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Saturday, June 19, 2010

Boundary Violations and Sexual Exploitation in Psychotherapy

In my last article, I discussed the topic of  How Psychotherapists' Self Disclosure Affects the Relationship with Clients.  As I mentioned in that post, boundary violations between psychotherapists and clients often begin on the "slippery slope" with inappropriate self-disclosure by the therapist. In this article, I will focus on when boundary violations occur where there is sexual exploitation of clients by their psychotherapists.

What Are "Boundaries" in Psychotherapy?
The term "boundaries" in psychotherapy is a metaphorical term that refers to the definition and professional structure of the psychotherapy relationship. It defines the psychotherapeutic relationship as being different from a personal relationship or a friendship. The boundaries of the psychotherapeutic relationship include, but are not limited to, the time that the psychotherapist and client spend together in a professional setting, the fee arrangement, the psychotherapist's self-disclosure, the type and frequency of between-session phone calls, the prohibitions with regard to physical touch, and other related issues.

The purpose of maintaining appropriate professional boundaries in psychotherapy is, first and foremost, to protect the client from inappropriate behavior by the therapist which can be psychologically harmful. Secondly, maintaining appropriate professional boundaries also protects the therapist with regard to accusations of unethical and illegal behavior which could result in malpractice lawsuits, professional sanctions and, in the worst cases, revocation of professional licenses and/or arrests.

As I mentioned in my prior article, it is always the therapist's responsibility to maintain appropriate professional boundaries in treatment, regardless of whatever the client might do or the type of therapy.

How Often Do Boundary Violations Occur in Psychotherapeutic Relationships?
It is difficult to come up with accurate numbers because many boundary violations, especially sexual exploitation, are not reported. Many clients feel ashamed and blame themselves for the boundary violations.

Most boundary violations occur with male therapists who are older, more established, and also well trained. This is not to say that boundary violations never occur with female psychotherapists. However, based on available data, it seems to be less prevalent. In the US, it is estimated that nearly half of all malpractice suits are related to psychotherapists' sexual exploitation of clients and most of these suits are against psychiatrists.

The good news is that these type of boundary violations seem to have decreased somewhat over the years, possibly due to stiffer penalties, professional sanctions, refusal of malpractice insurance companies to provide insurance to therapists who have transgressed with clients, and better training. While this is good news, even one boundary violation between a therapist and a client is one too many.

Non-Sexual Boundary Violations that Can Lead Down the "Slippery Slope" to Sexual Exploitation:

Excessive self-disclosure: See prior blog post

Dual relationships:
Most mental health professionals' codes of ethics prohibit dual relationships because it is recognized that this is usually harmful for the client. The psychotherapeutic relationship should be the only relationship between therapist and client. Even when the dual relationship is not sexual, it violates the professional boundary between therapist and client. For instance, if a therapist has a client who happens to be stock broker, the therapist should not ask the client for stock market advice and, it goes without saying, that the therapist shouldn't ask the client to handle his or her money for stock market transactions. Once the professional boundaries have been breached, the treatment is placed at risk for even greater boundary violations.

Too Many Unnecessary Phone Calls Between Sessions:
While most therapists recognize the necessity of some phone calls between sessions to reschedule appointments or to help clients who are in a particular crisis, most therapists also know that too many unnecessary phone calls between sessions should be explored during in-person sessions with the client. Needless to say, I'm not talking about clients who are home bound or sick and have phone sessions with their therapists. Rather, I'm referring to clients who might not understand the professional treatment frame and who want to treat their therapist like a friend. As in all of these examples, it's up to the therapist to address the issue and set appropriate limits.

Therapist's Failure to Maintain the Treatment Frame:
While it is understood that there are times when certain clients might need extra time in a therapy session due to a crisis or they might need a temporary fee agreement due to financial necessity, when the therapist fails to maintain the treatment frame on a frequent basis with a particular client, this is usually indicative of the therapist's boundary violation in the treatment, which might be conscious or unconscious on the therapist's part.

I often work with clients on a sliding scale basis, when I have available open slots to do so. I have also extended my services to longstanding clients on a pro bono basis for a limited amount of time when they've lost their jobs. However, in all these instances, I've carefully considered the particular circumstances of the client and the nature of our professional relationship to make sure that I'm not enacting a boundary violation by giving "special treatment" to certain clients. If it's clear that a client can afford to pay the full fee, I see no reason to provide a sliding scale fee and I would see this as an unprofessional enactment with the client.

Touching or Frequent Hugs:
As a matter of course, I do not touch my clients. I am very aware that, for many clients, touching has particular inappropriate implications, especially for clients who were sexually abused, and even more so in cases of incest. The therapeutic relationship can often take on the appearance and feeling of a parent-child relationship. It's very important for the client to feel that he or she can trust the therapist. No matter how non-hierarchical or egalitarian a therapist might try to be, the client-therapist relationship is, by definition, an unequal relationship where the therapist has more power than the client--even in therapy relationships where the client is a therapist.

