Tag Archives: shame

When post-abortion emotions need unpacking

By Bethany Bray April 3, 2018

Catherine Beckett, an American Counseling Association member with a private practice in Portland, Oregon, has made it a habit to avoid using “must” phrases with clients. “It sends a message to the client about what they’ve experienced,” says Beckett, who specializes in grief counseling. “I don’t ever want to say, ‘Oh, you must feel so guilty,’ or ‘You must feel so isolated,’ because that may not be the case at all.”

A case in point: when clients reveal in counseling that they have had an abortion at some point in their past. Some clients consider that experience to be just another piece of their life story, free of any negative associations. For others, the experience can evoke a range of issues, from spiritual and familial turmoil to attachment difficulties and feelings of loss. When dealing with such a highly charged topic, counselors must be prepared to put their own personal views aside to support clients who fall into either camp — and those who present a range of emotions in between.

Research cited by an American Psychological Association task force found that the majority of women who elect to have an abortion will not experience mental health difficulties afterward (see apa.org/pi/women/programs/abortion/). In February 2017, JAMA Psychiatry published a study titled “Women’s mental health and well-being 5 years after receiving or being denied an abortion.” The study observed 956 women over the course of five years, including 231 who initially were turned away from abortion facilities. Among the authors’ conclusions: “In this study, compared with having an abortion, being denied an abortion may be associated with greater risk of initially experiencing adverse psychological outcomes. Psychological well-being improved over time so that both groups of women eventually converged. These findings do not support policies that restrict women’s access to abortion on the basis that abortion harms women’s mental health.”

Even though most women will not experience long-term mental health problems after an abortion, some may still endure feelings of loss or encounter other negative emotions caused by external factors such as culture or family. For certain clients, a past abortion experience, whether it took place one month ago or decades ago, can be at the root of a range of issues — low self-esteem, relationship problems, disenfranchised grief — that surface during counseling sessions.

Beckett notes that most of the women she works with aren’t questioning their decision to have an abortion but rather “struggling to process it and place it in the narrative of their own lives in a way that feels comfortable.”

“As a practitioner, you should know about [abortion] and understand that within the population you’re seeing, it’s probably in their story,” says Jennie Brightup, a licensed clinical marriage and family therapist in private practice outside of Wichita, Kansas. “You need to be prepared to know how to work with it.”

Counselors should approach the revelation of an abortion just like any other experience or issue that clients may have in their histories, Brightup says. “Have an open mind. Allow it to be something that can be a problem for your client. See that it could be an issue … [and] have some knowledge about how to treat it.”

‘You think you’re alone’

The Guttmacher Institute, a reproductive health research organization, estimates that in 2014 (the most recent data available), 926,200 abortions were performed among women between the ages of 15 and 44 in the United States. This comes out to a rate of 14.6 abortions per 1,000 women.

The institute notes that this marks America’s lowest abortion rate since the process was legalized nationwide by the Roe v. Wade Supreme Court decision in 1973. The U.S. abortion rate has seen a steady decline after peaking in 1980 and 1981 at close to 30 abortions per 1,000 women. Using the 2014 data, the Guttmacher Institute extrapolates that 5 percent of U.S. women will have an abortion by age 20; 19 percent will have an abortion by age 30; and 24 percent will have an abortion by age 45.

Abortion is more common than many people, including mental health practitioners, think, says Trudy Johnson, a licensed marriage and family therapist who presented on “Choice Processing and Resolution: Bringing Abortion After-Care Into the 21st Century at ACA’s 2012 Conference & Expo in San Francisco. Johnson, who had an abortion in college, says that for many people, processing the abortion experience is “a slow burn. It doesn’t affect you until later on. [Many] women have had an abortion, but you think you’re alone. You don’t feel you get to grieve it. … It’s a gut-level thing, a tender place. Many have never told a soul,” says Johnson, who specializes in trauma resolution, including abortion-related issues.

Connecting issues

For clients who have yet to process and place a past abortion into their self-narrative, it can feel like a sadness that they can’t quite pinpoint or define. “It’s kind of like a phantom pain. It’s there, but you don’t know why,” Johnson says.

Clients with a variety of presenting issues may have unprocessed emotions surrounding a past abortion that could be compounding their struggles, Johnson says. These issues can include:

  • Depression and anxiety
  • Complicated grief
  • Anger
  • Shame and guilt (especially shame that is undefined or has no apparent cause)
  • Self-loathing and self-esteem issues
  • Relationship issues (including destructive relationships)
  • Destructive behaviors (including substance abuse)

For certain clients, their unprocessed emotions can feel like a weight they have carried and buried deep within themselves for a long time without sharing it with anyone, Johnson says.

Johnson recalls one client who initially came for couples counseling with her husband but eventually started seeing Johnson for individual counseling. During a session, Johnson recognized that the woman was becoming upset, so she handed her a blanket and pillow for comfort. The client put the blanket over her head, obscuring her face, and disclosed that she had had an abortion 18 years prior. Her family had shamed her for the decision, and her feelings of shame were still so overwhelming that putting the blanket over her head was the only way she could bring herself to talk about the experience, Johnson recounts.

“You just can’t imagine the shame that [some of] these clients carry,” says Johnson, a private practitioner who splits her time between Arizona and Tennessee. “They just have to talk about it. We, as professionals, can be that safe place.”

Clients who have had abortions sometimes question whether they have the right to grieve because there was a choice involved to terminate their pregnancies, says Beckett, who is an adjunct faculty member in the doctoral counseling program at Oregon State University. The concept of the experience of disenfranchised grief — those who are not supported in their grief because it is not culturally recognized or validated — applies in these instances, Beckett says. In fact, the disenfranchisement can be both external (a loss not recognized by the client’s culture) and internal (a loss that the client, individually, does not recognize).

“People do not have the same kind of support and validation [to grieve a loss] when they’re disenfranchised, and that is a huge part of abortion grief,” Beckett says. “The emotional aftermath is so impacted by spiritual, political and ethical values and beliefs. That will really color how they process it and how much they’re able to reach out and get support. This all needs to go into our assessment of a client. What was their experience, but also how are they talking to themselves about it? All of that should inform how we offer support.”

Broaching the subject

Practitioners might want to consider asking clients (female and male) about pregnancy loss, including abortion, on intake forms. Brightup asks clients about past pregnancy loss in a genogram exercise she does in the first few sessions of counseling. If the client mentions an abortion, she simply makes a note and keeps going. It is not a topic she feels a need to jump on immediately, she says, and she doesn’t want to risk retraumatizing clients or prompting them to talk about it if they are not ready. Some clients may not mention an abortion on an intake form or genogram because they don’t consider it a loss or associate it with trauma, Brightup says. Others have buried the issue so deep that they don’t think about it or feel that it is worth mentioning, she adds.

“When you’re hearing their story, you can find places to check in and ask questions. Most of the time, I allow them to come around and tell me. It’s a core secret. If you feel [judgmental] to them, they’ll never tell you and they’ll run [stop coming to therapy],” says Brightup, a certified eye movement desensitization and reprocessing (EMDR) therapist.

Practitioner language is also important, Beckett notes. “For some people, asking [if they have an abortion in their past] is giving them permission to talk about it. And the way we ask about it may give them clues about whether or not it is safe to talk to us about it,” she says. “For example, there’s a difference between, ‘Is this something you have experience with?’ and ‘Well, you haven’t had an abortion, have you?’”

Even the word “abortion” can provoke an intense reaction for some clients, Johnson says. In some cases, she will use the phrase “pregnancy termination” or even “the A word” with clients who feel triggered and begin to close themselves off.

