Not Getting Clean: It’s A Killer

  • May 3, 2013 12:15 pm

In his recent book Clean, author David Sheff writes about addiction treatment and why it fails to help so many addicts. The idea for the book came out of his struggles helping his son with his addiction, which led to further research on the state of addiction treatment in the U.S. In a recent article on Time.com, he started his article by stating that:

“Every year in the U.S., 120,000 people die of addiction. That’s 350 a day.”

He goes on to write that “A growing body of evidence has proved that addiction isn’t a choice subject to willpower but a brain disease that’s chronic, progressive and often fatal.” He then writes that in spite of this, there are a shocking number of treatment programs which do not use techniques that are based on research on effectiveness. He writes that it is crucial that people need to find and utilize these programs which “use therapies that have proved effective in clinical trials, including cognitive-behavioral therapy designed to train addicts to recognize and interrupt the cues that trigger the relapse mechanism; motivational interviewing, a therapy approach widely used to treat many psychological disorders that helps addicts engage in treatment; contingency management, which essentially rewards addicts for clean time; and psychopharmacology.” These treatment programs can also include “alternative” therapies that have been proven effective, such as meditation, acupuncture, and animal-assisted therapy.

Importantly, he goes on to say that “most researchers agree that no single therapy is appropriate for every addict. Often they’re used in concert. An effective treatment regimen may include AA, but only for those patients who are open to it.”

One of the most important points that he makes is about how unregulated rehabilitation is, and how widely the programs vary.  He writes:

Currently there’s a chasm between these and other evidence-based treatments (EBTs) and rehab programs. Every day addicts fall into it, and many never make it out. Most people in need find themselves in the same frustrating position I was in when I was desperate and overwhelmed, shopping for programs and doing the best I could to navigate an unnavigable system that’s also largely unregulated. In many states, anyone can open a rehab program — no licenses or accreditation are required.

This is slowly changing. More people are being educated about the fact that addiction is a disease and therefore requires treatments based on the medical model. The more consumers are educated and demand EBT, the more the billion-dollar rehab industry will adapt and offer it. That is, the industry will adapt or it will die and be replaced. In the meantime, those who need treatment must do the best they can to find programs that offer EBT. The place to start is by receiving an assessment from a psychologist or psychiatrist who is trained in addiction medicine. … A competent doctor can determine the severity of addiction and the presence or lack of co-occurring psychological disorders and prescribe the next step. It may include a brief intervention, therapy, psychopharmacology, an inpatient or outpatient program that offers quality care or a combination of these things.

Sheff’s points are crucial and a matter of life or death for many. For some addiction programs, even “certifications” are simply designed by people who had theories rather than based on research and/or outcome studies. His plea for standard of care for addiction is critical – for the health and well-being, and even life or death, of so many.

Samantha Smithstein, PsyD

(Re)Defining Justice

  • April 13, 2013 10:48 am

Restorative Justice is a process to involve, to the extent possible, those who have a stake in a specific offense and to collectively identify and address harms, needs, and obligations, in order to heal and put things as right as possible.”

– Howard Zehr, 1990

Restorative (or Reparative) Justice is based on the Native American principle that criminal behaviors are offenses against human relationships and that after these behaviors are committed, there are both dangers and opportunities:

  • The danger is that everyone emerges further alienated, more damaged, disrespected, disempowered, feeling less safe and less cooperative.
  • The opportunity is that injustice is recognized, equality is restored and the future is clarified. So that participants are safer, more respectful, and more empowered and cooperative with each other and society.

Restorative justice is a process designed to try to “make things as right as possible” for everyone involved.  That includes: repairing what has been broken, making society safer, attending to needs related to the behavior, and making amends.

Traditional criminal justice seeks answers to three questions: What laws have been broken? Who did it? and What do the offender(s) deserve? Restorative justice instead asks: Who has been harmed? What are their needs? Whose obligations are these?

Restorative Justice can take place in a diversity of settings, including neighborhood courts, schools, therapy groups, and nations. The 12-step community has also attempted to address the need for restoration through steps 8 and 9: making a list of the persons harmed and making direct amends to such people whenever possible. Making amends is different from an apology – one is simply an acknowledgement and expression of regret, whereas the other attempts to create restoration. Sometimes people also talk about “living” amends, which has to do with choosing to live differently so as to not create more harm.