Like most examples, there are some limited exceptions. At the conclusion of a long-term therapy relationship, many clients spontaneously hug their therapists. This is usually an expression of their gratitude and caring for the therapist. While I don't initiate these hugs, I would not hurt a client's feelings by trying to ward off a hug under these circumstances.

The problems with touching and frequent hugs is that they can easily develop into more inappropriate seductive touching of an intimate or sexual nature, once again, crossing the therapeutic boundaries of treatment.

The above list is certainly not exhaustive, but it represents some of the more common non-sexual boundary violations that often lead to sexual boundary violations.

To illustrate the points that I have made above, the following fictionalized account is an example of a sexual boundary violation between a psychotherapist and his client:

Betty began attending psychotherapy sessions with Dr. Smith after she lost the third job in a row for getting sexually involved with her supervisor. Dr. Smith was highly recommended to her by a friend as a psychiatrist who was both a psychotherapist and psychopharmacologist.

Betty, who was in her mid-20s, had never been in therapy before, so she didn't know what to expect. Dr. Smith talked to her about what would be expected of her with regard to the treatment frame (i.e., coming to sessions regularly and on time, paying fees in a timely manner, the length of treatment sessions, and other related issues). He also talked to her about his professional obligations with her.

After several sessions, Betty began to have erotic feelings for Dr. Smith, which is not unusual in psychotherapy. This is often part of clients' transferential feelings for their therapist. Most of the time, these tranferential feelings have little to do with the therapist and more to do with the client's underlying, unconscious issues.

Betty tended to be seductive in her relationships with most people, including her professors, work supervisors and other authority figures in her life. At that point in the therapy, she was unaware of how she attempted to sexualize her relationships. So, it was not surprising when she began to come to therapy with revealing, low-cut blouses and short skirts.

When Dr. Smith addressed and explored this seductive behavior in therapy, Betty wasn't sure how to respond to this. In the past, due to her seductive nature and the fact that she was extremely attractive, most people responded to her seduction by engaging in sex with her. Although she usually felt powerful at first, these sexual encounters ended up being emotional disasters for her. It was the cause of many problems for her in college as well as in her work relationships with supervisors.

As the therapy progressed, it came to light that Betty had been sexually abused by her maternal uncle from the time that she was 10 until she was in her late teens. According to Betty, it began with inappropriate touching and progressed to sexual intercourse when she was in her teens. As an only child of a single, alcoholic mother, Betty craved attention and she was easy prey for her uncle, who lived with Betty and her mother.

Although she felt that her uncle's sexual attention was wrong, she was vulnerable to him because she was an emotionally neglected child. She also told herself that she must be "special" for her uncle to want to spend time with her in this way, so she never told anyone about it. The only reason that the incest stopped was because as Betty got older, her uncle, who turned out to be a pedophile with other children too, no longer found her sexually exciting. As is often the case with pedophiles, he needed to enact his sexual transgressions with children so he stopped approaching Betty in a sexual manner. And, even though she attempted to seduce him back into their incestuous relationship to get his attention, he "abandoned" her, presumably, for a younger child.

Having been sexually violated at such a young age, Betty learned to sexualize most of her relationships with men when she wanted attention. As a result, she continued to enact the sexual transgressions as an adult but, instead of being the one who was seduced, she took on the role of the sexual aggressor, albeit with adults and not children, to continue to get attention and gratify her emotional needs.

When Dr. Smith did not respond to her sexually provocative clothing in session, she began calling him between sessions "to chat." Dr. Smith responded to her calls by telling her that, unless she had an urgent matter or she needed to change an appointment time, she should wait for their next therapy session to talk to him. Undeterred, Betty began leaving frequent voicemail messages for Dr. Smith late at night, letting him know that she was thinking of him and couldn't wait to see him again.

At that point, Dr. Smith consulted with his former, more experienced clinical supervisor to get clinical advice on how to handle this client. His supervisor knew Dr. Smith well and knew him to be an ethical psychiatrist. However, he also knew that Dr. Smith was going through a tumultuous divorce, he was lonely, and he could be vulnerable to Betty's seduction. He reminded Dr. Smith of his professional and ethical obligations under their professional code of conduct. Then, he asked Dr. Smith about his countertransferential feelings for Betty. Dr. Smith admitted to his supervisor that he found Betty very attractive and sexually tantalizing, as most men probably would. However, he told his supervisor that he didn't want to cross the professional boundary with this client.

Dr. Smith's supervisor told him that if he could work out this issue with Betty, it could be an important breakthrough in her treatment and she could deal with the original incest rather than continuing to engage in sexual enactments. However, he also told him that if he thought that he might violate the therapist-client professional boundaries with Betty, he should refer her to another therapist, preferably a woman. Dr. Smith's supervisor knew that Dr. Smith had a narcissistic streak to his personality, and he assured him that referring the client to another therapist would not be considered a professional failure. Rather, it would be a wise move to protect the client and to protect himself from crossing the professional boundary, especially at a time when Dr. Smith was in so much emotional turmoil himself and he was feeling lonely.