“You might need to say it differently,” Johnson advises. “Abortion immediately turns it into a political, socially charged [issue]. Changing the terminology helps it to be safer.”

The key is to foster a safe, trusted bond so that clients will feel free to bring the topic up themselves when they are ready, Johnson says. “The most important thing is building a relationship of safety,” she emphasizes.

Different points on a path

Clients who disclose having an abortion in their past may vary widely on how they feel about the procedure and how much they have processed those feelings.

“There are clients who will come in and do not report having any mental health issues related to their abortion experience. Understand that they’re out there. But the other side is out there too,” Brightup says. Practitioners must be prepared to work with clients who express either sentiment — or a range of feelings in between.

Counselors should watch their clients’ body language and other cues, especially in cases in which a client is emphatic or even defensive when talking about an abortion. It is wise to unpack the client’s experience and associated feelings over time, Brightup says.

If counselors disagree with a client’s assertions concerning how she feels about the procedure, “you can lose the client because they won’t come back [to therapy],” she says. “Agree with their narrative. In little pieces, once they trust you, you can come back to the story and probe a little, ask a few questions as gently and carefully as you can.”

Some clients will have fit the abortion into their self-narrative and moved on, whereas others won’t be as far along in the journey. Still others will have worked through their feelings surrounding the procedure in a healthy way previously but may find themselves struggling with it again as they move into another life stage such as pregnancy or motherhood, Beckett says.

This was the case for one of Beckett’s clients who sought counseling because she was struggling with powerful emotions that had resurfaced. The client had undergone an abortion when she was 17. Later in her life, she had a daughter, and that daughter was now turning 17 herself. Even though her daughter wasn’t facing any type of decision regarding pregnancy or abortion, her age triggered feelings in the client that needed more therapeutic attention.

The client’s abortion had been illegal at the time where she lived, so she had felt compelled to keep it a secret, Beckett explains. The client realized her daughter was now the age she had been when she had an abortion. “The mother saw, for the first time, how young she [had been] and how desperately she had needed love and support at the time, and she didn’t get it,” Beckett says. The realization was “exquisitely painful” for the client, but at the same time, it brought “a new level of compassion for her 17-year-old self,” Beckett recounts.

“She took a great deal of comfort in knowing that if her daughter were to get pregnant, it would be an entirely different experience. Her daughter would have the support of her family and better care,” Beckett says.

The hard work of unpacking

Just as clients will differ in the work they have done — or haven’t done — to process the emotions surrounding an abortion, the support and interventions they might need from a counselor will also vary.

“People grieve very differently, and we need to be ready to support people however they are doing it,” Beckett says. “Some people are going to want to take action or give back somehow. Others will respond to more creative processes or ritual creation. Others will want a quiet, safe place to process.”

Normalizing a client’s experience can be a much-needed first step. Beckett says that talking about how common abortion is, and the fact that many people feel a need to process their feelings afterward, can bring relief to clients. Practitioners can also help clients reframe their thoughts to realize that feelings of relief after the procedure are common, as is a fear of judgment and a sense of isolation that can accompany that fear.

“Figure out what this particular client’s experience is and then, if appropriate, offer normalization of that,” Beckett says. “Support them to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

In Brightup’s experience, post-abortion work with clients often falls into four quadrants:

  • Reconciling how clients feel about themselves
  • Engaging in grief work around how clients perceive and feel about the loss (if they do indeed view it as a loss)
  • Working through clients’ spiritual issues or any inner tensions related to “rules” that were broken
  • Working on clients’ relationships and how they relate to people: Are there areas that need healing?

From there, practitioners should tailor their approaches to meet each client’s individual needs and pacing, Brightup says. She often uses sand tray therapy as a tool to help clients talk about post-abortion loss and find closure. Journaling, writing letters or poems, creating art and engaging in other creative outlets can also be helpful, she says. Certain clients may respond to creating some kind of physical memorial or taking time out of a counseling session to do a remembrance with just the two of you, Brightup adds.

Beckett agrees that counselors should collaborate with clients to find a ritual or activity that works for them. Although many clients will make progress through talk therapy or by connecting in group work to those who have had similar experiences, others will feel a need to take some kind of action, Beckett says. Creating memorials and rituals, writing letters or participating in other creative interventions can help these clients to process their emotions and experiences.

For one of Beckett’s clients, healing involved creating a special ritual on what would have been her child’s due date. Each year, the client would be intentional about spending time with a child — whether a niece or a nephew or the child of a friend — who was the same age that her child would have been.

“She came in pretty soon after her abortion, and she knew she needed help to process it,” Beckett says. “She wasn’t questioning the decision, but she was having trouble [with the fact] that her life would move forward but the life of the baby she had not had wouldn’t move forward. She wrote a letter to that baby expressing her caring and regret and explaining why she felt she couldn’t bring him or her into the world. Every year on her due date, she would find a way to connect with a child she knew that would be that age. She would spend time with that child and make it a good day for them.”

Whereas this intervention helped this particular client to find peace, “for other clients, the thought of that would seem hellish,” Beckett stresses. “There’s no prescription for this. It’s a process of figuring out what is still remaining and needs to be released. Talk with the
client to find creative ways to be able to do that.”

Counselors can help clients navigate areas in which they feel emotionally stuck, Beckett explains. For example, one of her clients was struggling even though she had worked through many of the emotions she had experienced after an abortion. The client had three children, and when she became pregnant with a fourth, she and her partner made the decision to terminate the pregnancy.

“There was one part that she couldn’t get OK with: ‘I see myself as someone who takes care of others,’” Beckett says. “That’s where we focused: How did she define ‘taking care’? How did this decision threaten her self-concept? We dove into that area and she eventually realized that terminating the pregnancy was taking care of her fourth child. That was the best way to take care of that child, instead of bringing the child into an already-overwhelmed system that wouldn’t have been able to provide what the child needed.”

Johnson finds narrative therapy a useful approach when focusing on post-abortion issues with clients. Giving them the freedom to tell the story of their abortion — how old they were, how it happened, who came with them that day — can be powerful, she says. Sometimes clients won’t remember the details about their abortion because they’ve blocked them out, Johnson says, but as they open up and talk about the experience in therapy, they often start to recall things.

“This has been in their head for years. When they finally start talking about it, they go on and on because that’s [often] what they need,” Johnson says. “You can see the layers coming off as they’re processing it verbally, the whole story. … Letting them talk about the details and tell their story is a starting point.”

When relevant, Johnson also helps clients identify all the points of grief connected to the abortion beyond the loss of a pregnancy. For example, clients might have experienced a breakup with their romantic partners or the breakdown of a relationship with their parents or other family members either leading up to or after the abortion. Giving clients permission to grieve and accept the loss of these things is an important step, Johnson says.

There are “so many layers to this. The main thing [for counselors] is being a safe place. The impact of a hidden abortion could really be affecting the outcome of your therapy if it’s not addressed. Be aware that there could be this issue under all of the other stuff [the presenting issues],” Johnson says.

“Treat this as a disenfranchised and complicated grief situation, and take out all the political mess and pros and cons,” she continues. “The client has already made a choice. Let’s forget about that and just work on the grief. They’re not the same person that they were when they made the choice. They’re a different person now, so they need to have permission to revisit that time in their life and be free of it. The therapist is kind of a vessel of freedom for that, and it’s a wonderful place. … You’re helping them overcome the bondage, pain and grief that’s been with them for so long.”

Putting personal feelings aside

Abortion remains one of the most politically and socially polarizing issues in modern-day America. Despite this — or, in some cases, because of this — certain clients are going to need to work through issues related to abortion in the counseling office. A practitioner’s role is to be a support through it all, regardless of his or her own personal views on the topic.