Restorative Justice, or making amends, doesn’t require forgiveness. Forgiveness is a step that the victim(s) may or may not be able or willing to choose. Instead, Restorative Justice seeks to restore and heal, so that everyone may move forward less broken, and more whole.

Samantha Smithstein, Psy.D.

Is Sexual Addiction a Real Addiction?

  • March 16, 2013 8:31 am

By M. Deborah Corley, PhD, LMFT, LCDC, LSOTP, CSAT, CMAT
Co-owner/founder of Santé Center for Healing (www.santecenter.com)

The acceptability of a vast range of sexual behaviors in the United States reflects our changing society in which every form of expression of sexual behavior is available to anyone with access to the Internet. But even those who do not use the Internet for viewing sexual materials, engaging in sexual conversations, or arranging meetings for sexual purposes, anyone who has access to mainstream media has been exposed to explicit coverage of sexual behaviors in the news or in prime time television and movies. Strip clubs have moved from the backroom into multimillion dollar establishments and are available in every state in the union. However, engaging in one or several of these types of behaviors does not make someone a sex addict. Sexual addiction like any addiction – it is not so much about the type or amount of behavior, but about the impact the behavior has on someone’s life. For people who are finding it hard to control their sexual impulses, many fear they are sex addicts but are not sure if it is a real addiction or what to do about it.

Although it was in 1980 that a very famous researcher and clinician from Johns Hopkin University, Dr. John Money, proposed that sex addiction existed, it was later in the early 1980’s that Dr. Patrick Carnes really began the conversation about whether sex addiction was a disorder or not. Sex addiction has been used synonymously with sexual compulsivity, sexual dependency, and excessive sexual desire and hypersexual disorder and the discussions about the definition have been ongoing for the past thirty years. In the past year, the American Society of Addiction Medicine (ASAM) took the lead in the debate about whether sexual addiction is really an addiction. ASAM set about to define addiction with a focus on what happens in the brain for an addict and they included what mental health professionals refer to as process or behavioral addictions like sex, gambling, and Internet use.

ASAM defines addiction as a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by an inability to consistently abstain, impairment in behavioral control, and craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (ASAM, 2012)

The criteria most recently proposed for the DSM-V (Diagnostic and Statistical Manual, sort of the psychiatrist’s encyclopedia of mental health disorders) contains aspects of the criteria mental health professionals have been using for some time now in addiction treatment center sand private practices all over the United States. Basically, criteria requires the behavior must be occurring over a period of at least six months – so it is not about just an affair or two, or two weeks of looking at pornography on the Internet. There is a persistent and pervasive pattern of behavior in which a person is not able to control their sexual fantasies, urges, and/or behaviors despite negative consequences to self or others. The person spends excessive amounts of time seeking or engaging or recovering from the sexual activity and generally uses the behavior as away to cope with anxiety, depression, or emotionally distressing situations. And the behavior can’t be the result of drug use or another medical condition like a brain injury. (APA, 2010)

Most people report that the behavior started in adolescence. Women sex and love addicts report more sexual abuse as children than do men but more men have the disorder than women.In a recent study of women sex and love addicts, exposure to pornography as a child was the greatest predictor of sexual addiction, even more than sexual abuse. The most common behaviors reported in studies of sexual addicts includes masturbation with the use of pornography, followed by sex with a consenting adult, and then cybersex activities on the Internet.

Studies done in the recent past have identified how both women and men put themselves and others in harm’s way. Women sex addicts also tend to stay in relationships after they become abusive as compared to other women. Women sex and love addicts report higher numbers of unplanned pregnancies, terminated pregnancies, depression, suicide attempts, and infertility problems than do non-addicted women. Both women and men report an average of 15 different sex partners in a year, unprotected sexual encounters, and higher rates of sexually transmitted infections than non-addict groups so in many ways sex addiction is also a public health problem. Other behaviors often reported by sex addicts that have caused a variety of negative consequences includes use of prostitutes, multiple affairs, viewing pornography on Internet at work, having sex with employees, and heterosexual men having sex with other men.

