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How to Overcome Barriers to Forgiveness

This article was written by Linda Graham, MFT and was reprinted with her permission.

It’s hard to let go of the suffering caused by someone else’s wrongdoing. What barriers stand in the way of forgiveness—and how can we overcome them?

Laurie and Jamie sat in my office a few months ago, locked in an impasse all too common in couples therapy. The previous week, Laurie discovered that Jamie had done the seemingly unforgivable: He had had a brief fling with the new administrative assistant in his office while Laure was out of town visiting her ailing father. Jamie was genuinely remorseful, but he also carried a grudge of his own about Laurie’s repeated overspending on their credit card, despite his many requests to stay within their agreed upon budget.

We all know how painful it feels to suffer these kinds of hurts, betrayals, or abuse—and to have this pain harden into lasting grudges or resentments. I’ve spent 20 years helping couples like Laurie and Jamie recover a sense of trust after they have violated their vows or broken their agreements. In that time, I’ve found that helping people understand each other’s underlying motivations is crucial to repairing a rupture between them.

But I’ve also learned that helping people forgive each other is essential, even when there is good reason to resist. Indeed, study after study has suggested that being unable to forgive these past wrongs can wreak havoc on our mental and physical health.

Forgiveness is the practice of letting go of the suffering caused by someone else’s wrongdoing (or even our own). It does not mean excusing, overlooking, forgetting, condoning, or trivializing the harm or jumping to a premature or superficial reconciliation; it doesn’t necessarily require reconciliation at all. Instead, it involves changing our relationship to an offense through understanding, compassion, and release. Two decades of social psychology research have repeatedly demonstrated the emotional, physical, and social benefits of forgiveness. True forgiveness repairs relationships and restores inner well-being.

Yet we often find it hard to let go, forgive, and move on. According to research, even when we can feel compassion and empathy for the person who harmed us, we can remain stuck in fear or hostility for days, months, even years.

Why is something so good for us so hard to do? That’s the questions Ian Williamson at New Mexico Highlands University and Marti Gonzales at the University of Minnesota have explored through research on the psychological impediments to forgiveness.

In a recent study published in the journal Motivation and Emotion, Williamson, Gonzales, and colleagues identify three broad categories of “forgiveness aversion.” Traditionally, ideas for helping one person to forgive another have implied either expanding one’s empathy or compassion for the offender or “distancing,” not taking things so personally. But their research on forgiveness aversion suggests another approach: Forgiveness comes not necessarily by appealing to kindness or compassion but by addressing the victim’s fears and concerns. Williamson and Gonzales’ research suggests how to work with perceived risks to forgiveness and to move toward forgiveness in a safe and genuine way.

Below I offer a brief tour of the three barriers to forgiveness, along with ways to overcome them, drawing on research and my own clinical experience with hundreds of couples and individuals. Understanding these barriers to forgiveness can be very useful to clinicians and to anyone who has ever struggled to forgive—in other words, most of us.

Barrier #1: Unreadiness

The first block is “unreadiness,” which Williamson and Gonzales define as an inner state of unresolved emotional turmoil that can delay or derail forgiveness. People can feel stuck in a victim loop, ruminating on the wrongs done to them by another person or by life, and be unable to shift their perspective to a larger view, to find the meaning, purpose, lessons, and possibilities for change from the events.

Who is most likely to experience unreadiness? Williamson and Gonzales found that people’s tendencies to be anxious and ruminate on the severity of the offending behavior reliably predicted an unreadiness to forgive. People showed more reluctance to move toward forgiveness especially when they held a fear that the offense would be repeated,

How can we overcome the barrier of unreadiness?Williamson and Gonzales’ research validates the folk wisdom that “time heals all wounds” and establishes the importance of not rushing the process, not coming to forgiveness too quickly. Certainly the passage of time is an important factor in helping people get some distance from the initial pain, confusion, and anger; it helps the offender establish a track record of new trustworthy behavior and helps the victim reframe the severity of the injury in the larger context of the entire relationship.

Over the three months that I worked with Laurie and Jamie, I saw them confront and ultimately overcome the barrier of unreadiness. In taking that much time, Laurie was able to place Jamie’s transgression in the context of a 17-year marriage that had already survived even greater challenges than Jamie’s one night of out-of-bounds behavior. And over time, Jamie was able to trust the turn-around in Laurie’s spending habits, relaxing his vigilance about her every move.

Tips to Overcome Unreadiness

1. Recall the moment of wrongdoing you are struggling to forgive. “Light up the networks” of this memory by evoking a visual image, noticing emotions that arise as your recall this memory, notice where you feel those emotions in your body as contraction, heaviness, churning. Notice your thoughts about yourself and the other person now as you evoke this memory. Let this moment settle in your awareness.

2. Begin to reflect on what the lessons of this moment might be: what could you have done differently? What could the other person have done differently? What would you differently from now on? When we can turn a regrettable moment into a teachable moment, when we can even find the gift in the mistake, we can open our perspectives again to the possibilities of change, and forgiveness.

