle with a sudden loss of structure and purpose.
  • Physically or metaphorically, cancer patients have lost pieces of themselves.
  • Scars, hair loss, skin changes, bloating, weight gain or loss, medical devices such as intravenous ports or ostomy bags, and other changes in appearance frequently have a negative effect on body image.
  • The physical and psychological effects of treatment can cause lasting intimacy issues, both physically and emotionally.
  • A professional clinical counselor can be the one person who never tires of hearing about the individual’s cancer experience and helps the individual make meaning of that experience and find their new “normal.”

Seeking solid ground

Cancer patients are often surprised by their reaction to the last day of treatment, says licensed professional clinical counselor Cheryl Fisher, a private practitioner in Annapolis, Maryland, whose specialties include counseling clients with cancer. Most cancer clinics have some kind of ceremony — a bell to ring or a certificate to present — so there is a feeling of celebration, she notes.

But then? Fisher says these patients often have a sudden realization: “Oh, crap. Now I’m on my own.”

The medical support group that has sustained those in treatment week after week, month after month, suddenly is no longer there, notes Fisher, a member of the American Counseling Association. Yes, the physicians and nurses are still available, but those reassuring regularly scheduled visits that provided a consistent sense of forward momentum are over, leaving patients unsure of what comes next and whether they’ll truly be OK.

During treatment, patients are essentially swept along, focused on navigating the tasks placed in front of them, Fisher explains. “What do I do next? What do I do next? OK, tell me what do I do next?” she says. “You’re just going through the motions almost on autopilot.”

And then, suddenly, the merry-go-round stops, and survivors are left standing still, yet psychologically awhirl with everything they’ve lived through. “Your body, your mind, your neurology is still trying to catch up with all that has happened,” Fisher says. “You’re still processing it.”

ACA member Mary Kathryn Rodrigue, a licensed professional counselor who is certified in psychosocial oncology with a focus on young adults, agrees. Many of the clients who come to her practice after completing cancer treatment are just beginning to process their grief, she explains, because they felt compelled to put everything else — financial worries, job concerns, questions about fertility, relationship concerns — on the back burner during treatment.

Rodrigue, founder and co-owner of The Wellness Studio, located in Baton Rouge and Covington, Louisiana, uses the Functional Assessment of Cancer Therapy-General, a scale that measures physical, social/family, emotional and functional well-being, to help determine her clients’ needs. In addition, she administers standard depression and anxiety assessments.

Many of her clients present with anxiety surrounding “what if” scenarios. Rodrigue describes exploring these fears as “peeling back layers of an onion.” Follow-up tests are a frequent source of anxiety. “I have a scan coming up. … What if the doctor doesn’t call right away? How will I cope?”

Rodrigue frequently uses journaling with her clients and says that “worry journals” can be very effective. “It’s allowing you to tangibly take that worry that feels like it’s on a ticker tape and put it somewhere else,” she says. Clients might also use their journals to play out the worst-case scenario, imagining that a scan shows evidence of cancer, taking stock of their support systems, and attempting to formulate a plan. Examining that fear and planning possible responses keeps clients from “back burnering” their fears and letting them build momentum, Rodrigue says.

She also teaches clients mindfulness and grounding techniques such as environmental awareness — noticing the temperature of a room, focusing on the feel of clothing against the skin, and identifying the textures and tastes of the food they are eating, for example.

Fisher, who is also the director of the online master’s program in clinical counseling for the California School of Professional Psychology at Alliant International University, says scan anxiety is a constant concern for many of her clients, some of whom face scans every three months. When the first scan comes back clear, Fisher says, clients begin “just testing the toe on the water, trying to gain some semblance of this new normal. What does it look like?” But then, as the next scan time approaches, their anxiety amps up again. Fisher helps clients develop tools to manage their fears without derailing the process of reengaging in life.

She recalls one client whose scans indicated a small recurrence of cancer on the lung. “There’s this little, teeny, tiny spot. It’s not growing fast. They’re actually not going to do surgery. They’re just going to watch it,” Fisher explains. And, so, the client had to make peace with the unknown.

Fisher asked the client what she was feeling.

“I’m afraid,” the client said.