The good news is that sexual addiction can be treated. There are several screening tests that can be used to help identify people that meet the criteria for sexual addiction (see list at end of article.) People in the early stages of the disorder have had success by attending 12-step meetings for sex addicts or group therapy specifically for sexual addiction. (Individual therapy can be very helpful however, group therapy lets an addict be with peers who are dealing with the same issues and thereby has access to others who can be supportive as well as hold the addict accountable for his or her actions.) When people have combined other addictive behavior like alcohol or other drug use with sexual addiction or have had the disorder for a long time and have a long history of secret keeping or trying without success to stop, more intense therapy is often needed like that offered in intensive outpatient programs or in a residential setting where a safe environment helps the addict have enough time in therapy, support, and accountability to learn other ways to manage emotional distress and life’s challenges.

Some behaviors that have severe negative consequences include illegal behaviors. Sexual offenses are beyond the scope of this article, but the addiction model has also been found useful for those who have engaged in sexual offending behaviors. Family therapy is an important component to any addiction treatment. Family members, especially spouses/partners have been betrayed by the addict through his/her behavior. Support of a family member can be significant in an addict’s path to recovery. Yet being supportive when a person has been betrayed is difficult, so everyone in the addict’s immediate support system needs a chance to heal and learn to respond in a healthy way to the addict’s behaviors. Therapy and mutual help groups are also beneficial for family members.

Sexual addiction is a complicated disorder that deserves additional research to clarify
who is most at risk and the most effective treatments. This will take time. As we learn more, it is
important to see that people who suffer from this disorder get the help that is needed. If you have questions about sexual addiction, the Pathways Institute would be happy to answer them for you. Additionally, SASH (Society for the Advancement of Sexual Health) is a national organization devoted to helping sexual addicts and their families find help (www.sash.net). For other assessment, treatment information, referrals, or copies of recent research articles, you can contact www.santecenter.com.

Screening tests:
Sexual Compulsivity Scale (Kalichman & Rompe, 1995. Available at www.santecenter.com)
W-Sexual Addict Screening Test (www.sexhelp.com) (for women)
Hypersexual Behavior Inventory (RReid@mednet.ucla.edu)
Internet Sex Screening Test (Delmonico@duq.edu)

M. Deborah Corley, PhD, LMFT, LCDC, LSOTP, CSAT, CMAT is co-founder and co-owner of Santé Center for Healing, a residential treatment center for addictions near Denton, Texas. She serves as clinical consultant to the Santé treatment team. She won the 2008 Merit Award from Society of the Advancement for Sexual Health (SASH), the 1999 Carnes Award for outstanding achievement in the field of sex addiction and was the co-recipient with Dr. Schneider of the Clinician’s Most Valuable Article Award by the American Foundation for Addiction Research in 2003 for their work on disclosure. She is the past president of the Board for SASH and a clinical member of the American Association of Marriage and Family Therapists. Licensed both as an addiction treatment specialist and marriage and family therapist, Deb has over 30 years of experience working with and conducting research on addictive disorders and high risk families. As an international speaker in the US and Canada, her focus on treatment of addictions, trauma resolution, disclosure, interpersonal neurobiology and meeting attachment needs is well received. In addition to Disclosing Secrets and Surviving Disclosure, she is co-author of Making Advances: A Comprehensive Guide to Treatment of Female Sex and Love Addicts.