Barrier #2: Self-Protection

The second block to forgiveness is “self-protection”—a fear, very often legitimate, that forgiveness will backfire and leave the person offering forgiveness vulnerable to further harm, aggression, violation of boundaries, exploitation, or abuse.

Who is most likely to experience self-protection? People who have experienced repeatedly harmful behavior, and lack of remorse or apology for that behavior, are most likely to resist forgiving the offending party, according to the research by Williamson and Gonzales. In fact, they found that even the strongest motivation to forgive—to maintain a close relationship—can be mitigated by the perceived severity of the offense and/or by a perceived lack of sincere apology or remorse. Refusing to forgive is an attempt to re-calibrate the power or control in the relationship.

According to their study, one of the hardest decisions people ever face about forgiveness is: Can I get my core needs met in this relationship? Or do I need to give up this relationship to meet my core needs, including needs for safety and trust? The ongoing behavior of the offender is key here. If the hurtful behavior continues, if any sense of wrongdoing is denied, if the impact of the behavior is minimized, if the recipient’s sense of self continues to be diminished by another, or trust continues to be broken, or the victim continues to be blamed for the offender’s behavior—if someone experiences any or all of these factors, then forgiveness can start to feel like an impossible, if not a stupid, thing to do.

How can we overcome the barrier of self-protection?“Victims may be legitimately concerned that forgiveness opens them up to further victimization,” write the researchers. “Intriguingly, when people perceive themselves to be more powerful in their relationship, they are more likely to forgive, perhaps because they have fewer self-protection concerns in their relationships with their offenders.”

In other words, people sometimes have understandable fears that offering forgiveness will be (mis)interpreted by the offender as evidence that they can get away with the same behavior again. People very often need to learn they have the right to set and enforce legitimate boundaries in a relationship. Forgiveness can also involve not being in a relationship with the offender any longer or changing the rules and power dynamics for continuing the relationship.

Only when Laurie stopped her overspending and came to respect Jamie’s limits on their monthly budget could Jamie relax his need for self-protection and offer genuine forgiveness for Laurie’s past transgressions. When Laurie could again trust the sincerity of Jamie’s remorse and apology over his betrayal, and trust that indeed the behavior would never happen again, she could relax her need for self-protection and forgive.

How to Set Limits

1. Identify one boundary you’ve been reluctant to set with the person you are struggling to forgive.

2. Clarify in your own mind how setting this limit reflects and serves your own values, needs, and desires. Reflect on your understanding of the values and desires of the other person. Notice any common ground between the two of you; notice the differences.
3. Initiate the conversation about limits with the other person. Begin by expressing your appreciation for him or her listening to you. State the topic; state your understanding of your own needs and of theirs.
4. State the terms of your limit, simply, clearly, unequivocally. You’ve already stated the values, needs and desires behind the limit; you do not have to justify, explain or defend your position. State the consequences for the relationship if this limit is not respected.
5. Negotiate with the other person what behaviors they can do, by when, to demonstrate that they understand your limit, the need for it, the benefit of it.
6. At the end of the specified “test” period, discuss with your person the changes in the relationship, if the limit was respected, or the next step in consequences if the limit is not respected. You may have to repeat this exercise many times to shift the dynamics in your relationship.

Barrier #3: “Face” Concerns

The third block is “face” concerns—what we might call the need to save face in front of other people and protect one’s own public reputation, as well as avoid threats to one’s own self-concept—i.e, feeling that “I’m a pushover” or “I’m a doormat.”

As social beings, we’re primed to not want to appear weak or vulnerable or pathetic in front of other people. We will protect ourselves from feeling inner shame in many ways, which may include a reluctance to forgive. Researchers have also found that hanging on to a grudge can give people a sense of control in their relationships; they may fear that forgiveness will cause them to lose this “social power.” If our concerns about saving face foster a desire to retaliate or seek vengeance rather than forgive, we may need to re-strengthen our inner sense of self-worth and self-respect before forgiveness can be an option.

Who is most likely to experience face concerns? People who feel their self-worth has been diminished by the offense, or who experience a threat to their sense of control, belonging, or social reputation, or even feel a need for revenge, are more likely to experience the face concerns that could block forgiveness. “To the extent that victims fear that they may appear weak by forgiving, and are concerned with projecting an image of power and interpersonal control, they should feel more averse to the prospect of forgiving,” write the researchers.

How can we overcome the barrier of face concerns? Very often people who have been hurt by another need to recover their own sense of self-respect and self-worth to create the mental space where forgiveness looks like a real option. We need to develop and maintain an inner subjective reality—a sense of self—that is independent of other people’s negative opinions and expectations of us. Good friends, trusted family members, therapists, or clergy can be very helpful in functioning as a True Other to someone’s True Self—they’re figures who can help generate a more positive sense of self.