“OK, great,” Fisher responded. “Acknowledge that you’re afraid. Call upon it, sit down, have a conversation with it [through journaling or self-talk]. What’s the fear about? What’s the greatest aspect of the fear? What is it telling you, teaching you? How would it ask you to live your life differently now, with the unknown? What would that look like?”

The client was anticipating the birth of her second grandchild and was afraid that she wouldn’t be around to experience it. So, Fisher asked the woman to think about how her plans might be altered by knowing there was no guarantee she would be in the child’s life. The client decided to make some preparations for the birth of the child. She had previously been putting off her plans, paralyzed by fear of the unknown. As it turned out, the woman’s follow-up scan showed no sign of any growths.

“What we do with fear,” Fisher says, “is tell fear, ‘OK, I know you’re going to co-journey with me around this. I know you’re going to be there, but you cannot lead it. You cannot be the leader of my life. What I’m going to do is … to pull you out periodically. We’re going to have a conversation. I’m going to allow myself to experience you, cry, be angry, journal, do some work around it. Then I’m going to tuck you back in and tell you [that] you have to walk beside me, not in front of me.’”

Fisher emphasizes that this intentional practice allows clients who have experienced cancer to decide what is essential — the nonnegotiable things they want to experience no matter what.

All that you can’t leave behind

As clients learn to negotiate their fears and reengage with life, they will inevitably need to reevaluate. Everything. But especially the people in their lives.

“Your whole world turned upside down,” Fisher asserts. Clients’ perspectives are altered — sometimes radically — by what they’ve been through. “Now you’re really evaluating people, places, things, and how they’re serving you in your life,” she explains. When assessing relationships, clients are seeking reassurance that the people around them are able to allow them to move forward while still understanding — and respecting — the radical life changes cancer has brought on.

Rodrigue was struck by a presentation she attended in 2019 on issues affecting young women with breast cancer that described three different categories of relationships and the need — particularly in times of significant change — to do an inventory of the people in one’s life and where they fit. The first category comprises the closest relationships — those built on unconditional love in which people willingly make sacrifices for each other. The speaker emphasized that it is essential not to have too many of these relationships because it is easy to spread oneself too thin. The second category consists of reciprocal relationships — people who do things with you and for you, Rodrigue says. And the third category of relationships includes people in your life by default — family members, friends you’ve known for a long time, individuals with whom you were brought together by a crisis or a project, etc.

Major life changes and shake-ups tend to call attention to those relationship lines, Rodrigue says, explaining that it is not uncommon for people who have recently gone through cancer treatment to feel anxious about their relationships. She encourages clients to ask themselves several questions: What is driving their anxiety? How are relationships not meeting their expectations? Is there a lack of reciprocity? A tendency to be unavailable or unsupportive? Perhaps a previously unnoticed pattern of negative and undermining comments and behavior? Is the pattern a new development caused by a change in friendship dynamics, or was the relationship never based on equal footing?

In many ways, cancer survivors have an even greater need for support once they’ve finished treatment. Not knowing whom to count on or being betrayed by someone who seemed like a trusted ally can have a significantly detrimental effect on clients’ emotional and physical health. Taking a relationship inventory that allows clients to recognize the need to “refile” or even release a relationship can reduce anxiety and help eliminate unnecessary conflict.

Both Rodrigue and Fisher say another significant challenge cancer survivors encounter in their relationships is everyone else’s need for them — the patient — to be “OK.” But they’re not. At least not all of the time.

This inability on the part of others to consider the person as anything less than “good as new” sometimes comes from a place of selfishness or ignorance, but it can also come from fear, Fisher says. Those close to the client have endured months or even years fearing the loss of their loved one, so they desperately want to believe the person will be fine, she explains.

And cancer survivors often want to ease that burden, to say they’re fine even when they’re not, Fisher continues. “Oftentimes, we still are in that protective role, where we’re like, ‘Yeah, yeah. I’m good. I’m fine,’ rather than saying, ‘You know what? I could still use a weekend away,’ or ‘I don’t know if I can take on my full life right now in one swoop.’ … So, now it’s like, OK, on your mark, get set, go. It’s too much. It’s overwhelming.”