References:
Corley, M. D., & Delmonico, D. (2011). Closing the gap: Results from the women’s sexuality
survey on female sex and love addicts. Presentation at Society for the Advancement of
Sexual Health Conference, LaJolla, CA.
Corley, M. D. & Hook, J. N. (2012). Women, female sex and love addicts, and use of the
Internet. Sexual Addiction and Compulsivity, 19, 53-76.
Corley, M.D. & Schneider, J.P. (2012). Disclosing secrets: An addicts guide to when, to whom,
and how to much to reveal. Tucson, AZ: Recovery Resources Press. Available at
www.amazon.com.
Langstrom, N. & Hanson, R. (2006). High rates of sexual behavior in the general population:
Correlates and predictors. Archives of Sexual Behavior, 35, 37-52.
Reid, R., Carpenter, B. & Lloyd, T. (2009). Assessing psychological symptom patterns of
patients seeking help for hypersexual behavior. Sexual and Relationship Therapy, 24, 47-
63.
Reid, R. et al. (2012). Report of findings in a DSM-5 trial for hypersexual disorder. Journal of
Sexual Medicine,
Reid, R., Garos, S., & Carpenter, B. N. (2011). Reliability, validity, and psychometric
development of the hypersexual behavior inventory in an outpatient sample of men.
Journal of Sexual Addiction and Compulsivity, 18(1), 30-51.
Schneider, J. P. & Corley, M. D. (2012). Surviving disclosure: A part

This is your brain on dope(amine)

  • January 25, 2013 11:32 am

Dopamine is a neurotransmitter responsible for movement, pleasure, motivation, and cognitive processes, such as learning. For the purposes of understanding its role in addiction, let’s concentrate on pleasure and motivation.

Whenever we do something that propagates the advancement of our species, dopamine is released in order to motivate repetition of the action. When we sleep, eat, and have sex dopamine is released in our brain and the message is, “That was great, do it again!” We also release dopamine whenever we find something pleasurable. Be it 18th century poetry, heroin, or Radiohead, our brain will release dopamine to encode the stimulus as something that brings us pleasure.

Dopamine not only serves to categorize the good things we encounter in life, it also programs our pre-frontal cortex (the part of the brain involved in judgement and decision making) to alert us when the pleasurable stimulus is available. If your brain cells could talk, it might sound something like, “OMG! There’s a flyer on that lamppost for a Radiohead concert. Go look at it!” In other words, we become hyperaware of opportunities for engaging in behaviors that bring us pleasure. In fact, a study on people with alcoholism found they were more likely to spot alcoholic beverages in a busy photograph than people who don’t have problems with alcohol.

When we consume substances, it makes us feel good because our brains release dopamine, but drugs elicit a higher amount of dopamine release than is necessary. This is part of what causes experiences of euphoria and feeling high. Sometimes the amount of dopamine released is so great, the chemicals in our brain become unbalanced and we may experience hangover or withdrawal. In time, our brain regains chemical equilibrium. However, if one abuses substances, the brain may develop a tolerance (meaning the person needs to use greater amounts to get high) or dependence on the substance as a source of dopamine. If one becomes dependent on a drug, it may take some time for the brain to regain equilibrium and the person may experience extreme physical discomfort and emotional distress when they aren’t using. The period of re-calibration depends on the amount, type, and frequency of the drug used. For this reason, it’s always a good idea to be under medical supervision and receive support from friends, family, and a mental health professional if you’re dependent on a drug and want to stop or decrease your use.

The mechanism of tolerance is also evident in impulse control disorders, such as sex addiction, kleptomania, and compulsive gambling. Although it doesn’t appear that persons with an impulse control disorder undergo the same intensity of withdrawal that persons addicted to substances experience, there can certainly be a period of re-calibration of dopamine receptors during which a person feels irritable and agitated after stopping a behavior.

Based on the information presented here, we can conclude that we are all hard-wired to potentially become addicts and you may be asking yourself, “If this is true, why do some people become addicted and others don’t?” This is a really good question and the answer is “We don’t really know.” We can predict the likelihood of someone becoming an addict based on factors such as first age of substance use and family history of addiction, and we know that a lack of social support and coping strategies (especially when coupled with mental illness) can also lead to addiction, but there is no conclusive answer to date.

The best ways to prevent addiction are to educate yourself about the substances you use (or to abstain from substance use altogether) and to be mindful about the choices you make. If you have a mental illness, ensuring that you are getting appropriate treatment and maintaining social support are good preventative measures.

Jennifer Fernandez, PhD

We Admitted We Were Powerless

  • December 3, 2012 4:13 pm

The very first step of every 12-Step program begins with these words – an admission of powerlessness. For many people, that very first step makes participation in a 12-Step program very difficult and with good reason: powerlessness is an uncomfortable feeling and not one that most people seek out or admit to.