Brightup urges counselors to rely on their training, which includes setting personal opinions aside and being what the client needs.

Creating a neutral and welcoming space for clients to talk about such a sensitive topic is paramount, Johnson agrees. “If you don’t have any experience working in this area, you can do more damage without meaning to,” she says. “Or, for some people, there’s a hidden implication that if you help a client through feelings related to an abortion, you’re condoning abortion.” That is simply not true, she stresses.

Beckett agrees. “Clients need a safe and nonjudgmental space to share [about their abortion experience], and that’s hard for some counselors based on their own belief system. It’s not going to be easy for all counselors — that affirmation of [the client’s] right to grieve. [But] a client needs support to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

 

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Disclosing an innermost secret

As clients process post-abortion emotions, they may struggle with the decision to tell others, including a current or former partner. What should a counselor’s role be in that process? Read more in our online-exclusive article: wp.me/p2BxKN-54z

 

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Related resources

  • The upcoming ACA 2018 Conference & Expo in Atlanta includes an education session titled “Compassion and Self-compassion: Therapeutic Approaches to Heal From Grief and Loss” (Saturday, April 28, 7:30 a.m.). See the full conference program at counseling.org/conference.
  • For more on the mandate for counselors to practice competent, nonjudgmental care, refer to the 2014 ACA Code of Ethics at counseling.org/knowledge-center/ethics/code-of-ethics-resources. ACA members with specific questions can schedule a free ethics consultation by calling 800-347-6647 ext. 321 or emailing ethics@counseling.org.
  • Interested in networking with other ACA members on this and other related issues? ACA has interest networks that focus on women’s issues, grief and bereavement, sexual wellness and other topics. Find out more at counseling.org/aca-community/aca-groups/interest-networks.

 

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

Letters to the editorct@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.

 

Understanding and treating survivors of incest

By David M. Lawson March 6, 2018

Adults with histories of being abused as children present unique challenges for counselors. For instance, these clients often struggle with establishing and maintaining a therapeutic alliance. They may rapidly shift their notion of the counselor from very favorable to very unfavorable in line with concomitant shifts in their emotional states. Furthermore, they may anxiously expect the counselor to abandon them and thus increase pressure on the counselor to prove otherwise. Ironically, attempts at reassurance by the counselor may actually serve to validate these clients’ fears of abandonment.

The motivating factor for many of these clients is mistrust of people in general — and often for good reason. This article explores the psychological and interpersonal aspect of child sexual abuse by a parent and its treatment, with a particular focus on its relationship to betrayal trauma, dissociation and complex trauma.

Incest and its effects

Child abuse of any kind by a parent is a particularly negative experience that often affects survivors to varying degrees throughout their lives. However, child sexual abuse committed by a parent or other relative — that is, incest — is associated with particularly severe psychological symptoms and physical injuries for many survivors. For example, survivors of father-daughter incest are more likely to report feeling depressed, damaged and psychologically injured than are survivors of other types of child abuse. They are also more likely to report being estranged from one or both parents and having been shamed by others when they tried to share their experience. Additional symptoms include low self-esteem, self-loathing, somatization, low self-efficacy, pervasive interpersonal difficulties and feelings of contamination, worthlessness, shame and helplessness.

One particularly damaging result of incest is trauma bonding, in which survivors incorporate the aberrant views of their abusers about the incestuous relationship. As a result, victims frequently associate the abuse with a distorted form of caring and affection that later negatively influences their choice of romantic relationships. This can often lead to entering a series of abusive relationships.

According to Christine Courtois (Healing the Incest Wound: Adult Survivors in Therapy) and Richard Kluft (“Ramifications of incest” in Psychiatric Times), greater symptom severity for incest survivors is associated with:

  • Longer duration of abuse
  • Frequent abuse episodes
  • Penetration
  • High degree of force, coercion and intimidation
  • Transgenerational incest
  • A male perpetrator
  • Closeness of the relationship
  • Passive or willing participation
  • Having an erotic response
  • Self-blame and shame
  • Observed or reported incest that continues
  • Parental blame and negative judgment
  • Failed institutional responses: shaming, blaming, ineffectual effort
  • Early childhood onset

Incest that begins at a young age and continues for protracted periods — the average length of incest abuse is four years — often results in avoidance-based coping skills (for example, avoidance of relationships and various dissociative phenomena). These trauma-forged coping skills form the foundation for present and future interpersonal interactions and often become first-line responses to all or most levels of distress-producing circumstances.

More than any other type of child abuse, incest is associated with secrecy, betrayal, powerlessness, guilt, conflicted loyalty, fear of reprisal and self-blame/shame. It is of little surprise then that only 30 percent of incest cases are reported by survivors. The most reliable research suggests that 1 in 20 families with a female child have histories of father-daughter child sexual abuse, whereas 1 in 7 blended families with a female child have experienced stepfather-stepdaughter child sexual abuse (see the revised edition of The Secret Trauma: Incest in the Lives of Girls and Women by Diana E. H. Russell, published in 1999).

In 1986, David Finkelhor, known for his work on child sexual abuse, indicated that among males who reported being sexually abused as children, 3 percent reported mother-son incest. However, most incest-related research has focused on father-daughter or stepfather-stepdaughter incest, which is the focus of this article.

Subsequent studies of incest survivors indicated that being eroticized early in life disrupted these individuals’ adult sexuality. In comparison with nonincest controls, survivors experienced sexual intercourse earlier, had more sex partners, were more likely to have casual sex with those outside of their primary relationships and were more likely to engage in sex for money. Thus, survivors of incest are at an increased risk for revictimization, often without a conscious realization that they are being abused. This issue often creates confusion for survivors because the line between involuntary and voluntary participation in sexual behavior is blurred.

An article by Sandra Stroebel and colleagues, published in 2013 in Sexual Abuse: A Journal of Research and Treatment, indicates that risk factors for father-daughter incest include the following:

  • Exposure to parent verbal or physical violence
  • Families that accept father-daughter nudity
  • Families in which the mother never kisses or hugs her daughter (overt maternal affection was identified as a protective factor against father-daughter incest)
  • Families with an adult male other than the biological father in the home (i.e., a stepfather or substitute father figure)

Finally, some qualitative research notes that in limited cases, mothers with histories of being sexually abused as a child wittingly or unwittingly contribute to the causal chain of events leading to father-daughter incest. Furthermore, in cases in which a mother chooses the abuser over her daughter, the abandonment by the mother may have a greater negative impact on her daughter than did the abuse itself. This rejection not only reinforces the victim’s sense of worthlessness and shame but also suggests to her that she somehow “deserved” the abuse. As a result, revictimization often becomes the rule rather than the exception, a self-fulfilling prophecy that validates the victim’s sense of core unworthiness.

Beyond the physical and psychological harm caused by father-daughter incest, Courtois notes that the resulting family dynamics are characterized by:

  • Parent conflict
  • Contradicting messages
  • Triangulation (for example, parents aligned against the child or perpetrator parent-child alignment against the other parent)
  • Improper parent-child alliances within an atmosphere of denial and secrecy

Furthermore, victims are less likely to receive support and protection due to family denial and loyalty than if the abuser were outside the family or a stranger. Together, these circumstances often create for survivors a distorted sense of self and distorted relationships with self and others. If the incest begins at an early age, survivors often develop an inherent sense of mistrust and danger that pervades and mediates their perceptions of relationships and the world as a whole.