This is where counselors need to step in and educate their clients. Fisher tells her clients that their A-game no longer looks the same; that there is no “back to normal” — inevitably, it is a new normal; and that finding secure footing on the path forward takes time. People will want to assume that the person who went through cancer treatment is fine, so it is up to that person to set boundaries, to let others know when they need time off or to say, “I can’t deal with your bull,” Fisher asserts.

Sometimes, helping clients manage others’ expectations requires bringing in the third party. Fisher had a client who was a cancer survivor and a widow. The woman’s daughter would come to town to visit and had a hard time hearing that her mother had bad days. During one of these visits, the client asked Fisher if she could bring her daughter to a counseling session so that they could work on expectations together.

“That was where, of course, the daughter was able to break down and say, ‘I’m scared. I can’t stand the idea of seeing Mom vulnerable. I have to see her as super mom,’” Fisher recounts. “Mom is crying, saying, ‘I would love to be that super mom, but that’s not my M.O. anymore. I learned that trying to be super mom actually was killing me. I need you to know honestly that some days are great, some days are not great. I need to have the ability to do what I need to do on those not-so-great days without worrying that it’s upsetting you.’”

The elephant in the room

Life after cancer treatment means reengaging not just in platonic relationships but in intimate ones as well — if and when the survivor is ready, Fisher says. Again, it’s complicated.

Survivors are scarred and often not comfortable in their bodies, Rodrigue explains. It’s hard to reclaim your body when part of it is missing, especially in cases with mastectomies, she continues. Survivors need a safe mental health setting in which they can express their rawness and grief over the loss.

Fisher notes that breast cancer survivors with hormone-positive cancer grapple with an additional complication — hormone-blocking pharmaceuticals such as tamoxifen or aromatase inhibitors. Tamoxifen usually forces women into early menopause and the physical aspects that come with it, such as hot flashes, dryness and discomfort.

Many survivors aren’t even ready to think about a sexual relationship at that point, but if they have a partner, the topic comes up sooner rather than later, Fisher says. For women who don’t have partners but are interested in a sexual relationship, the process of finding one may feel more complicated. Fisher quotes one client as an example: “The next time I’m going to be sexually intimate with somebody, I’m going to have to feel safe enough to tell my story.”

“It really requires trust to be able to expose the scars, talk about the scars, experience a relationship with somebody in the scars,” Fisher says.

Too often, survivors struggle alone with reestablishing their sexuality. Even clinicians are often hesitant to address sexuality after cancer, Fisher says. She asserts that counselors should be asking these clients about their body image and their identities as sensual and sexual persons.

“Talk to me about what you’re experiencing now. What are your fears? What would you like it to look like?” Questions like these will open the door and allow clients to talk about their sexuality, Fisher says.

Counselors should also make sure they are up to date, comfortable with and educated about the aftermath of cancer treatment and reengaging in sensual, sexual, and body image components, Fisher says. “Sexologists, sex therapists are excellent resources,” she suggests. “The interesting thing is, finding them is kind of challenging at times. [Find] out who’s in the area so you can refer clients. Then, hey, you know what? Normalizing [with clients]. This is really normal stuff.”

She also recommends that counselors consult with physical therapists who are knowledgeable about pelvic rehabilitation. “They educate you from A to Z in terms of what could possibly be interfering with both physical and sexual functioning.”

Again, it is about getting clients back into contact with their “new bodies” and embracing the changes — not just in terms of sexuality but in redefining their own beauty, Fisher says. She finds yoga and breathwork to be particularly effective ways for clients to reconnect with bodies that they may feel betrayed them.

Rodrigue has had many clients tell her that they no longer feel beautiful or even functional. It was such a common refrain that when it came time for her to open her practice, she made a specific request of the interior designer — a friend and former Project Runway winner. “Everything is made from repurposed materials, stuff people threw away,” she says. Rodrigue encourages her clients to see themselves in the materials — not broken but rather remade with a new purpose.

Fisher has a similar view of the healing process. “When is it over? I don’t think it’s ever over,” she says. “I think you just get to the other side of it, and it’s repositioned and informed your life. … Just because the treatment is over doesn’t mean the processing and healing are over.”

 

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Laurie Meyers is a senior writer for Counseling Today. She was diagnosed with breast cancer in February 2019 and finished active treatment this past January. Her discovery that there is no survival guide for life after cancer inspired this article. Contact her at lmeyers@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.