In fact, most of us spend a great deal of energy, time, and effort attempting to try to control things and other people in our lives. We work hard to try to create a life of happiness, as we should. However, these efforts often involve trying to gain control over something we don’t have control of, like an addiction. Other times, the efforts involve trying to change or control other people who are in our lives. And understandably, because the people in our lives – their choices and behaviors – affect us; sometimes profoundly.

But when we stop and look at how effective our efforts are to bend others’ actions to our will – when we really examine how well our efforts to control things go – we find that, in fact, we cannot figure out a way to make others be or do what we want. We discover that using all of our efforts to control someone so they don’t cause us pain doesn’t, in fact, protect us. As the program of Alanon says: we don’t cause the behavior of others, we can’t control it, and we can’t “fix” it. Trying to do so simply makes our life feel unmanageable and increases our unhappiness.

Acknowledging that we are powerless is not about acknowledging that we are weak. Instead it acknowledges what is true, and allows us to focus on the things that we can control and the person who we can help: ourselves. Acknowledging the ways we are powerless also allows us to be more accepting of others, and to find a more peaceful way of being in the world and in relationships.

Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing. Helen Keller

Enjoy Your Life

  • September 1, 2012 8:51 am
Sometimes change is simple, even if it’s not easy

Enjoy your life and be happy. Being happy is of the utmost importance. Success in anything is through happiness. More support of nature comes from being happy. Under all circumstances be happy, even if you have to force it a bit to change some long standing habits.

Just think of any negativity that comes at you as a raindrop falling into the ocean of your bliss. You may not always have an ocean of bliss, but think that way anyway and it will help it come. Doubting is not blissful and does not create happiness. Be happy, healthy and let all that love flow through your heart.

— Maharishi Mahesh Yogi

 

To many, this quote by Maharishi Mahesh Yogi may seem trite, or overly simplistic. And indeed, there are times when we need more than this to create happiness—we may to make changes in our lives or our behaviors, we may need insight and/or healing. We may need transformation through meditation, psychotherapy, or relationship before we can apply new ways of thinking effectively.

However, there is a basic truth to the above quote, as evidenced by Cognitive Behavioral Therapy (CBT); a psychotherapeutic approach that addresses dysfunctional emotions, behaviors, and cognitions through a goal-oriented, systemic process. It is also evidenced through programs such as the 12-Step programs, which helps its members transform, in part, through addressing habits of thought. Programs such as this address a basic truth in the same way Maharishi does: habits of thought create an experience in life, and sometimes we have to consciously change those habits in order to create a different experience, one of happiness.

Addiction or Excuse?

  • September 1, 2012 8:47 am
Public shaming is counterproductive and simply wrong.

Whether it’s food, alcohol, or sex, there are a number of people who react strongly to hearing that someone has engaged in self-destructive behaviors because they are an addict by saying, “Don’t use addiction as an excuse for your behavior! Take responsibility!”

This concept of an “addiction excuse” is relatively new, and while it captures the imagination of those who are hurt, angry, or frustrated by the behavior of an addict, or by someone who lacks basic understanding of addiction, it simply doesn’t hold water for people who are addicts or those who work with people who struggle with addiction. People who speak about addiction as a “convenient excuse for bad behavior” or a “way to not take responsibility,” don’t comprehend what addiction is, and what the experience is like for the person who struggles with it.

Addiction is a psychological and physiological disorder. Even for “process addictions” such as those related to eating, sugar, sex, gambling, and stealing, there is strong scientific evidence that the neurological pathways related to dopamine are activated similarly to an addiction to cocaine. So addiction is not something made up by people to explain something away, it is a real condition, with both biological and psychological underpinnings.

For the vast majority of people who suffer from an addiction or impulse control disorder, acknowledging an addiction is one of the most difficult steps they will ever take. Most are in denial for years, believing in the “free will” that addiction naysayers speak about; addicts want to believe they are in control, and can stop any time they want. Many struggle for years to gain that control and feel deep shame when they fail, again and again.