Betrayal trauma theory

Betrayal trauma theory is often associated with incest. Psychologist Jennifer Freyd introduced the concept to explain the effects of trauma perpetrated by someone on whom a child depends. Freyd holds that betrayal trauma is more psychologically harmful than trauma committed or caused by a noncaregiver. “Betrayal trauma theory posits that under certain conditions, betrayals necessitate a ‘betrayal blindness’ in which the betrayed person does not have conscious awareness or memory of the betrayal,” Freyd wrote in her book Betrayal Trauma: The Logic of Forgetting Childhood Abuse.

Betrayal trauma theory is based on attachment theory and is consistent with the view that it is adaptive to block from awareness most or all information about abuse (particularly incest) committed by a caregiver. Otherwise, total awareness of the abuse would acknowledge betrayal information that could endanger the attachment relationship. This “betrayal blindness” can be viewed as an evolutionary and nonpathological adaptive reaction to a threat to the attachment relationship with the abuser that thus explains the underlying dissociative amnesia in survivors of incest. Under these circumstances, survivors often are unaware that they are being abused, or they will justify or even blame themselves for the abuse. In severe cases, victims often have little or no memory of the abuse or complete betrayal blindness. Under such conditions, dissociation is functional for the victim, at least for a time.

Consider the case of “Ann,” who had been repeatedly and severely physically and sexually abused by her father from ages 4 to 16. As an adult, Ann had little to no memory of the abuse. As a result of the abuse, she had developed nine alternate identities, two of which contained vivid memories of the sexual and physical abuse. Through counseling, she was able to gain awareness of and access to all nine alternate identities and their functions.

Although Ann expressed revulsion and anger toward her father, she also expressed her love for him. At times, she would lapse into moments of regret for disclosing the abuse, saying that “it wasn’t so bad” and that the worst thing that had happened was that she had lost her “daddy.” During these moments, Ann minimized the severity of the abuse, wishing that she had kept the incest secret so that she could still have a relationship with her father. This was an intermittent longing for Ann that occurred throughout counseling and beyond.

Thus, understanding attachment concepts is critical for understanding betrayal traumas such as incest. Otherwise, counselors might be inclined to blame survivors or might feel confused and even repulsed by survivors’ behaviors and intentions. For many survivors, the caregiver-abuser represents the best and the worst of her life at various times. She needs empathy and support, not blame.

Dissociation

As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, dissociation is “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, perception, body representation, motor control and behavior.” Depending on the severity of the abuse, dissociative experiences can interfere with psychological functioning across the board. Survivors of incest often experience some of the most severe types of dissociation, such as dissociative identity disorder and dissociative amnesia (the inability to recall autobiographical information). Dissociative experiences often are triggered by perceived threat at a conscious or unconscious level.

As previously noted, betrayal trauma theory holds that for incest survivors, dissociative amnesia serves to maintain connection with an attachment figure by excluding knowledge of the abuse (betrayal blindness). This in turn reduces or eliminates anxiety about the abuse, at least in the short run. Conversely, many survivors of childhood incest report continuous memories of the abuse, as well as the anxiety and felt terror related to the abuse. Often, these individuals will find a way to leave their homes and abusers. This is less frequently the case for survivors who experience dissociative amnesia or dissociative identity disorder.

Depersonalization and derealization distort the individual’s sense of self and her sensory input of the environment through the five senses. For example, clients who have experienced incest often report that their external world, including people, shapes, sizes, colors and intensities of these perceptions, can change quickly and dramatically at times. Furthermore, they may report that they do not recognize themselves in a mirror, causing them to mistrust their own perceptions.

As one 31-year-old incest survivor stated, “For so many years, everything within me and around me felt and looked unreal, dull, dreary, fragmented, distant.” This is an example of depersonalization/derealization. She continued, “This, along with the memory gaps, forgetfulness and inability to recall simple everyday how-tos, like how to drive a car or remember the step-by-step process of getting ready for the day, made me feel crazy. But as I improved in counseling, my perceptions of my inside and outside worlds became clearer, more stable, and brighter and more distinct than before counseling. It all came to make more sense and feel right. It took me years to see the world as I think other people see it. From time to time I still experience that disconnection and confusion, but so much less frequently now than before.”

Initially, some real or perceived threat triggers these distorted perceptions of self and outer reality, but eventually they become a preset manner of perceiving the world. Reports such as this one are not uncommon for survivors of incest and often are exacerbated as these individuals work through the process of remembering and integrating trauma experiences into a coherent life narrative. For many survivors, a sense of coherence and stability is largely a new experience; for some, it can be threatening and trigger additional dissociative experiences. The saying “better a familiar devil than an unfamiliar angel” seems to apply here.

The severity of dissociation for survivors of incest is related to age onset of trauma exposure and a dose-response association, with earlier onset, more types of abuse and greater frequency of abuse associated with more severe impairment across the life span. Incest is associated with the most severe forms of dissociative symptoms such as dissociative identity disorder. Approximately 95 to 97 percent of individuals with dissociative identity disorder report experiencing severe childhood sexual and physical abuse.

Fragmentation in one’s sense of self, accompanied by amnesia of abuse memories, is particularly functional when children cannot escape the abuse circumstances. These children are not “present” during the abuse, so they often are not aware of the physical and emotional pain associated with the abuse. Yet this fragmented sense of self contributes to a sense of emptiness and absence, memory problems and dissociative self-states. Many survivors of incest are able to “forget” about the abuse until sometime later in adulthood when memories are triggered by certain events or when the body and mind are no longer able to conceal the memories. The latter results from the cumulative effect of lifelong struggles related to the incest (for example, interpersonal problems and emotional dysregulation). It takes a great deal of psychological and physical resources to “forget” trauma memories.

Dissociation, especially if it involves ongoing changes in perceptions of self and others, different presentations of self and memory problems, may result in difficulty forming and maintaining a therapeutic alliance. Dissociation disrupts the connection between the client and the counselor. It also disrupts clients’ connections with their inner experience. If these clients do not perceive themselves and their surroundings as stable, they will mistrust not only their counselors but also their own perceptions, which create ongoing confusion.

Thus, counselors must remain alert to subtle or dramatic fluctuations in survivors’ presentation styles, such as changes in eye contact or shifts in facial features from more engaged and animated to flat facial features. Changes in voice tone quality and cadence (from verbally engaged to silent) or in body posture (open versus closed) are other signs of possible dissociative phenomena. Of course, all or none of these changes may be indicators of dissociative phenomena.

Complex trauma

Incest, betrayal trauma and dissociative disorders are often features of a larger diagnostic categorization — complex trauma. Incest survivors rarely experience a single incident of sexual abuse or only sexual abuse. It is more likely that they experience chronic, multiple types of abuse, including sexual, physical, emotional and psychological, within the caregiving system by adults who are expected to provide security and nurturance.

Currently, an official diagnostic category for complex trauma does not exist, but one is expected to be added to the revised International Classification of Diseases (ICD-11) that is currently in development. Marylene Cloitre, a member of the World Health Organization ICD-11 stress and trauma disorders working group, notes that the new complex trauma diagnosis focuses on problems in self-organization resulting from repeated/chronic exposure to traumatic stressors from which one cannot escape, including childhood abuse and domestic violence. Among the criteria she highlighted for complex trauma are:

  • Disturbances in emotions: Affect dysregulation, heightened emotional reactivity, violent outbursts, impulsive and reckless behavior, and dissociation.
  • Disturbances in self: Defeated/diminished self, marked by feeling diminished, defeated and worthless and having feelings of shame, guilt or despair (extends despair).
  • Disturbances in relationships: Interpersonal problems marked by difficulties in feeling close to others and having little interest in relationships or social engagement more generally.
    There may be occasional relationships, but the person has great difficulty maintaining them.