Dr. Smith agreed to consider the wise advice of his clinical supervisor. He knew that he actually felt more tempted than he admitted to his supervisor to breach the professional boundaries of the relationship, but he also knew that he would perceive himself as a failure in this case if he referred Betty to a colleague, and he was determined to work through the transferential and countertransferential issues in this case.

As treatment continued, Betty continued to be seductive with Dr. Smith. The more he attempted to maintain the treatment frame, the more determined she appeared to be to violate it. He attempted to talk to Betty about her uncle's sexual abuse, but she would find ways to bring the conversation back to her erotic feelings for Dr. Smith.

During that same time, Dr. Smith was feeling increasing emotional pressure from his divorce proceedings, which became nasty and heated. He was receiving email messages from his wife telling him that she thought he was "less than a man" and he was "spineless." His lawyer encouraged him to settle on his wife's demands and put the whole thing behind him, but Dr. Smith didn't want to give up the battle.

This resulted in many sleepless nights, poor appetite, and the beginning of his isolation from friends, family and colleagues. Within a few months, he felt like an emotional wreck. He knew that he should probably take a short sabbatical from his private practice, but he didn't want to admit that he needed a rest, so he continued to see clients, including Betty.

At the end of a particularly difficult week where he had gotten very little sleep and he was emotionally and physically exhausted, Dr. Smith saw Betty for her usual weekly session. As usual, she was wearing a sexually provocative outfit and she talked to him about her erotic feelings for him. Whereas in the past, she limited herself to telling him that she was "turned on" by him and would like to have sex with him, this time, she was more sexually explicit. Dr. Smith felt himself getting sexually aroused, but he maintained his professional demeanor. However, by the end of the session, when Dr. Smith and Betty stood up for her to leave, she locked the door and began kissing him on the mouth. Emotionally depleted by his personal problems, Dr. Smith gave in to Betty's sexual advances during that session.

By the time Betty left, Dr. Smith began to panic and he called his clinical supervisor for an emergency session. His clinical supervisor met with Dr. Smith, reprimanded him for violating the client-therapist boundary, and told him that he needed to apologize to Betty and tell her that he could no longer see her and he would refer her to a female therapist. He told him take a sabbatical from his private practice, seek his own personal therapy to deal with this transgression and with his overwhelming personal problems, and consult with a malpractice attorney in case Betty took action against him.

He also told Dr. Smith that he was obligated to report this sexual exploitation to their ethics board who would investigate the case. In addition, he told Dr. Smith that if he did not agree to follow all of these recommendations, he would also report that to their professional ethics board immediately and advocate for his license to be suspended.

Dr. Smith felt a lot of remorse for crossing the client-therapist boundary. He knew that, regardless of his personal problems and regardless of how seductive Betty was, as a mental health professional, he was responsible for maintaining the professional boundary between them.
When he apologized to Betty and told her that he could not see her again, she was crushed. This boundary violation and termination of treatment represented a repetition of her earlier problems with her uncle. Dr. Smith referred Betty to a seasoned female colleague, admitting that he had violated the therapeutic relationship and expressing his remorse.

Over time, Betty was able to work through the sexual exploitation in her therapeutic relationship with Dr. Smith as well as the original incest with her uncle. It was not easy or quick, and Betty also tested the professional boundaries with the new therapist. However, ultimately, her therapy was a success.

Dr. Smith took a sabbatical from his private practice. He entered into his own personal therapy to deal with the boundary violation as well as his divorce and loneliness. He also consulted with a malpractice attorney. After long and careful consideration, he decided to change his career focus from his psychotherapy private practice to psychotherapy research.

As this fictionalized scenario demonstrates, even when the psychotherapist is determined to maintain professional boundaries and seeks out clinical supervision to deal with the erotic transference and countertransference, there are so many personal and professional factors that can jeopardize a treatment.

Psychotherapists need to be emotionally attuned to their own professional and personal vulnerabilities before they slide down the "slippery slope" of crossing boundaries with a client.

Although the fictionalized account that I presented was between a heterosexual therapist and client, these boundary violations also occur among gay and lesbian therapists and clients.

In most cases, sexual exploitation in psychotherapy doesn't occur immediately. It usually follows after minor boundary violations turn into larger violations, culminating in the most egregious violation of sexual exploitation.

Also, in many cases where there is sexual exploitation in therapy, the psychotherapist, and not the client, is the aggressor. So, it goes both ways.

I intentionally presented a fictionalized account where the client is seductive and has a history of seducing authority figures due to childhood incest because this is a common scenario. Also, I wanted to demonstrate that even if cases where clients are extremely seductive, the therapist is the one who is still accountable for maintainng profesional boundaries.

If you are a psychotherapist who has crossed professional boundaries with your client, it is very important that you seek clinical supervision, no matter how long youve been practicing or how experienced you are. In most cases, therapists who have violated clients' boundaries should also seek their own personal therapy to work through these issues and do some soul searching as to whether they are in the right profession.

If you are a client who has been sexually exploited in therapy, don't suffer in shame alone. Although it might be hard for you to trust another therapist again, first, seek out a psychotherapy recommendation from your doctor or a trusted friend to work through this abuse.