Acknowledging an addiction, therefore, is an incredibly important first step. No problem can be solved if the problem is not acknowledged. Until someone admits, “I have lost control of this situation and can’t stop myself,” they cannot possibly be open to learning and working on the steps it takes to change their behavior. To the addict, acknowledging an addiction may be the most difficult, shameful, and scary step they take … but is also a crucial first step in saving his or her life. In fact, rather than being about shirking responsibility, acknowledging an addiction is the first step to taking responsibility.

As a society, we must stop shaming them further by telling them that acknowledging their addiction is an “excuse” and that they should “take responsibility for acting badly” and just feel ashamed. Instead, addicts must be supported in their first step and invited to take the many steps— psychological, physiological, spiritual, and emotional—that must take place for them to become well.

It may be that part of what people are reacting to is the overwhelming list of addictions that we hear about these days. People have begun to feel as if it is an overused term, and that there simply can’t be so many people in our society addicted to so many different things. Sadly, this is also not something that is made up. It doesn’t take much work to look around and see the sheer numbers of people who are addicted to food, shopping, electronics, alcohol, drugs, gambling, sex, and the myriad of ways available to us to avoid the profoundly beautiful but sometimes acutely painful process of being human.

Samantha Smithstein, Psy.D.

Lust, Love, and the Brain

  • June 22, 2012 12:00 pm

What is the connection between desire and love? This question has been one that relationship scientists and couples therapists have concerned themselves with for a long time, but the answer has remained elusive.

Recently, researcher Jim Pfaus, professor of psychology at Concordia University, co-authored a study published in the Journal of Sexual Medicine that set out to use brain imaging to try to shed some light on the differences and similarities between sexual desire and love.

It turns out that love and desire activate specific but related areas in the brain. The researchers found that two brain structures in particular, the insula and the striatum, are responsible for tracking the progression from sexual desire to love. The insula is a portion of the cerebral cortex folded deep within an area between the temporal lobe and the frontal lobe, while the striatum is located nearby, inside the forebrain.

Love and sexual desire activate different areas of the striatum. The area activated by sexual desire is usually activated by things that are inherently pleasurable, such as sex or food. The area activated by love is involved in the process of conditioning by which things paired with reward or pleasure are given inherent value. That is, as feelings of sexual desire develop into love, they are processed in a different place in the striatum.

Somewhat surprisingly, this area of the striatum is also the part of the brain that associated with drug addiction. Pfaus explains there is good reason for this. “Love is actually a habit that is formed from sexual desire as desire is rewarded. It works the same way in the brain as when people become addicted to drugs.”

This habit has its pros and cons.  For some, the experience can turn into an addictive process, whereby they seek out, again and again, the experience of falling in love, unable to form a long-term relationship bond.  For most, however, the habit of love activates pathways in the brain that are involved in monogamy and pair bonding, and is connected to parts of the brain that are more abstract and complex – so that the experience of love is not as dependent on the physical presence of someone else.  Another way of understanding it would be that desire and love are on a spectrum that evolves from integrative representations of sensation to an ultimate representation of feelings.  Thus they are not the same thing, but are intimately connected.

According to Pfaus, cognitive neuroscience has given researchers a deep understanding of where intelligence and problem solving sit in the brain, but there is still a lot to discover when it comes to love. He hopes that studies such as his will not only give us a map of where these experiences are located in the brain, but perhaps more importantly deepen our understanding of how these feelings and experiences – so central to our existence as humans – grow and evolve.

Samantha Smithstein, Psy.D.

When Is Therapy Done?

  • March 27, 2012 3:27 pm

Everyone who has been in psychotherapy has had the question arise: When am I done here?

This question is a good one, as there is no obvious ending point for psychotherapy – it isn’t like a course of antibiotics, or a broken bone, when the ending of treatment can be prescribed.  With psychotherapy, the ending has to do with 1. the goals of the therapy (which can grow and change), 2. the ability of the therapist to adequately address those goals and 3. the ability and/or willingness of the patient to do the work necessary to complete the goals.

Let’s address each of those questions individually.

1.    Have I achieved the goal(s)?

This question is an interesting one.  Often, people come into therapy with acute problems which tend to improve after a while, sometimes within several months.  If the goal was to address these acute problems, there can be a perception on the part of the patient that therapy has done its work and they are therefore done.  That is certainly one way of looking at it but is it a good enough reason to end therapy?