Early onset of incest along with chronic exposure to complex trauma contexts interrupts typical neurological development, often leading to a shift from learning brain (prefrontal cortex) to survival brain (brainstem) functioning. As explained by Christine Courtois and Julian Ford, survivors experience greater activation of the primitive brain, resulting in a survival mode rather than activation of brain structures that function to make complex adjustments to the current environment. As a result, survivors often exhibit an inclination toward threat avoidance rather than being curious and open to experiences. Complex trauma undermines survivors’ ability to fully integrate sensory, emotional and cognitive data into an organized, coherent whole. This lack of a consistent and coherent sense of self and one’s surroundings can create a near ever-present sense of confusion and disconnection from self and others.

Regular or intermittent complex trauma exposure creates an almost continual state of anxiety and hypervigilance and the intrinsic expectation of danger. Incest survivors are at an increased risk for multiple impairments, revictimization and loss of support.

Treatment issues

Although a comprehensive description of treatment is well beyond the scope of this article, I will close with a general overview of treatment concepts. Treatment for incest parallels the treatment approaches for complex trauma, which emphasizes symptom reduction, development of self-capacities (emotional regulation, interpersonal relatedness and identity), trauma processing and the addressing of dissociative experiences.

Compromised self-capacities intensify symptom severity and chronicity. Among these self-capacities, emotional dysregulation is a major symptom cluster that affects other self-capacity components. For example, if a survivor consistently struggles with low frustration tolerance for people and copes by avoiding people, responding defensively, responding in a placating manner or dissociating, she likely will not have the opportunity to develop fulfilling relationships. The following core concepts, published in the May 2005 Psychiatric Annals, were suggested by Alexandra Cook and colleagues for consideration when implementing a treatment regimen for complex trauma, including with incest survivors and with adaptations for clients with dissociative identity disorder.

1) Safety: Develop internal and environmental safety procedures.

2) Self-regulation: Enhance the capacity to moderate and rebalance arousal across the areas of affective state, behavior, physiology, cognition, interpersonal relatedness and self-attribution.

3) Self-reflective information processing: Develop the ability to focus attentional processes and executive functioning on the construction of coherent self-narratives, reflecting on past and present experience, anticipation and planning, and decision-making.

4) Traumatic experiences integration: Engage in resolution and integration of traumatic memories and associated symptoms through meaning making, traumatic memory processing, remembrance and mourning of traumatic loss, development of coping skills, and fostering present-oriented thinking and behavior.

5) Relational engagement: Repair, restore or create effective working models of attachment and application of these models to current interpersonal relationships, including the therapeutic alliance. Emphasis should be placed on development of interpersonal skills such as assertiveness, cooperation, perspective taking, boundary and limit setting, reciprocity, social empathy and the capacity for physical and emotional intimacy.

6) Positive affect enhancement: Work on the enhancement of self-worth, self-esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery seeking, community building and the capacity to experience pleasure.

Typically, these components are delivered within a three-phase model of counseling that is relationship-based, cognitive behavioral in nature and trauma focused:

  • Safety, self-regulation skill development and alliance formation
  • Trauma processing
  • Consolidation

The relational engagement component is particularly critical because for many survivors, to be attached often has meant to be abused. Furthermore, accompanying feelings of shame, self-loathing and fear of abandonment create a “failure identity” that results in low expectations for change. Additionally, it is important for counselors to attend to client transference issues and counselor countertransference issues. Courtois suggests that ignoring or assuming that such processes are irrelevant to the treatment of survivors can undermine the treatment process and outcome.

In addition, strength-based interventions are critical in each phase to help survivors develop a sense of self-efficacy and self-appreciation for the resources they already possess. A strength-based focus also contributes to client resilience.

For some clients, dissociated self-states or parts will emerge. Counselors should assume that whatever is said to one part will also be heard by the other parts. Therefore, addressing issues in a manner that encourages conversation between parts, including the core self-structure, is critical. It is also important to help parts problem-solve together and support each other. This is not always an easy proposition. A long-term goal would be some form of integration/fusion or accord among alternate identities. Some survivors eventually experience full unification of parts, whereas others achieve a workable form of integration without ever fully unifying all of their alternate identities (for more, see Treating Trauma-Related Dissociation: A Practical, Integrative Approach by Kathy Steele, Suzette Boon and Onno van der Hart).

Finally, it must be mentioned that repeated exposure to horrific stories of incest can overwhelm counselors’ capacity to maintain a balanced relationship with clear boundaries. A client’s transference can push the boundaries of an ethical and therapeutic client-counselor relationship. Furthermore, the frequent push-pull dynamics between counselor and client can be exhausting, both physically and mentally for counselors. Therefore, it is important for counselors to frequently seek supervision and consultation and to engage in self-care physically, psychologically and spiritually.

 

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

David M. Lawson is a professor of counselor education and director of the Center for Research and Clinical Training in Trauma at Sam Houston State University. His research focuses on childhood sexual and physical abuse, complex trauma and dissociation related to trauma. He also maintains an independent practice focusing on survivors of posttraumatic stress disorder and complex trauma. Contact him at dml3466@aol.com.

Letters to the editorct@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.

 

Talking through the pain

By Laurie Meyers January 30, 2018

By the time the 43-year-old man, a victim of an industrial accident, limped into American Counseling Association member David Engstrom’s office, he’d been experiencing lower back pain for 10 years and taking OxyContin for six. The client, whose pain was written in the grimace on his face as he sat down, was a referral from a local orthopedic surgeon, who was concerned about the man’s rapidly increasing tolerance to the drug.

“He often took twice the prescribed dose, and the effect on his pain was diminishing,” says Engstrom, a health psychologist who works in integrated care centers.

The man’s story is, unfortunately, not unusual. According to the National Institutes of Health, 8 out of 10 adults will experience lower back pain at some point in their lives. As the more than 76 million baby boomers continue to age, many of them will increasingly face the aches and pains that come with chronic health issues. And as professional counselors are aware, mental health issues such as depression, anxiety and addiction can also cause or heighten physical pain.

Those who suffer from chronic pain are often in desperate need of some succor, but in many cases, prescription drug treatments or surgery may be ineffective or undesirable. Fortunately, professional counselors can often help provide some relief.

Treating chronic pain

At first, the client had only one question for Engstrom: “I’m not crazy, so why am I here?”

Although the man’s physician did not think that the pain was all in the man’s head, it is not uncommon for sufferers of chronic pain to encounter skepticism about what they are experiencing. “It was important … to defuse the idea that I might think he was imagining his pain,” Engstrom says. “So I [told him] that I accepted that his pain was real and that all pain is experienced from both body and mind. I told him that we would be a team and work on this together.”

Engstrom and the client worked together for five months. As they followed the treatment plan, the man’s physician slowly eased him off of the OxyContin.

Engstrom began by teaching the client relaxation exercises such as progressive muscle relaxation. “When in pain, the natural inclination of the body is to contract muscles,” Engstrom explains. “In the long term, this reduces blood flow to the painful area and slows the healing process. Contracted muscles can be a direct source of pain.”

Engstrom also began using biofeedback to promote further relaxation. In biofeedback sessions, sensors are attached to the body and connected to a monitoring device that measures bodily functions such as breathing, perspiration, skin temperature, blood pressure, muscle tension and heartbeat.

“When you relax, clear your mind and breathe deeply, your breathing slows and your heart rate dips correspondingly,” Engstrom explains. “As the signals change on the monitors, you begin to learn how to consciously control body functions that are normally unconscious. For many clients, this sense of control can be a powerful, liberating experience.”

As Engstrom’s client learned to control his responses, he began reporting a decrease in pain following the relaxation exercises.