How to See Yourself

1. Sit comfortably, allowing your eyes to gently close. Focus your attention on your breathing.

2. When you’re ready, bring to mind someone in your life in whose presence you feel safe. This person could be a dear friend, a therapist, a teacher, a spiritual figure, your own wiser self.
3. Imagine yourself sitting with this person face-to-face. Visualize the person looking at you with acceptance and tenderness, appreciation and delight. Feel yourself taking in his or her love and acceptance of you.
4. Now imagine yourself being the other person, looking at yourself through his or her eyes. Feel that person’s love and openness being directed toward you. See in yourself the goodness the other person sees in you. Savor this awareness of your own goodness.
5. Now come back to being yourself. You are in your own body again, experiencing the other person looking at you again, with so much love and acceptance. Notice how and where you feel that love and acceptance in your body – as a smile, as a warmth in your heart – and savor it.
6. Take a moment to reflect on your experience. You are recovering a positive view of your own self again. Set the intention to remember this feeling when you need to.

Laurie and Jamie had kept their struggles private from friends or family, so they didn’t have strong face concerns about social reputations. But they did need to move beyond the shaming-blaming behaviors prevalent when they first came into couples therapy. They had to work on not taking things so personally and on feeling appreciated and worthy in each other’s eyes again before they could move toward forgiveness.

Forgiveness is not easy. It takes sincere intention and diligent practice over time. But overcoming reluctance, even refusal, to forgive can be facilitated by understanding these specific aversions to forgiveness, and by implementing strategies to address these barriers skillfully.

Originally published at Greater Good.

Warning: Being Bad Can Feel So Good

Recently, researchers Nicole Ruedy, Francesca Gino, Celia Moore, and Maurice Schweitzer, at the University of Washington, the London Business School, Harvard and the University of Pennsylvania published an article titled The Cheater’s High: The Unexpected Affective Benefits of Unethical Behavior in the The Journal of Personality and Social Psychology.

Conventional theories of moral behavior and decision making assume that unethical behavior triggers negative emotions, and indeed, when participants in the study were interviewed before the study, they themselves reported an expectation that if they were to act unethically, they would feel guilty about it. These theories help support the idea that we are internally motivated to do the right thing, because it makes us feel bad not to.

But when put to the test, so to speak, the people who cheated actually experienced an immediate boost in emotion, which the researchers termed a “cheaters high.” The researchers went on to say that once people have this experience, it may be difficult to resist future unethical behavior, especially when someone can “derive both material and psychological rewards” from the behavior.

Those of us working in the field of “process addictions” or compulsive behaviors (such as compulsive stealing or sexual behavior, gambling, compulsive eating, etc) are certainly not surprised by these results – it validates the behavior we see all of the time. Indeed, many of the people we see are they themselves flummoxed by their own behavior – they don’t understand why they continue to repeat a behavior they don’t feel good about and goes against their morals, beliefs, and even self-image, and wreaks havoc in their lives.

The short answer, which these researchers have validated, is that they do it because in the moment it feels good. It gives the person a boost and if that person is feeling depressed, anxious, having difficulty coping, can’t assert what they need and want in a healthy way, etc. this little boost is a way to escape all of that, for a moment. And the escape works, which is why when all of the negative feelings return (which they always do, in addition to the feelings of shame due to the behavior), eventually the desire to do it again comes back, and thus the compulsion is born.

This important study helps to explain how and why motivation, behavior, and feelings don’t always align with morals and values. It also helps to make a case for treatment for people who compulsively repeat these behaviors; they need help with a transformation that will give them a deeper, longer-lasting experience of happiness, so they can give up the “boost” of the “cheater’s high.”

Samantha Smithstein, PsyD

The Myth of the Average

The following is an interview Todd Rose, faculty member at the Harvard Graduate School of Education, author of Square Peg, and co-founder of Project Variability. In his recent Sonoma TedX talk “Ban the Average he explains the myth of the average and how it harms kids in the education system by depriving them of learning, and our society as a whole, robbing us of needed talent and creativity.

We found his work to be highly relevant to the work we do at Pathways Institute, where it is part of our stated mission to help all children “function at their highest level and bring their unique gifts to the world.” We began the interview by asking him about the Myth of the Average:


L. TODD ROSE:  The Myth of Average is a belief that’s been prominent in most sciences and in education. It’s the belief that we can use statistical averages to understand individuals. Scientists have come to realize that it’s a myth, and over the last 10 years have been moving from averages to individuals, so for example we’re hearing a lot of things like ‘personalized medicine.’  Unfortunately, education has not quite realized the myth yet, and so what we have is a situation where not only do we accept the idea of designing something for the individual based on the average, we actually promote it.  The myth is that the average is fits for most people, when, in fact, it doesn’t.

Interviewer:  And how does that hurt us?