Second, if you should decide to take legal action against this therapist for what he or she did to you and because you suspect that the therapist might be perpetrating this inappropriate behavior with other clients, seek out the advice of the ethnics board for the professional organization with whom the therapist is affiliated. So, it would be the American Psychiatric Association for psychiatrists, the American Psychological Assocation for psychologists, and the National Association of Social Workers for clinical social workers. You can also seek out the advice of the ethnics department for the State licensing board, who provides licensure for that particular profession. You can find this information online for your particular State.

I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist.  I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (212) 726-1006.

Friday, June 18, 2010

How Psychotherapists' Self-Disclosure Affects the Therapeutic Relationship with Clients

The topic of psychotherapists' self-disclosure is still a controversial and much-talked about subject in therapeutic circles. I believe that most psychotherapists try to strike a balance between rigid adherence to no self-disclosure vs. too much self-disclosure. The primary goal should always be that self-disclosure is in the interest of the work with the client and not based on the needs of the therapist.

How Psychotherapists' Self Disclosure Affects the Therapeutic Relationships with Clients
The Problems with Too Much Self-Disclosure:
The problems with too much self-disclosure are many. First and foremost is that too much personal self-disclosure can lead to boundary violations between psychotherapists and their clients, the most egregious being sexual violations. Studies have shown that, when there were sexual boundary violations between psychotherapists and clients, it most often occurred along a slippery slope when psychotherapists began by divulging too much personal information to clients, creating a sense of intimacy in the therapeutic relationship that was inappropriate. In these cases, regardless of the type of therapy or the client involved, the therapist is always responsible for boundary violations.

Another problem with too much self-disclosure on the part of the psychotherapist is that the treatment should be focused on the client, not on the therapist. So many clients come to therapy because they were emotionally neglected in their families of origin or they just were not "seen" in their families, so that the psychotherapist should not, however unwittingly, replicate this experience in therapy.

Psychotherapists who find themselves either disclosing a lot about themselves indiscriminately to their clients, or who are tempted to self-disclose a lot, should seek professional supervision to deal with this issue and/or seek their own personal therapy because something is a miss and needs to be rectified before clients are hurt by this.

Several years ago, I remember talking to a client who had just left a prior therapy because her therapist tended to focus the therapy on herself rather than the client. The client was struggling with a breakup and the therapist divulged that she had also just gone through a breakup in her relationship.

The client felt that the therapist completely hijacked their sessions with the personal details of the therapist's breakup. This particular client had a history of feeling "not seen" by her mother, who always tried to "one up" the client with whatever problem that client had as a child. If the client was feeling bad about something, her mother made it a point to tell her that she was feeling worse. The client had a very emotionally depriving experience when she was growing up, and the prior therapist, who seemed caring in other ways, had, without realizing it, created the same experience in therapy.

As I often do, with the client's permission, I called the prior therapist and we discussed this aspect, as well as other aspects, of the prior therapy. Unfortunately, this therapist was not very well trained, and prior to our conversation, she had no idea how her self-disclosure had affected the client. Worse still, there seemed to be no therapeutic reason for her self-disclosure, how ever misguided that might have been. There seemed to be no forethought about it at all. Although she seemed to be a very caring person, she just had very poor boundaries in her psychotherapy sessions. It was not my job to criticize or correct her. I only wanted to understand, from her perspective, what happened, since I was dealing with the aftermath of this boundary violation in the current therapy with this client.

Psychotherapists Must Self Disclose Based on What is Best for the Client
Another problem with too much self-disclosure is that it affects the client's transference in the therapeutic relationship. On the most basic level, transference can be understood as the feelings (often projected, but sometimes quite accurate) that the client has towards the therapist. Many times, the client transfers his or her own feelings for a mother or father onto the therapist. If a therapist is psychoanalytically or psychodynamically trained, he or she will use the transference to work through the client's issues. Working through the transference usually provides an emotionally safe place for clients to work through issues in therapy that they could not work through with their families of origin. Obviously, the more that a client knows about his or her therapist, the less room there is for transference, so it deprives the therapist and the client of an important aspect of the therapeutic environment for healing and growth.

How much self-disclosure is too much? Reasonable people can disagree. Like most things, it depends on the particular client-therapist relationship. It's usually obvious to most therapists when self-disclosure, or a client's demands for self-disclosure, are starting to go down the seductive slippery slope to possible boundary violations in the treatment, and this needs to be dealt with and avoided for the safety and effectiveness of the treatment.

But what about inadvertent self-disclosure? By this, I mean self-disclosure that might occur unintentionally.

For instance, I remember a psychiatrist, who was a psychoanalyst, telling me years ago that one of his clients felt deeply crushed when he saw the psychiatrist driving a Chevy rather than a Mercedes Benz or some other luxury car. The client just happened to be walking along the same street where the psychiatrist was driving, so this was not a planned event and no one could accuse this psychiatrist of perpetrating a boundary violation. Yet, the client was extremely upset because, in his transference towards the psychiatrist, he needed to see his psychiatrist in a particular way, and seeing him driving in a Chevy didn't fit with the picture that he needed to have of him. According to the psychiatrist, this incident was the subject of numerous psychotherapy sessions with this client, who felt that his image of his psychiatrist was shattered.