Engstrom also used cognitive behavior therapy (CBT) methods, including asking the man to keep a daily journal recording his pain level at different times of the day, along with his activity and mood. Through the journal, the man started recognizing that his pain level wasn’t constant. Instead, it varied and was influenced by what he was doing and thinking at the time.

Engstrom highly recommends CBT for pain treatment because it helps provide pain relief in several ways. “First, it changes the way people view their pain,” he says. “CBT can change the thoughts, emotions and behaviors related to pain, improve coping strategies and put the discomfort in a better context. You recognize that the pain interferes less with your quality of life and, therefore, you can function better.”

In this case, the client was trapped by thoughts that “the pain will never go away” and “I’ll end up a cripple,” Engstrom says. He and the client worked on CBT exercises for several months, keeping track of and questioning the validity of such negative future thoughts. They also practiced substituting more helpful thoughts, including “I will take each day as it comes” and “I will focus on doing the best I can today.”

Chronic pain often engenders a sense of helplessness among those who experience it, Engstrom says, so CBT also helps by producing a problem-solving mindset. When clients take action, they typically feel more in control of their pain, he says.

CBT also fosters new coping skills, giving clients tools that they can use in other parts of their lives. “The tactics a client learns for pain control can help with other problems they may encounter in the future, such as depression, anxiety or stress,” Engstrom says.

Because clients can engage in CBT exercises on their own, it also fosters a sense of autonomy. Engstrom often gives clients worksheets or book chapters to review at home, allowing them to practice controlling their pain independently.

Engstrom notes that CBT can also change the physical response in the brain that makes pain worse. “Pain causes stress, and stress affects pain-control chemicals in the brain, such as norepinephrine and serotonin,” he explains. “By reducing arousal that impacts these chemicals, the body’s natural pain-relief responses may become more powerful.”

Although Engstrom acknowledges that he could not completely banish the discomfort his client felt, he was able to lessen both the sensation and perception of the man’s pain and give him tools to better manage it.

Taking away pain’s power

Mindfulness is another powerful tool for lessening the perception of pain, says licensed professional counselor (LPC) Russ Curtis, co-leader of ACA’s Interest Network for Integrated Care.

Mindfulness teaches the art of awareness without judgment, meaning that we are aware of our thoughts and feelings but can choose the ones we focus on, Curtis continues. He gives an example of how a client might learn to regard pain: “This is pain. Pain is a sensation. And sensations tend to ebb and flow and may eventually subside, even if just for a little while. I’ll breathe and get back to doing what is meaningful to me.”

Engstrom agrees. Unlike traditional painkillers, mindfulness is not intended to dull or eliminate the pain. Instead, when managing pain through the use of mindfulness-based practices, the goal is to change clients’ perception of the pain so that they suffer less, he explains.

“Suffering is not always related to pain,” Engstrom continues. “A big unsolved puzzle is how some clients can tolerate a great deal of pain without suffering, while others suffer with relatively smaller degrees of pain.”

According to Engstrom, the way that people experience pain is related not just to its intensity but also to other variables. Some of these variable include:

  • Emotional state: “I am angry that I am feeling this way.”
  • Beliefs about pain: “This pain means there’s something seriously wrong with me.”
  • Expectations: “These painkillers aren’t going to work.”
  • Environment: “I don’t have anyone to talk to about how I feel.”

By helping people separate the physical sensation of pain from its other less tangible factors, mindfulness can reduce the suffering associated with pain, even if it is not possible to lessen its severity, Engstrom says.

According to Engstrom, mindfulness may also improve the psychological experience of pain by:

  • Decreasing repetitive thinking and reactivity
  • Increasing a sense of acceptance of unpleasant sensations
  • Improving emotional flexibility
  • Reducing rumination and avoidant behaviors
  • Increasing a sense of acceptance of the present moment
  • Increasing the relaxation response and decreasing stress

Curtis, an associate professor of counseling at Western Carolina University in North Carolina, suggests acceptance and commitment therapy (ACT) as another technique to help guide clients’ focus away from their pain.

“ACT can help people revisit what their true values are, whether it’s being of service, having a great family life or creating art,” he notes. Encouraging clients to identify and pursue what is most important to them helps ensure that despite the pain they feel, they are still engaging in the things that give their lives meaning and not waiting for a cure before moving forward, Curtis explains.

Teamwork and support

In helping clients confront chronic pain, Curtis says, counselors should not forget their most effective weapon — the therapeutic relationship. Because living with chronic pain can be very isolating, simply sitting with clients and listening to their stories with empathy is very powerful, he says.

Counselors have the opportunity to provide the validation and support that clients with chronic pain may not be getting from the other people in their lives, says Christopher Yadron, an LPC and former private practitioner who specialized in pain management and substance abuse treatment. The sense of shame that often accompanies the experience of chronic pain can add to clients’ isolation, he says. According to Yadron, who is currently an administrator at the Betty Ford Center in Rancho Mirage, California, clients with chronic pain often fear that others will question the legitimacy of their pain — for instance, whether it is truly “bad enough” for them to need extended time off from work or to miss social occasions.

Curtis says it is important for counselors to ensure that these clients understand that the therapeutic relationship is collaborative and equal. That means that rather than simply throwing out solutions, counselors need to truly listen to these clients. This includes asking them what other methods of pain relief they have tried — such as supplements, over-the-counter painkillers, physical therapy, yoga or swimming — and what worked best for them, Curtis says.

The U.S. health care system has led many people to believe that there is a pill or surgery for every ailment, Curtis observes. This makes the provision of psychoeducation essential for clients with chronic pain. “Let them know there’s no magic bullet,” he says. Instead, he advises that counselors help clients see that relief will be incremental and that it will be delivered via multiple techniques, usually in conjunction with a team of other health professionals such as physicians and physical therapists.

Curtis, Yadron and Engstrom all agree that counselors should work in conjunction with clients’ other health care providers when trying to address the issue of chronic pain. Ultimately, however, it may be up to the counselor to put the “whole picture” together.

A 60-something female client with severe depression was referred to Engstrom from a pain clinic, where she had been diagnosed and treated for fibromyalgia. After an assessment, Engstrom could see that the woman’s depression was related to continuing pain, combined with social isolation and poor sleep patterns. The woman was unemployed, lived alone and spent most of her day worrying about whether her pain would get any better. Some of her previous doctors had not believed that fibromyalgia was a real medical concern and thus simply had dismissed her as being lonely and depressed. Despite finally receiving treatment for her fibromyalgia, the woman was still in a lot of pain when she was referred to Engstrom.

Engstrom treated the woman’s depression with CBT and taught her to practice mindfulness through breathing exercises and being present. Addressing her mood and sleep problems played a crucial role in improving her pain (insomnia is common in fibromyalgia). By dismissing the woman’s fibromyalgia diagnosis, discounting the importance of mood and not even considering the quality of her sleep, multiple doctors had failed to treat her pain.

Engstrom points out that in this case and the case of his client with lower back pain, successful treatment hinged on cognitive and behavioral factors — manifestations of pain that medical professionals often overlook.

 

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

Letters to the editor: ct@counseling.org

 

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

 

Food for thought

By Laurie Meyers January 25, 2018

With January now behind us, the annual barrage of diet and fitness commercials has started to fade. Many people who made New Year’s resolutions to lose weight or “get fit” have already labeled themselves failures for indulging on leftover holiday chocolate and not making it to the gym more than twice per week. Other determined warriors in the fight to attain the perfect size and shape may stick to their resolutions and lose the desired amount of weight, only to find that they’ve gained it all back (and then some) within six months. This cycle of dieting and weight loss, followed by weight gain, is a process that many Americans go through over and over again, often in search of an unattainable or unsustainable ideal.