L. TODD ROSE:  When it comes to designing environments it hurts us in two ways.  As I said in my TEDX talk, the first is that you can be incredibly talented in one area, but average or below average in another. For example, say you’re really gifted in math, but you are an average or below average reader. The way our education system is designed will make it very hard for us to be able to get at your talent, because even in math class many of the problems are reading problems, so the reading problem can mask what you’re really good at.

The second way it hurts us is that someone can be unbelievably gifted in something, but their environment won’t challenge them because it’s teaching to the average. They end up getting on-board and doing only what they are supposed to. In this way, designing environments to averages end up hurting even our best and brightest.

Interviewer:  So how does that play itself out in our everyday world?  How are these problems going to effect all of us, even if they don’t harm us personally?

L. TODD ROSE:  Good question.  To me, the effect of the Myth of the Averages is even broader than education.  It’s really about how we develop our current and future talent pool, and as you know we have big challenges in our society and need all of the talent and creativity we can get.

We already have all the raw talent that we need! If you think about something as big as finding a cure for cancer, we need as many people who have the talent and the work ethic becoming scientists and chasing down this problem as possible.  But if we design our educational environment so that an individual’s limitations make it almost impossible for us to get to their talents, then we are going to lose a whole bunch of talented individuals, and in my mind we’re in danger of losing the cure for cancer.  If we extend this myth of averages all the way it has very serious implications, because when we studied cancer on the average, it led us to conclusions that were not helping us actually cure people.  And since we’ve gone away from average and started studying cancer, individual cancer, we’ve made great progress.

The workforce environment is not dissimilar. We’re trying to get people to be the most productive and effective person they can be. But if the environment is designed around averages, it makes people less efficient, less creative. So, you know, in every sector of society this idea of average has turned out to be a sort of barrier to advancement.

Interviewer: I see.  And so what does Ban the Average mean?

L. TODD ROSE:  Well, to me it’s step one of a two-step process that gets us away from this average and toward helping our institutions become institutions of opportunity that can actually nurture individuals.  So Ban the Average is the first step. It’s about helping people realize the average really is the problem. We can’t move forward until we realize that.

The phrase “Ban the Average” comes from the Air Force, which gained insight about the Myth of Average 60 years ago, when cockpits, jumpsuits, and instruction was designed for the mythical average person.  They they realized it was a problem, and even though they didn’t really know what the solution was that didn’t stop them from saying, ‘You know what?  We know the average is hurting our performance and shrinking our talent pool, so we’re going to ban the use of average.’ That initial step was enough to make a signal to the market that things were going to change, and it forced designers and entrepreneurs to create better solutions.  So we can talk about solutions, which is ultimately what needs to be done, but until we have the common understanding that the myth of average is a problem we’re not going to get very far.  So Ban the Average is the first step.

Interviewer:  And how does Project Variability fit into this?

L. TODD ROSE:  Project Variability is an enabling organization.  We see this emerging new science of the individual and we have the knowledge that we to be able to create an environment that understands individuals and nurtures individual potential.  At the same time, we’re seeing a massive shift toward technology in every sector of society, from workforce to science, and in education.  So we see a wonderful opportunity to combine those two in ways that enable us to do things that are almost magical, quite honestly, and that won’t actually cost more money. We can do things in education today that we only dreamed of before.  But it requires making good choice.

What we realized as a team was that those choices are rarely going to be made on their own because people in all parts of the current system have an interest in keeping the status quo.  What we’ve decided to do is be an organization that exists solely to initiate the transition from average to individual.  We’re doing it as a messaging campaign: to communicate to the public so people understand what’s possible and what to ask for, to ultimately create the demand. At the same time, we’re going to enable scientists and entrepreneurs to create solutions that will meet the demand. The truth is, is we exist to put ourselves out of business.  We just need to change the demand structure and help create some new solutions. At that point our goals have been met.

We highly recommend you watch Todd Rose’s Sonoma TedX talk “Ban the Average.

And a special thank you to Peter Dippery of Fuse Media for help making this interview possible.

Stealing From Our Children?

It was recently reported that six employees of the San Francisco Unified School District have been arrested for stealing and that they face no less than 205 felony charges stemming from the alleged misuse of an estimated $15 million in grant funding.  The allegations include redirecting money into slush funds, bonuses and non-approved pay increases.  The San Francisco DA reports that approximately $250,000 went towards the SFUSD employees’ personal use.

One of the defendant’s attorney, stated that his client “felt she had the right to do it”.  Currently there are many unanswered questions in this troubling case but one very important question is can it be possible that people are so unclear about what stealing is or are able to justify it to themselves?  Is it so complex and confusing to understand what is and isn’t mine, either professionally or personally?  It may seem clear to some of us, and we can only imagine people in this scenario acting out of pure greed or selfishness. And that may be the case. But people with stealing disorders – as with other addictions or compulsions – often use justifications and twisted logic to rationalize their out of control behavior.