Often the improvement someone experiences is because they have been able to identify the problem, learn new communication skills, and experience being heard through nonjudgmental inquiry and feedback from the therapist.  They learned their part in their problem and/or the psychological impact of the problem and have been able to begin to talk freely about the problem.

However, several months, or even a year, is usually not long enough to address the underlying vulnerabilities that led to the acute problems in the first place.  This makes the person highly vulnerable to repeating the acute problems in the future.  It is also not typically long enough to create a lasting change, so that the person may find that they are coping better but they have not made the deeper changes that address their orientation to life, work, or relationships.  If the goal is to have fewer symptoms and feel generally better, that goal might have been met, but if the goal is to have a broader understanding of themselves and a shift of perception enough to implement lasting change, they may not be.

Take, for example, the case of Marty: Marty came to therapy to try to figure out why she was so burnt out in her chosen field as a creative director in an advertising agency.  Her goal for therapy was to get back her passion and excitement about her work.  Through therapy she discovered that it wasn’t really her work that was the problem.  She and her husband were parenting three teenagers and had very little time for themselves and each other.  Her therapist came to feel that an underlying issue was Marty’s lack of self-care, and began to work with Marty on it. Marty discovered it wasn’t that easy.  It was easy to support her husband to go swimming and get back to his passion for woodshop.  But for some reason she couldn’t seem to sign up for yoga, painting and ask her kids to pitch in more.  Slowly her therapist suggested that perhaps they needed to look a little more closely at her childhood growing up with an alcoholic mother and father.  Marty was willing to consider adding this to her goals and realized that she was never very good at taking care of herself, she was good at surviving in an out of control alcoholic family.  After a few months she was able to sign up for yoga and a few months after that she signed up for weekend painting class.

As in the example above, deeper work often means a revision of the goals.  Sometimes it means that the therapist and patient do not have shared goals – the therapist may see the potential for greater change and the patient may not be interested (see #3).  But often as the patient and therapist work together they come to see that there are goals that were not initially apparent.

2.    Is my therapist capable of helping me achieve my goals?

This is also a very important question and one that can be difficult to assess.  Sometimes people encounter frustration with their therapist and feel they must leave – that they are not done with therapy but done with that therapist. This very well may be an accurate assessment on the part of the patient: even if people seek specialists for their particular problem, or they get a recommendation from someone who they know, not every therapist can work well with every person – there needs to be a “fit” for the therapy to work.  Additionally, some therapists are more skilled than others.

However, often people underestimate their therapist and leave instead of working with their therapist to see if the frustration can be resolved.

Take, for example, the case of Sue and Dave: Sue and her husband Dave brought their child to a therapist because they had reports from school that he wasn’t doing well academically and were concerned that their son had an emotional issue that was causing him to lose concentration.  Sue and Dave luckily saw an adult & child psychologist, Dr. Lee, who not only specialized in mood disorders but also in learning disorders.  After an initial evaluation the psychologist told them that he felt their son didn’t have mood based learning problems, rather he suspected the neurological based learning disorder dyslexia.  Initially Sue and Dave were upset by this thought, and felt Dr. Lee was the wrong therapist for their son. However, after discussing it further with Dr. Lee they agreed to testing and discovered Dr. Lee had been correct.  Dr. Lee was able to work with the family to help them accept the diagnosis, including the depressed feelings Dave initially experienced as a result. Dr. Lee was able to support Dave to work on all his feelings and now both Sue and Dave are involved parents and advocates for their son, and their son was able to receive the help that he needed.

Often, the therapist and patient can work through the impasse together and the process itself can be a very effective part of the therapy.

3.    Am I willing and/or able to do the work necessary?

This final question is crucial.  The process of therapy is intense and powerful. Often when people find their symptoms are (temporarily) alleviated, they feel incredible relief, and this feeling of relief allows them to feel the possibility of wellness.  Typically, as they continue in therapy, they then begin to feel uncomfortable. The therapy process begins to take a deeper look into the person and his or her life. Unpleasant feelings can emerge, such as feelings of dependency, or a deeper unhappiness.  More subtle thought distortions, relationship patterns, or acting out can begin to be revealed, and all of this can be frightening or make the patient feel worse.  This is a common time when people have the urge to leave.