“The primary message we get from popular culture is that our worth is based on our appearance and the ability to achieve a thin and beautiful cultural ideal,” says Laura H. Choate, editor of the book Eating Disorders and Obesity: A Counselor´s Guide to Treatment and Prevention, published by the American Counseling Association. “When individuals internalize this message — that they are only worthwhile or acceptable if they are able to achieve this ideal — they develop a negative body image, which can lead to dieting and disordered eating behaviors.”

According to the National Eating Disorders Association, in the United States, approximately 20 million women and 10 million men will struggle with a clinically significant eating disorder at some point in their lives. Experts say that many millions more will engage in disordered eating — patterns of behavior that resemble those of eating disorders but which do not meet clinical criteria. Symptoms of disordered eating may include chronic dieting, frequent weight fluctuations, extremely rigid and unhealthy food and exercise regimens, emotional eating and a preoccupation with food, body and weight issues that causes distress.

Ashamed to eat?

Licensed mental health counselor Tamara Duarte, a private practitioner in the Vancouver, Washington, area who specializes in treating women with eating disorders and body and food issues, says that we live in a culture that has normalized chronic dieting. She refers to this phenomenon as the “dieting roller coaster.”

Women come to Duarte, an ACA member, having spent years pingponging back and forth between restrictive diets and binge eating. After attempting to limit their consumption only to “good” food, these clients have typically fallen off of their diet wagon and ended up in a binge cycle, during which they eat all of the foods they consider “bad,” Duarte explains. Feeling guilty, the women go back to dieting and start the cycle all over again.

Duarte also sees clients who have gained weight as they have aged and want to get their former bodies back — even if it is through unhealthy means. “People come in and tell me that they used to have a restrictive eating disorder and wish they could go back to that time so that they could be thin,” Duarte says.

What all of these clients have in common is a sense of shame about food and their bodies, Duarte says. Fear of being or becoming fat is so prevalent in our society that this shame has become normalized, she says. The irony is that much of the research has found that dieting ultimately leads to weight gain, Duarte notes. Chronic dieting (even at a subclinical level) may even be harmful to the body, and Duarte and other eating disorder experts say that the benefit of weight loss through dieting is unclear.

Like many who study or treat disordered eating and eating disorders, Duarte wants to remove the stigma attached to different-sized bodies. “Fat is just an adjective,” she says.

Part of breaking free of disordered eating — and eating disorders — is learning body acceptance, Duarte says. “Helping a person to accept their body as is can be a very slow, complex process,” she admits.

“I read something posted on Instagram once that said, ‘You cannot obtain recovery while actively trying to change the size and shape of your body,’” Duarte continues. “I really liked that, and I introduce that very early on in the counseling process. Throughout counseling, we look at the beliefs the client has about their body and where those stem from. Typically, thoughts like ‘I’m ugly and unlovable in this body’ stem from society or family members. It’s interesting because none of my clients so far have thought others are unlovable because of their body size, so I question what makes them different. We also look at how screwed up society is for picking one body size as being beautiful and acceptable. With a recovering mind, they are able to recognize how erroneous these thoughts are.”

Duarte also asks clients to get rid of their scales. “Not relying on an arbitrary number to tell them whether they are ‘good’ or ‘bad’ frees them up to connect in with themselves to figure out how they are feeling,” she explains.

Intuitive eating and Health at Every Size

Duarte has personal experience both with eating disorders and the power of that “arbitrary number.” She had been in recovery for more than 10 years when she happened to gain about 45 pounds because of some medication she was taking. Uncomfortable in her new body size, Duarte was ready to put herself on a diet and workout regimen. But then she attended some seminars on intuitive eating, an approach created by dietitian Evelyn Tribole and nutrition therapist Elyse Resch, both of whom specialize in eating disorders. Intuitive eating rejects dieting. Instead, it advocates listening to the body’s signals of hunger and fullness and getting rid of the idea of “good” and “bad” foods, among other principles.

Duarte also learned about Health at Every Size (HAES), a program and social movement inspired by the book written by Linda Bacon, a nutrition professor and researcher. HAES advocates the acceptance of bodies of all sizes, rejects dieting and calls for addressing health concerns directly with healthy behaviors. Both intuitive eating and HAES also encourage physical activity in whatever form a person naturally enjoys.

“I immediately recognized the power of teaching IE [intuitive eating] and HAES to clients,” Duarte says. “Both HAES and IE teach that when you listen to your body and feed it what it wants, when it wants, how much it wants, your body will naturally go to its set point range — the weight range where it works optimally. HAES tells me that I am OK no matter what my body looks like and that I can love and accept it right now.”

After learning about intuitive eating and HAES, Duarte started following the principles found in each approach. “At that point, I had a laundry list of good foods and bad foods, so I did the work to incorporate my ‘bad’ foods back into my diet,” she says. “An incredible thing happened: As I allowed myself to want and have these foods, the power they used to hold went away. Pizza was pizza. In the past, I would not allow myself pizza, and if I did decide to allow it, I would eat like five pieces because it tasted so good and I was telling myself I wouldn’t have it again. When pizza became accessible, I realized I only wanted one or two slices, and then I was able to step away because I knew that the next time I wanted pizza — in 10 minutes or 10 days — I would be able to eat it.”

Duarte also realized that although she enjoyed going to the gym, the activity she loved best was going on walks with her dog. So, instead of carving out time to devote to workouts, she started spending more time walking her dog.

“I really enjoy my walks when I go on them, and I am kind to myself when life gets busy and I can’t or don’t want to fit them in,” she says. “I no longer berate myself because the walks are for self-care, not to manipulate the size and shape of my body. I enjoy the array of foods I eat. I love opening a menu and deciding based on what I want instead of what I ‘should have.’ I never thought I would have this kind of relationship with food or my body.”

For those who might wonder whether Duarte lost weight, she responds that it doesn’t matter because her body shape and size have no bearing on her happiness or success.

Combating body hatred

Knowing from personal experience that intuitive eating and HAES can be very effective, Duarte now incorporates the approaches into her counseling work. “Every single client that calls my office for a free consultation ends up telling me that what they want most from counseling is freedom,” she says. “Freedom from the eating disorder, the never-ending thoughts about weight and food, freedom from self-hatred. I know that HAES and IE [are huge pieces] of the puzzle when it comes to freedom.”

“I don’t have to tell my clients about my experience with HAES and IE,” she continues. “I just have it with me when I am helping to guide them through it. It influences the way I feel and think about my clients’ bodies as well. I do not hold judgments about people’s bodies because of what I have learned in my journey, and my clients know I don’t judge them. When I tell my clients that their body is acceptable no matter what it looks like, I mean it, and they know it.”

Duarte discusses how HAES and intuitive eating helped guide her treatment of a teenage client she calls “Sara,” who was restricting her food intake and using exercise and vomiting to purge. “Sara believed that her body was wrong and ugly because it didn’t look like her family members, who were taller and built leaner than she was,” Duarte says. “One of the first things I had Sara do was put her scale away in a place that she wouldn’t have easy access to.”

Duarte introduced Sara to intuitive eating and its philosophy that foods should neither be demonized nor celebrated. Sara was particularly resistant to this concept, but Duarte successfully encouraged Sara to slowly add “forbidden foods” back into her diet.

Duarte also used mindfulness to help Sara with her purging behavior. “We worked on mindfulness, so she was able to identify when the urge to purge was coming on,” Duarte says. “She would write down for me everything that she was thinking — why she wanted to purge and why she didn’t.”