In our years of working with people who have stealing disorders we have discovered that there are many people who steal who otherwise spend most of their time contributing to society and their families in a positive way. These people are therefore very confused about their stealing behavior.  While they are almost always clear that  when they go into a store and steal a watch they are stealing, they are often unclear if it is stealing to taste fruit at a grocery store before purchasing it, take something out of the communal fridge at work without asking, skim a little money from their wealthy employer, or take home office supplies from work.  These scenarios (and even stealing a watch from a store) get rationalized and thinking becomes distorted in the face of emotional reactivity.

In our work with people with stealing disorders, therefore, it becomes a priority to help them keep their thinking simple.  In other words, we encourage them to ask questions such as: Does this thing or money belong to you?  Have you already purchased it for it’s full price?   If the answer is “no” and you take it, then you are stealing.  If the answer is “I don’t’ know” then you have to ask if you can have it for free.

People with stealing disorders are often unable to distinguish what is stealing and what isn’t.  Their impulsivity overrides their thinking and their emotional empathy which would allow for them to formulate the question of whether or not a certain thing or money belongs to them.  The impulsivity is often driven by several factors which include: internal and/or external stressors, at times co-occurring mental or medical health issues, co- addictions and the neurobiological dopamine reward cycle taking place in their brain each time they steal.  The urge to get something for nothing feels like a “high” or a “win” but most importantly it is feels really good (and even alters their brain chemistry) and therein lies their problem: people get addicted to it.  When people are addicted they formulate all kinds of defenses, cognitive distortions, rationalizations, conscious and unconscious that allows them to repeat the cycle in order to get the payoff of good feelings again and again.

It is disheartening when we see cases like this and of course can’t imagine how could someone who has spent their life serving the public good get caught up in something like stealing from the very institutions and people they serve.  It is easy in a case like this to be cynical and political in our commentary, and it is possible these people are stealing out of pure greed, lack of empathy, and criminality. However, stealing occurs every day all day, all over this city, country and world, and some of it is by people who can’t help themselves.  There is treatment and help for individuals who compulsively steal and it is our hope that everyone with this problem can get the help they need so we can all live in a safer world.  

Elizabeth Corsale, MA, MFT

Not Getting Clean: It’s A Killer

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, 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

Is Sexual Addiction a Real Addiction?

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

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 ( For other assessment, treatment information, referrals, or copies of recent research articles, you can contact

Screening tests:
Sexual Compulsivity Scale (Kalichman & Rompe, 1995. Available at
W-Sexual Addict Screening Test ( (for women)
Hypersexual Behavior Inventory (
Internet Sex Screening Test (

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.

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
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-
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

The Right of Every Child

Recently, in anticipation of National Child’s Mental Health Awareness Week, the Directors of Pathways Institute interviewed a colleague who has a daughter with learning and attention differences.  Pathways Institute works therapeutically with people who have learning and attention differences and their families, and helps them to navigate the system to get services.

When did you notice your daughter’s learning differences? 

I was lucky: when my daughter was quite young – a little over one year old – I noticed she didn’t have hand dominance.  I remembered reading an article about hand dominance as a possible early indicator of learning disabilities while I was in graduate school.  At that point I started to pay closer attention to the how she was developing.

What happened next?

In preschool they did a “ready for kindergarten” screening and the occupational therapist conducting the screening noticed a couple of things.  She noticed the lack of hand dominance and the inability to cross the midline, meaning she would start drawing on the left side of the paper with her left hand get to the middle and switch to her right hand.  She alerted us that we might want to have her assessed.  We set that up and discovered a couple of things that surprised us: our daughter had weak core strength and no hand dominance.  The recommendation was she do occupational therapy.  We started it and it was helpful.  She spent two years in OT and at the end was able to cross the midline and the OT felt she chose to be right handed.  At this point she is still quite ambidextrous.

How did she do when she started kindergarten?

This was the beginning of a very difficult time for her and us.  She had a great deal of difficulty learning to write her letters and she was already identified as a child that was unable to pick up the first pieces of reading.  It was recommended to us she do some afterschool work with her kindergarten teacher on phonics.  We signed her up and she did two rounds of 6 weeks.  At the end very little progress was made and when we asked the teacher, who had a masters level degree as a reading specialist, if she thought we were dealing with dyslexia, she wouldn’t answer the question.  I learned later that she wasn’t allowed by the school district to answer.  This will remain forever immoral and unconscionable to me.  Here we had a child who needed help and they refused to tell us, for political reasons.  But in spite of this lack of information, I knew that learning disabilities are genetic, and I have a sister who is dyslexic, so I was now “on the case,” so to speak.

Was the school supportive?

We had to push and push for testing, and finally at the end of second grade she was tested.  But she still somehow managed to fall in the low, low averages which would not qualify her as learning disabled.  The testing showed just a couple areas of significant deficit: in particular, she scored at 2% for short term visual memory processing.  Because she was strong in other areas, she didn’t qualify.