In this case, the transference, which was positive before this incident, quickly became negative. The client was disillusioned and disappointed because he needed to see his psychiatrist as being "powerful," and "powerful" to this client meant that the psychiatrist should drive a luxury car. This incident was all "grist for the mill" in therapy and, ultimately, the client and the therapist were able to explore the multiple layers of meaning that it had for the client and how it related to deeper psychological issues relating to his father. The client longed for his father to be "powerful" when he was growing up but, unfortunately, he often saw his father disempowered. So, ultimately, what started as a source of pain and disappointment for this client turned into a rich and fruitful topic to be mined by the psychiatrist, who happened to be an extraordinarily talented and caring psychoanalyst.

In my own experience, I have run into clients outside the therapy room several times over the years. While this is often a common occurrence in small towns, you wouldn't think it would happen too often in NYC, but it does. My experience has been that, for some clients, running into their therapist in a restaurant or in the neighborhood, is not a big deal. For other clients, it's a deeply exposing experience. They prefer to think of their therapists as remaining in the therapy room until their next session. Some clients will express curiosity about these incidents and others don't want to know anything and they are uncomfortable even discussing how it made them feel to see their therapist outside of the therapy room. Once again, this is all rich material to explore in treatment and it often has deeper meaning.

After my psychoanalytic training, I obtained training in the substance abuse field. Initially, I was surprised and somewhat concerned about how much substance abuse counselors disclose to their clients. Many, although not all, substance abuse counselors are recovering addicts themselves and often disclose their experience to clients who come for treatment. Most of the time, I think this is done in service to the clients so they know that their counselors understand, on a personal level, what they're going through. It's a sort of "joining" with the client. I understand now that it often helps to dispel the shame that many clients feel about their addiction. It also raises the question, which is too large a topic for this article, of whether a therapist or counselor must have the same experience as the client in order to be effective.

I would say that self-disclosure under these circumstances has many factors to be considered. In many cases, it can enhance the work, but I've also seen cases where it was detrimental because the therapist or counselor can make certain assumptions about the client, which might not be true. So much will depend on the training and expertise of the particular professional involved. However, I believe that, like any form of self-disclosure, this should be done with much caution and forethought for the particular client involved, and it should always be in the primary interest of the client and not the counselor.

The Benefits of Carefully-Attuned Self-Disclosure in Psychotherapy:


The Benefits of Carefully-Attuned Self-Disclosure in Psychotherapy
Compared to prior times, when psychotherapists were encouraged to be "blank slates" to their clients, which was unrealistic and often emotionally depriving to clients, most psychotherapists today recognize that some self-disclosure, when done in a therapeutically appropriate way, can be beneficial, at times, to clients. Also, even when a therapist does not make overt self-disclosures, clients who are astute often intuitively pick up on aspects of the therapist's personality or the therapist's state (e.g., the therapist looking tired), so that, in my opinion, therapists are never complete "blank slates."

Once again, I believe that therapists need to be exquisitely and carefully attuned to the particular client and the particular client-therapist relationship and what effect self-disclosure will have on the treatment.

Self-disclosure should always be done when it will be in service to the client's treatment and not to satisfy the needs of the therapist. Making that distinction is not always easy. Many therapist, especially those who are in full-time private practice, feel isolated at times in their work and, if they are not careful, they can self-disclose as a way of satisfying their own emotional needs rather than serving the client. This is also why it's so important for therapists to have rigorous professional training, including clinical supervision, and also have rich personal and collegial relationships.

So, when would self-disclosure be beneficial to clients and under what circumstances?

Often, psychotherapists will self-disclose judiciously when it's what the client needs at that time. For instance, some gay and lesbian clients want a therapist that they know is an "out" gay or lesbian therapist from the outset. For psychotherapists who are open to self-disclosing their sexual orientation, they will often be open to clients who only want a gay or lesbian therapist.

However, although this is often a positive use of self-disclosure, it cannot be assumed that this self-disclosure won't also create problems in the therapy with regard to some client's transference issues. Just like any other topic, a client can project his or her own feelings of inadequacy or internalized homophobia onto a therapist who self discloses that he or she is gay. And what might start out as the client's positive transference to the therapist could turn into a negative transference quickly. But, once again, if a therapist is psychoanalytically or psychodynamically trained, both the positive and the negative transference are useful in furthering the treatment.

Psychotherapists Must Use Good Judgment When Self Disclosing
Other beneficial self-disclosures might be much smaller and less personal. For instance, in the case of a client who came to therapy because she had difficulty asserting herself, she had a particular problem one day asserting herself with her insurance company. She was getting the runaround and she was being bounced from one representative to another. The result was that her hospital claim, which should have been paid by the insurance company, was not being paid and the client was getting bills from the hospital. At that point, I told her how I was faced with a similar issue for a professional insurance claim (not a personal claim), and how I was able to handle it with the insurance company.