The urges would usually pass, and over time, Sara was able to get through them by using tools she had learned in session. Duarte teaches all of her clients distraction and self-soothing skills drawn from dialectical behavior therapy. Examples of distraction activities include dancing to a favorite song, writing or drawing, calling or texting a friend and going for a walk or a drive. Self-soothing might involve clients taking a shower, painting their fingernails (an activity that Duarte says is great for people with bulimia because they can’t induce vomiting with wet nails) or giving themselves a foot massage.

With time — and the help of the tools she had learned — Sara no longer experienced urges to purge. It took awhile for Sara to grow comfortable with her body, but she began to enjoy the increasing sense of physical strength that came from no longer restricting her food intake, Duarte says. Over time, that physical feeling of strength also became psychological.

“She struggles from time to time with not liking how she looks, but she’s able to identify what’s really going on at those times,” Duarte says. “Typically, Sara is stressed or scared, and instead of feeling [that], she focuses on her body and her need to change it. [But now] she uses the tools we have worked on in session, and she feels her feelings effectively, and most often, the body hatred goes away too.”

Alternatives to emotional eating

Licensed professional counselor Rachael Parkins is a practitioner at the Bucks Eating Support Collaborative in Bucks County, Pennsylvania, where she currently runs a support and therapy group for emotional eating. The group meets weekly and serves as a place for women to share their challenges, support one another and get professional guidance from Parkins. Group members may be struggling with a variety of concerns, but food is their common method of coping with emotions and issues such as stress, insecurity, self-esteem and body image, Parkins explains. Most of the women are working with a dietitian, and group members also have access to an intuitive eating coach.

The goal of the group is to learn how to handle emotions in a healthy way by working on methods such as distress tolerance. Group participants identify distressing emotions, such as loneliness, and Parkins helps them identify alternative ways to cope with what they’re feeling. Sometimes, this can be as simple as group members going out of their way to be kind to themselves and practice self-care, such as putting on lotion or taking a bubble bath. Other methods are more concrete, such as journaling or completing a decatastrophizing worksheet. In that case, participants write down their worst thoughts, evaluate the worst-case scenario and the likelihood of it happening, and identify other possible outcomes.

Parkins also encourages group members to acknowledge the small victories they experience in pursuit of their personal goals by recording them in a log. For example, a group member might state a goal of practicing better self-care. For this particular group member, an action such as getting out of bed and taking a shower might represent a small victory. Another participant might want to stop procrastinating. Calling to set up a doctor’s visit could be a small victory, even if the group member doesn’t keep the appointment.

Parkins also helps group members break free of comparisons, both with other people and themselves. She explains that participants regularly hold themselves and how they look up not only to the perceived “successes” of others in their lives, but also to their own past selves. Parkins says it is not uncommon for group members to express a desire to go back in time to when they were thinner, even if it was a miserable point in their lives.

“They have this idea in their head that if they get to this size or number on the scale, that’s going to bring happiness,” she says. “Losing weight might be desirable, but as an emotional focus, it’s never enough. I’m helping people accept that losing weight is not the answer.”

Signs of a problem

Although not every client who diets is engaging in disordered eating, counselors should regularly assess for eating and body issues, says Choate, a professor of counselor education at Louisiana State University.

“We know that a large proportion of the population experiences problems related to eating and negative body image, so it is reasonable for counselors to assess for these issues with all of their clients,” she says. “Because clients with eating-related problems might come to counseling with other issues — depression, anxiety, relational problems — asking questions specifically related to eating patterns and body image is a good way to explore to see if these problems are contributing in any way to the client’s presenting issues.”

Choate suggests asking the following questions:

  • Is the disordered eating pattern causing problems in the person’s life?
  • Does the disordered eating pattern interfere with the person’s relationships with others? With the enjoyment of life activities? With completing daily routines?
  • Does the client’s weight, shape or appearance unduly influence self-esteem?
  • Does the client believe that she or he is less acceptable if weighing a few pounds more than in the past or, conversely, that she or he is more acceptable if weighing a few pounds less?

When assessing clients for signs of an eating disorder, Duarte says, it is essential that counselors not be misled by the stereotypical presentation of extreme thinness. The stigma attached to larger bodies often can obscure the reality that eating disorders may occur in people of all sizes, she says. In part because our society generally expects that people who do not fit into an idealized size range want and need to lose weight, counselors may be less likely scrutinize dieting behavior and weight loss in larger clients. Like Choate, Duarte believes that counselors should assess all clients for signs of disordered eating.

Choate also offers one final caution for counselors. “While there are some eating-related problems that might respond well to counseling alone, it is important to be aware that eating disorders are chronic, and anorexia in particular has the highest mortality rate of any psychiatric disorder. Treatment of these disorders requires specialized knowledge and training, and because eating disorders all involve a medical component, the involvement of a multidisciplinary treatment team is required. This would include, at minimum, a physician or medical professional, a dietitian and the counselor.”

 

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Defining eating disorders: Changes in diagnosis

Laura H. Choate notes that in the past, most individuals with eating disorders fell into the diagnostic criteria of eating disorders not otherwise specified (EDNOS), which led to changes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

The criteria for anorexia nervosa and bulimia nervosa were expanded to include more people. Binge eating disorder was added as a stand-alone disorder (rather than remaining as previously listed as a subcategory under EDNOS). EDNOS was renamed “other specified feeding or eating disorder” and includes issues such as:

  • Atypical anorexia nervosa: All criteria for anorexia nervosa are met; despite significant weight loss, the individual’s weight is within or above the normal range.
  • Bulimia nervosa of low frequency or limited duration
  • Binge eating disorder of low frequency or limited duration
  • Purging disorder
  • Night eating syndrome

 

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Multicultural considerations

Although often perceived as a “white” problem, eating disorders and disordered eating do occur among women and men of color, says Regine Talleyrand, an American Counseling Association member whose research focuses on eating disorders among women of color.

“Counselors should be aware that women of color do experience concerns regarding beauty and body esteem,” she says. “[However], the traditional methods of evaluating these factors — weight, body parts, preoccupation with thin body ideals — may not capture the real body appearance concerns of all women of color.” Talleyrand, an associate professor and coordinator of the counseling and development program at George Mason University in Virginia, says that characteristics such as hair, skin color and facial features may be more relevant when evaluating body image in women of color.

In addition, high rates of obesity and binge eating among Latina and African American women highlight the need to look beyond “traditional” eating disorders such as anorexia and bulimia when working with women of color who struggle with eating, weight or body issues, Talleyrand says. Because African American and Latina women are even more likely than white women to display eating disorder symptoms at any size, counselors who are evaluating clients of color for disordered eating should also look beyond the stereotypical underweight image, she emphasizes.

Of course, the factors influencing the risk of eating disorders in all populations go beyond appearance. These factors are often culturally specific. In particular, racism and oppression may play a significant part in eating disorder risk among Latina and African American women, Talleyrand says. In fact, the development of eating disorder symptoms — particularly binge eating — has been linked to racism and oppression experienced by African American women, she adds.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Eating Disorders and Obesity: A Counselor´s Guide to Treatment and Prevention, edited by Laura H. Choate

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Anorexia Nervosa” by Shannon L. Karl

Journal articles (counseling.org/publications/counseling-journals)

  • “Special Section: Assessment, Prevention and Treatment of Eating Disorders: The Role of Professional Counselors,” Journal of Counseling & Development, July 2012

 

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

Letters to the editor:ct@counseling.org

 

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

Helping female clients reclaim sexual desire

By Alicia Muñoz October 2, 2017

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

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

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

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

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

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

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

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

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

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

Interventions

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

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

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

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

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

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

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

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

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

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

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

A shift in attitude

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

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

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

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

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

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

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

Untapped potential

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

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

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

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

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

1) Take continuing education courses on sexuality.

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

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

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

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

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

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

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

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

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

 

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

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to 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.