Take, for example, the case of Tony: Tony came to therapy after his partner discovered Tony’s compulsive sexual behavior involving internet pornography, multiple affairs and frequent encounters with prostitutes.  His partner had told Tony if he didn’t get help to stop his behaviors, she would leave and take their three kids with her.  Tony was motivated to change, got into an intensive outpatient treatment program, joined a twelve step program and his wife joined a support group. Tony was hugely relieved that things started to calm down at home and he and his wife were finally able to communicate without painful arguments.  Six months into the therapy, Tony had a very deep session with his therapist acknowledging he thought he’d been depressed since his mom died when he was eleven years old.  A week later Tony came to therapy stating he was confident he was over his problems and decided after six months of no longer acting-out in his sexual compulsivity he was done.  His therapist asked him if he thought he’d touched on something very painful when he had brought up his mother and that he had more work to do to grieve her loss and look at the corresponding depression he’d had since that time.   Tony disagreed and in a couple of days sent her an email stating he would not return.  His therapist called him back and told him that her door was always open to him and encouraged him to consider a final session for closure.  Two months later he returned to therapy and said his wife had caught him again on an internet pornography site. His twelve step sponsor said he was still in his addiction and he needed to get additional help of therapy to get and stay sober.  He acknowledged he wasn’t done and indeed was really just getting started.  Tony later learned that when he had been in so much pain remembering his mother, it wasn’t his sober adult mind doing the thinking and acting, it was the addict defensive part of his mind that was telling him to run and hide from therapy. That was a part of his mind that had developed to help him survive a traumatic event when he was young but it was no longer helpful – it was self-destructive.

People spend a large portion of their lives acting without knowing really why or where the action is coming from.  Part of the goal of therapy is to develop a mind that can think “real thoughts” versus automatic responses, awareness of feelings and ability to tolerate them, so that conscious decisions can be made and intimacy can be created.  The discomfort – experienced as frustration, irritability, restlessness, sadness, pain, anger, unhappiness, etc – can be an indication that the real work can begin – the work of discovery and healing.  The deeper problems are now within reach and are available to be explored and resolved.

Samantha Smithstein, Psy.D. & Elizabeth Corsale, MFT

Can your partner change? Believe it, even if you don’t see it.

  • March 19, 2012 8:57 pm

Does the effort of changing your behavior to increase your partner’s happiness make a difference?  It turns out it does… but only if your partner sees it and believes it.

In a new Northwestern University study, professors Hui, Bond, and Molden studied romantic couples and found that the more you think your partner is incapable of changing, the more your partner’s sincere efforts fail to improve the relationship.  Conversely, the more you believe your partner is capable of change and trying to improve, the more secure and happy you will feel in your relationship.  This is true even if you feel they still could do more.

“The secret to building a happy relationship is to embrace the idea that your partner can change,” says Molden, “to give him or her credit for making these types of efforts and to resist blaming him or her for not trying hard enough all of the time.”

What is important about this formula is that there are two parts to it.  The first is obvious and one unhappy partners know well: in order for happiness to grow in a relationship, both people have to be willing to grow and change and act in ways that make their partner happier.  But the second part of the formula is less commonly recognized: those efforts only work if the other person sees the effort, appreciates it, and believes that their partner is capable of the change.

This second part is key, because so often couples get into a cycle of negative perception of the other and all efforts go unnoticed and/or viewed with skepticism.  This creates a cycle of frustration, apathy, and despair, and can often lead to the dissolution of the relationship.  However, once both members of the couple begin to believe that the other person is working to better the relationship, and begin to have faith that things could change, they can experience the relationship entirely differently, even if actual changes have not yet been that great.

Growth and change is never easy.  It can take time, and often takes encouragement and feelings of success along the way.  It is up to us then, as much as our partners, to not only work towards creating a greater happiness, but to also believe in the possibility that growth and change are possible, and that the partner we have chosen is capable of it as much as we are.

Samantha Smithstein, Psy.D.

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