When deciding how to respond to this client, who was feeling particularly helpless in this situation, I could have just provided her with information about what to do. But I thought it would be much more helpful to provide this information in the context of my own frustration with a professional claim that was not being paid and how I was able to overcome this problem by asserting myself with the insurance representative and asking for a supervisor.

It's important to note that I knew this client very well, and I knew the timing of this self-disclosure was right. We had been working together for a while, and I knew that this would be helpful to her for her particular problem and also helpful to our work together. As I assumed, she felt relieved that she was not alone in having problems with insurance companies and that I had struggled with the same issue and overcame it. I "joined" her with where she was at that particular time, and she didn't feel alone with her problem any more. She felt empowered and she was able to use this information to assert herself to get the bill paid.

However, if this was a client that I didn't know well, I probably would not have self disclosed in the same way because I couldn't be sure if this would serve the client or not. For instance, where there is a negative transference, this self disclosure might exacerbate the negative transference. Or, where clients don't want to know anything at all about the therapist, whether it is personal or professional, because they find it too impinging on them, I wouldn't have made this disclosure.

Self-Disclosure that Cannot Be Avoided:
Even the psychotherapist who is most conservative with regard to self-disclosure often finds him or herself in situations with clients where self-disclosure is unavoidable. In these cases, self-disclosure must be handled as carefully as possible. For instance, when a therapist becomes sick, he or she must often cancel clients' sessions. Recently, I lost my voice to laryngitis, and I had to cancel my sessions for several days until I recovered my voice. Fortunately, this did not cause problems for any of my current clients.

However, in the past, with certain clients who felt very emotionally vulnerable and who needed to feel that I was always "strong" or clients who had a lot of loss (deaths in the family) even if I had a simple cold, this created a lot of anxiety for them. I understood this in the context of their history and knew that it would be very meaningful and emotionally threatening to them. This is completely understandable, and yet, many times, it cannot be avoided. However, if it is handled with sensitivity and empathy, even these emotionally threatening situations for vulnerable clients can lead to the realization that people can become sick and survive, and not all illnesses result in loss.

The key is often how this is handled by the therapist or whoever the therapist appoints to handle these types of situations when he or she cannot handle it him or herself. Recently, a friend was telling me that he might need a psychotherapy referral from me because his therapist was ill, and he was not sure if the therapist was returning to his private practice. He told me that the therapist did not look at all well during their last session and when he called to make his next appointment, the therapist's wife told my friend that the therapist was very ill, and she asked my friend "not to call again."

Needless to say, this was very disturbing to my friend, who had been attending treatment with this therapist for over a year due to several close deaths in his family. He felt he had a strong bond with this therapist, and hearing the news that his therapist was seriously ill was very upsetting to him because he cares for his therapist but also because it triggered all of his feelings of loss and sadness. But being told "not to call again" by the therapist's wife was even more upsetting. It triggered the very issues that he came to therapy to work through, and it also made him feel completely shut out and emotionally abandoned.

Self Disclosure that Cannot Be Avoided
While it's true that spouses of therapists might not be trained on how to deal with this type of disclosure, it's the therapist's responsibility to leave instructions with a designated person, usually another therapist, on how to contact and work with clients in the event that the therapist cannot do it him or herself.

Another form of self-disclosure that often cannot be avoided is when a therapist will not be in the office due to a vacation. Most clients are able to handle this type of self-disclosure (i.e., the fact that the therapist will be on vacation, but not necessarily all of the details). However, some clients have a lot of difficulty with this, especially if the therapist is going to be away for an extended period of time. They might fear that the therapist might not come back or something will happen to the therapist while he or she is away and they will be abandoned. They might also be afraid that they won't be able to handle whatever might come up while the therapist is away. With clients who are vulnerable in this way, usually due to their own personal histories, I'll ask another therapist to be on-call in case a client needs to talk to a therapist while I'm away. In this way, clients who feel emotionally fragile during those times, often feel taken care of and know that there is someone that they can see, even if they never actually call on these therapists.

A colleague, who works with many clients who struggle emotionally as well as financially, told me that, even though she travels quite a lot on vacation outside of the country, she doesn't tell clients that she is going on vacation because she thinks it will make them feel badly that they cannot afford to go on vacation too. Instead, when she goes away, she always tells clients that she is going to a conference.

We had a lengthy discussion about this because it was an interesting topic with regard to psychotherapists' self-disclosure. On the one hand, I wouldn't want to second guess this colleague because she's the one who is actually "in the room" with these clients and has experience with them, whereas I'm hearing about this second hand. I also know that she happens to be a particularly empathic therapist and she thinks carefully about what she says and does beforehand so as not to harm clients.

On the other hand, I found it hard to believe that none of her clients could tolerate hearing that she was going on vacation and that, for some of them, it might be a good way to show that self care is important for their therapist as well as for themselves. Clients who tend to be focused on others and neglect themselves often benefit from hearing that their therapist is taking care of herself, and this type of self-disclosure can help them to reflect on their own self care or lack of self care.