There is an undeniable conflict of interest if the same institutions that have to provide the services are doing the testing.  I know most parents with dyslexic kids are shocked to discover – and the generable public should also know – that the acceptable averages to qualify as learning disabled are so low that kids have to be several grades behind in school before they qualify for services in California.  And even then some don’t.  My kid didn’t.  Most kids that fall that far behind experience depression and anxiety.  This should be unacceptable and people should be outraged.  In essence we didn’t get anywhere with the school district, we had incredible problems trying to get help for our daughter, but that’s a story for another day.  Suffice it to say that sadly schools and educational administrators don’t appear to be interested in why a child isn’t learning.  This should be the mission and mandate of special education, not “does a child simply qualify.”  It is a broken system where everyone ends up demoralized.

What was it like for you to be denied services for your daughter?

Traumatic.  My wife and I were incredibly confused, distraught and angry.  We really didn’t know where to turn or what to do.  And we were both well-educated professionals.   We couldn’t understand why no one seemed to want to talk to us or how could it be that all these education professionals, who must have evaluated hundreds of kids, were acting like they didn’t have clue?  Our daughter’s principle told us, “Why don’t you take her to one of the private schools that specialize in learning disabilities?”  It is hard to know if she was asking us to leave or telling us she couldn’t help or both.

Luckily we had a friend who told us about an amazing organization: Parents Education Network (PEN).  We were introduced to several PEN members, and talking with them was like walking out into the sunlight after being in the dark for years.  They told us to stop talking to parents of kids without learning disorders, stop talking to educators who don’t care or aren’t interested or able to think about your child, and surround yourselves with supportive friends, family and the parents of LD kids who are a few steps ahead, join PEN and get more information and education.  Finally, they said be prepared to sacrifice and invest in your child.  We were lucky that it was possible for us. It isn’t for most people and that is one of the great educational crimes of our time.  PEN saved our sanity and in ways ultimately our family.

What was it like for your daughter?

It’s very painful to recall.  During her K-3 years in school she just went down, down, down emotionally.  Every day she went to school and was frustrated and failing in making the kind of progress her peers were making.  She was a good kid and so she never acted-out in school, although some kids do.  But at home she was angry and in a dark place.  She hated school and didn’t want to be there but went anyway.  She was an incredible trooper as we were intervening with reading specialists and math tutors.  She’d go to school all day and then 4 days a week go to tutoring; she was exhausted.  She was sad.  She wasn’t well received socially; she did have a few friends but I think because she was so insecure and frankly exhausted she could be controlling and inflexible.  It was hard on her friends and hard on her.  Her insecurity stemmed from living in body with neurophysiology that was failing her in school.  I think she was riddled with fear and quite anxious.

What help and treatment did you seek?

We went to a very wise child psychologist, who told us to get her out the school, change her environment and put her in a school that specialized teaching kids who are dyslexic.  He told us this wasn’t a parenting problem – we had been told it was a parenting problem at different points by school administrators and unkind people who saw an unhappy kid and blamed us, the parents. He recommended we get her neuropsychological testing which was informative and verified what we knew in our gut: that our daughter had learning and attention disorders, although they failed to give her a diagnosis of dyslexia.  Once she was at the new school with experts they all said, “Your kid is dyslexic”.  As an aside, we were so glad to learn that finally, in the upcoming DSM-V, dyslexia will be included with an understandable and researched-based criteria.  You have no idea how relieving this will be for us and millions of parents and kids who are dyslexic.  An actual criteria worked on by the Shaywitzs, the leading researchers and experts in the field.

Did you feel relief after the neuropsychological evaluation and diagnosis? 

Recently, I saw a clip of an interview with James Redford about his new movie, The D Word.  It is about his son’s journey with dyslexia.  He was asked the same thing.  His answer was something like, “No I wasn’t relieved once there was a diagnosis, my son was functionally illiterate and I was still caught in the fear of wondering how this kid is going to make it in life.”  I nearly broke down in tears when I heard that clip – another parent, a father, that really understands.  I wasn’t relieved either.  I didn’t know how my daughter was going to do.  Would she ever get to a place of acceptance, would she learn to read, would she have the chance to go to college?  Would she plateau at a very low level, would she ever feel secure?  A child’s world and job is school, and when they start out failing the psychological impact is huge.  I knew that kids with LD and ADHD are at high risk for dropping out of school, drugs and other impulse disorders.  I wasn’t relieved I was still terrified.

You have seen a change in your daughter over the past few years.  What’s different now since she has been at the school these last 4 years?

My sister is a psychoanalystand I remember talking to her about my daughter when my daughter was about 7-years-old.  She said, “You know, some day she will need to tell you what is was really like for her.”  I was puzzled, I didn’t really get it because I thought I knew what it was like since I has been through it with her.  My sister said, “She will need to tell you how painful it has been and likely how angry she has been at you, because she is dyslexic and in that way different from you and Lori (my wife).  You and Lori didn’t struggle in school and you don’t struggle with learning now.”  At that time, my daughter would just express anger and shut-down, she never was able to talk about what was happening.  She was obviously young so I couldn’t expect it but was this ever going to happen, this kind of conversation with my daughter?