Another example of an unavoidable type of self-disclosure is when a therapist is pregnant. For many clients, this is not an issue. They might react in a number of ways, including being happy for the therapist. However, for some clients, finding out that their therapist is pregnant is cause for much unhappiness.

About 10 years ago, a colleague told me that some of her clients were very unhappy about her increasingly obvious pregnancy. Apparently, there were women in her private practice who were trying, unsuccessfuly, to get pregnant and the sight of my colleague's growing belly was a source of sadness and envy for them. Other clients, both men and women, felt uncomfortable with the obvious sign that their therapist was a sexual being. Whatever the particular issue, all of this was discussed and explored in therapy by my colleague with her clients, and, in most cases, it was useful in working through their own personal issues as well as their transferential issues with my colleague.

With the advent of the Internet and all of the personal information that one can find on almost anyone online, clients can often find information about their therapists, including information that is readily available becasue it's public (e.g, political contributions) or information that is obtained by paying a service online.

What might it mean to a client to find out that his or her therapist made a political donation to a particular candidate? Maybe this won't fit in with his or her perception of the therapist. Will it be disappointng or affirming? What might it mean to the client to find out that the therapist owns property or is married (or not married)?

What does it mean when a client reads a therapist's professional blog? Will he or she inadvertently find out certain things that were not known before. Hopefully, the therapist is very careful with whatever he or she writes online. But even though many therapists are keeping professional blogs these days, for some clients, it's uncomfortable to read it, while for other clients it's a way to continue to feel connected to the therapist between sessions.

Obviously, this is a big topic and I haven't covered all of the issues involved with psychotherapists' self-disclosure to clients.

The most important aspect of this topic that I want to emphasize to clients and therapists alike is that, even though the idea of the psychotherapist as a "blank slate" has mostly gone by the wayside in recent years, self-disclosure should always be done carefully and always in the service of the client.

Clients need to feel that their therapist is caring and has a positive regard for them. This includes the therapist protecting the therapeutic boundary with empathy and respect for the client to avoid boundary crossings.

I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing.

I work with both individuals and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up an appointment, you can call me at (212) 726-1006.

Also, see my article:  Boundary Violations and Sexual Exploitation in Psychotherapy

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Wednesday, June 16, 2010

Asking for Forgiveness: The Power of Making Amends

Making amends is an important process in the addiction and mental health recovery as well as in many religions and in life in general. Recognizing that we have hurt other people, our behavior has had consequences for ourselves and for others, feeling sincere remorse, expressing our remorse, where appropriate, and asking for forgiveness are important parts of that process.


Making Amends with Loved Ones
Making amends can seem like a daunting process, especially if our transgressions have been recurrent and longstanding. As we come to terms with what we did, there is often a lot of shame associated with this recognition. As such, part of the process of making amends is to be able to forgive ourselves, which is often harder than asking someone else to forgive us.

The Power of Making Amends
When we're contemplating making amends, it's often helpful to work through this process with someone else: a sponsor (if you're in A.A. or one of the other alcohol or addictions 12 Step programs), a psychotherapist, or a trusted mentor or friend. Their support, knowledge and expertise can be invaluable as you struggle to sort out what you did, who you hurt, whether it's the right time to contact the person or persons you've offended, and how to go about making amends.

How and When to Make Amends
It's also important to realize that just because you have decided to make amends doesn't mean that the other person is ready to hear from you or to accept your apology. When we're considering making amends, we might enter into vivid memories of what we did in such a powerful way that we feel like we're reliving these old experiences, even though it might be many years later. But just because we might be in that emotional state doesn't mean that the other person is there too.

So, when we're thinking about making amends, it's important to use good judgment about the "who, when, where, why, how and what" involved. And, if you're either early in your recovery or in the early stage of whatever process you might be going through, you might not have developed good enough judgment yet about how to make amends. So, you might not realize that, in some cases, making amends might cause more harm than good, and you want to be mindful of this as you're going through this process.

But assuming that you've given your decision careful thought and you realize that asking for forgiveness is the right thing to do, how do you go about making amends?

Recognizing that every situation is different, the following is one particular scenario. It is representative of many different cases and not related to any one particular person. After I outline this scenario, I'll go over the steps that are often helpful when you're in the process of making amends.

Robert:
Robert was in his early 50s when he admitted to himself that he needed help for his out of control drinking and drug addiction. While he was getting help, he was also diagnosed with bipolar disorder. Until then, Robert knew that his life was out of control and that he had struggled with alcohol and prescription drug addiction for many years, but he had no idea that he had bipolar disorder.

During his inpatient dual diagnosis rehab, where he was detoxed from alcohol and painkillers and stabilized on drugs for his bipolar disorder, he had a chance to work on many of his addiction-related issues with the rehab counselor and his peers. At that point, Robert began to feel the emotional weight of how much he had hurt his family when he was active in his addiction and unstabilized with his mood disorder.