Even after going to the new school my daughter struggled at first – she saw it as a school for losers.  She was projecting her own insecurity and lack of acceptance on the school and kids.  Gratefully, we were referred to a truly gifted child psychologist who worked with her.  This psychologist really understands LD kids and is so incredibly patient, sensitive to and interested in their amazing minds.  She has helped my daughter accept being dyslexic.  It wasn’t quick, and it wasn’t cheap, but the therapy and the education has been worth every penny, miles of carpool, and thousands of hours of time.

I always hoped the day would come as my sister suggested it might, that my daughter would be able to say to me and my wife the truth about her experience.  That day came about a month ago.  It happened when my daughter was having a brown out (unable to recall from memory knowledge she had the day before) and struggling with homework.  She was tired and frustrated and then just began to weep.  She said to me, “You don’t understand what it’s like.  I have to work so hard and sometimes I just can’t remember or find things in my mind.  And you aren’t dyslexic.  You and mom never have these kinds of problems and you’ll never know what it is like.”  I knew then that she had really begun to develop a place of deep acceptance of herself and that she could now tell me what was so painful, that things were easier for me, that she was different than her mom and me.  It was a deep expression of psychological security and healing.

I still get anxious – currently I worry about next steps as we begin to look at high schools – but I am not as scared.  And when I can sit back and just see what she has accomplished I am filled with the deepest respect and love for her.  I have to keep working on having faith so my own fears don’t get in her way.  I now believe that she is going to have an amazing future.  She is the strongest person I have ever known.

How does your daughter feel about herself today?

Well you’d really have to ask her.  What I see is that my daughter is learning, she values her unique out-of-the-box thinking mind, she wants to be a scientist, she has learned to be quite flexible, and has a full social life of friends.  She is able to laugh and recently just happened to say how she doesn’t feel angry any more.  We owe a great debt to all those who have supported her and us.  Both my wife and I feel that educational advocacy for this population of people will be our life’s work.  Every child and family should have this kind of success, whether they have money or not.  It is the right of every child to learn and grow to their fullest potential.

Sex addiction and sex offending: a growing and dangerous relationship

Before the Internet, people were forced to great lengths to commit a sex offense. Sex offenders were typically either compelled by a paraphilia or didn’t give a damn about the laws of society.  People who suffered from a sexual addiction, on the other hand, typically acted-out through legal means, such as having affairs or casual sexual encounters; the most common illegal means being the hiring of prostitutes.

Subsequent to the Internet, there has been an explosion of out-of-control and illegal sexual behavior. Activities such as viewing child pornography, soliciting sex with minors through chat rooms, and others are much more common.  Some of this has to do with the obvious fact that the Internet makes these activities much more available and easy.  However, there are other factors as well, such as an illusion of privacy while doing it, lack of immediate consequences for these actions, an idea that others are doing it to (that makes it feel less taboo), and that the need for new stimulation often leads to widening exploration.

Of course, some people committing sex offenses might have otherwise anyway, and there are still those driven by paraphilias or who are highly antisocial.  But some sex offenders are more aroused to the illicit and forbidden nature of the material or acts than to the actual material or act – it is the taboo that is exciting.  Many people committing sex offenses today are otherwise law-abiding citizens who may not have ever crossed the line to commit illegal sexual acts if it weren’t so easy and if they couldn’t do it from the privacy of their own home, and are truly shocked when they are discovered and/or arrested.

Does all of this make it okay or excusable to commit a sexual offense?  Absolutely not.  A sex offense is a sex offense because there is a potential victim involved – and the possibility that someone is harmed. However, it may be information that is important for us to think about when it comes to sentencing and (ideally) treating an individual who has committed a sexual offense.  Now more than ever we should be thinking about the possibility of a sexual addiction as the driving force of a sex offense, and that the standard treatment models for sex offending may not be a complete model.  Likewise, the sex addiction specialist who is working with a sex offender may not have all of the tools that he or she needs for a comprehensive treatment.

These two areas – sex addiction and sex offending – are increasingly entwined in a growing and dangerous relationship.  And yet the fields of sex offender treatment and sex addiction treatment remain fairly isolated from one another.  Many sex addicts who get caught up in illegal activities and prosecuted end up in sex offender treatment with their addiction untreated.  And many sex offenders who have not yet been caught end up in sex addiction treatment with a provider who has little or no training regarding work with sex offenders.  It would behoove us to create as much dialogue as possible between these fields, so that we may grow to meet the needs of this ever-increasing population of people who need our help – within a society that needs us to help them.

Samantha Smithstein, Psy.D.

Sometimes what you need is hard to swallow

Frequently when a therapist suggests that his or her patient might be helped by psychotropic medication the suggestion is met with concern, doubt, or even anger. This is even the case when a patient has been suffering for years from mood, impulse, or attention-related issues. Additionally, often patients try medication, experience relief, and then decide abruptly to stop taking medication without consultation with their therapist and psychiatrist; often while simultaneously self-medicating with illegal drugs, alcohol, or unhealthy behaviors. This can be especially true during the holidays, when the pressure to be happy is intense, the feelings of depression are frequent, and the availability of unhealthy behaviors is high.

No doubt prescribed psychiatric medication is not a perfect science: there are side-effects and sadly medication doesn’t always work and provide the relief of symptoms and quality of life improvement sought by the patient. However, all too often side effects and/or the efficacy of the medication are not the reasons people stop taking helpful medication. Instead, the reason expressed is more likely to be “I just don’t want to be on medication (for the rest of my life).” Why?

Unfortunately, in large part this is because there remains serious stigma, shame and fear of psychiatric medication and psychological treatment. According to NARSAD, the Mental Health Research Association, one in five Americans suffer from mental illness in a given year but only one-third seek treatment. In San Francisco it is estimated that close to ten percent of the population suffers from a serious mental illness. In a recent study, psychiatry residents – those doctors learning to help people with mental illness – acknowledged that while they would tell others about being in psychotherapy, they had not admitted to anyone that they were taking psychotropic medication because of the perceived stigma even amongst their peers and superiors. In a study earlier this year, it was found that even the drug companies that market psychotropic medications to doctors were perpetuating rather than breaking-down the stigma attached to mental health problems.

Of course, the ads from the medication companies and fears of the psychiatry residents are simply a reflection of the societal stigma that still exists. And yet medications have given so many people a chance at living a happier, more fulfilled life. Rather than a weakness, character flaw, or sign of a mental deficiency, a psychiatric condition is a medical condition that needs to be treated. Without a doubt, there are many ways to approach psychological problems without medication. This can range from psychotherapy, to meditation and/or yoga, to exercise, to lifestyle interventions, or some combination these interventions. But in some cases, just as with any medical issue, medication can make a tremendous difference. For example, medication can make a profound change in a patient who has been in psychotherapy for years and has made tremendous progress psychologically, emotionally, and in making healthy lifestyle choices, but remains unable to shake a pervasive negativity about herself that makes it very difficult for her to achieve satisfying, intimate relationships. Once on a low dose of anti-depressants, she may find that the negativity has lifted and she is much more healthy psychologically and capable of relationships than she imagined.

Part of the resistance to medication is due to a societal backlash. Pharmaceutical companies make a profit from selling medication and our culture has a tendency to look for the easy answer to problems, sometimes in a pill. Many have turned to medication inappropriately – over-medicating our children or those struggling with mental illness. It has become clear through these experiences and in research that medication is not always the answer and most often not enough as a solution. However, it is also clear that in some cases medication is one tool in the toolbox of interventions that can make a tremendous difference.

Samantha Smithstein, Psy.D. and Elizabeth Corsale, MA, MFT

Diagnostic conundrum part 2: compulsive behavior as an anxiety disorder

In a previous article, “process addictions” such as addiction to sex, stealing, food, etc. were explored as legitimate disorders and inclusion was called for in the diagnostic manual. One possibility explored in that article was that it be included in the category of “Substance-Related Disorders,” since the experiences of people who feel compelled to repeat these behaviors are often highly similar to the description of the experiences of people dependent on substances (the diagnostic criteria).

There is, however, another category of diagnoses under which process addictions could potentially be included: that of Anxiety Disorders such as Obsessive-Compulsive Disorder. A person with Obsessive-Compulsive Disorder has recurrent and persistent disturbing, intrusive and inappropriate thoughts or impulses that they cannot ignore or suppress. This person then feels driven to perform a behavior in order to reduce the thoughts or impulses. The behavior is either not realistically connected to the thought or is excessive.

Most traditionally, obsessions are related to fears (getting ill) and compulsions are related to simple, common acts such as hand washing, ordering, checking, counting, or repeating words silently. The person may even rationally know that the behavior won’t make the fear/thought go away, but they still feel compelled to action, over and over again.

However, it is possible that some people attempt to quash the intrusive thoughts or fears  by behaviors such as shopping, eating, or masturbating, and that the person feels driven to this behavior in spite of knowing that it will not, ultimately, solve their problems. Often people describe an experience of feeling anxious, alone, or generally “uncomfortable.” They seek out a behavior in an effort to feel better, even as they are aware that when they are done, they will feel even worse.  Sometimes they find themselves repeating the behavior over and over, such as masturbating for hours even after it ceases to feel pleasurable.

This way of thinking about compulsive or “addictive” behaviors is a less common way of conceptualizing it, but for some, it may be exactly what ails them.  And, as in the case of substance dependence, inclusion in the new diagnostic manual could get them the help (and medical coverage) they need.

Samantha Smithstein, Psy.D.

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