It helped him tremendously to be in a supportive environment where other people were going through a similar process, and he realized that he was not alone. However, he still felt somewhat overwhelmed when he thought about the pain that he had caused his wife and children.

Using the concept of "one day at a time," Robert was able to acknowledge that he hurt wife and children, as well as hurting himself, but not think too far into the future or too far into the past so that he was not completely overwhelmed with his shame and sense of remorse. He was also able to hang onto the idea that making amends would be a process that he could work out with a sponsor and in his after care treatment with a psychotherapist.

During family day at the rehab, Robert's wife and his two teenage daughters came to attend the educational series and to have sessions with Robert and his counselor. Robert's oldest son, John, who was in his 20s and living on his own, refused to come. John had gone through the worst of Robert's alcohol and drug binges and his rageful manic episodes, and he was unwilling to see or speak to Robert. Although it was very hurtful to Robert, he realized that he had no choice but to accept that his son wasn't ready and might not ever be ready to forgive him, and he could not control his son's feelings or behavior.

During Robert's sessions with his counselor and family, he acknowledged that he had caused his family a great deal of emotional pain, financial loss, and general upheaval in their lives. He also acknowledged that he realized that it might take a long time, if ever, before they trusted him again because he had breached their trust so many times. Robert expressed his sincere remorse, he took responsibility for his actions without making excuses for himself, and asked them to forgive him, if they could. He also told them that he realized that this would be a process and it wouldn't happen over night.

Robert's wife, Kathy, who had been very supportive of Robert during their 30 year marriage, talked to him about how important it was to her for Robert to finally acknowledge that he had a problem and that he hurt her and their children over the years with his addictive behavior and out of control manic episodes of rage, overspending, lost jobs, and the general chaos of their lives. She told him that she had loved him throughout their problems together and she still loved him. She was willing to start the healing process, but she knew that she would need time for her to trust him again. She also acknowledged that she was part of the dynamic and might have contributed to the overall chaos, and she wanted to understand this better by going to Al-Anon. But, overall, she was happy that he was getting help, and she hoped that she could trust that his remorse was genuine and he would continue in his recovery after he got out of the rehab.

Robert's older daughter, Susan, talked about how his dual diagnosis problems had affected her, and how she feared that she might become an alcoholic, a drug addict, or she might be diagnosed with bipolar disorder one day too. She struggled to put words to feelings because this was all new to her, but she told him that she loved him and she wanted him to get better.

Robert's youngest child, Beth, was very anxious. She cried through most of the meeting, and she told Robert that she wanted to understand what was going on with him, but she didn't. She and Susan both agreed that they would go to Al-A-Teen meetings.

After Robert was discharged from the rehab, he began attending A.A. meetings, he obtained a sponsor, and he started seeing a psychiatrist for medication and a psychotherapist for psychotherapy. At times, he felt overwhelmed, but most of the time, he was grateful for the support he was receiving.

Over time, Robert made efforts to reach out to his son through letters because his son refused to take his calls. Writing these letters to his oldest child, acknowledging that he had hurt him, expressing his remorse, and vowing to try to make it up to him, if his son was willing, was one of
hardest things that Robert had ever done in his life. Doing it while he was also new to sobriety and new to the knowledge that he was bipolar was also a challenge for him. There were many days where Robert was tempted to pick up a drink or call his old dealer to get painkillers. During those times, he reached out to his sponsor and his therapist, as well as peers in his support network, to just get through the day.

John acknowledged Robert's letters with his own responses, where he expressed his own anger, sadness, and lack of trust for Robert. John wasn't sure that he wanted to accept his father's apology or that he wanted to forgive him. He was afraid that if he forgave him, Robert would think that "everything was okay" and Robert might disappoint him again. But he agreed, for now, to keep the lines of communication open through these letters and he held out the possibility that he might be willing to talk to Robert in the future.

Robert offered to talk to John, when and if John was ready, about anything that John might want to know about Robert's addiction and mental illness. He was very careful to make this offer not as an excuse for his behavior, but as a way for John to understand the background of these problems. But during the first few months of Robert's recovery, John wasn't interested or ready for any explanations.

In the meantime, Robert continued to work on improving his relationships with his wife and daughters. It was a slow, painful process but, over time, he felt that his relationships with his wife and daughters were getting closer. He also sensed that they were beginning to trust him.

Robert also continued to work on forgiving himself. He knew that he couldn't turn back time to undo all the damage that he had done, and this was a hard concept for him to come to terms with. But he continued to work on his recovery, meet with his sponsor, attend his psychotherapy sessions on a weekly basis, see his psychiatrist and take his medication.

About a year after Robert completed his rehab, he received a call from his son. It was so unexpected that Robert hardly knew what to say. John told him that he still felt a lot of anger and ambivalence towards him, but he also recognized that, underneath his anger and sadness, he still loved his father and he wanted to begin the healing process between them. Robert felt that this was one of the happiest days of his life, and he was very grateful to his son.

The scenario above gives you a glimpse of how complicated the process of making amends can be. As I mentioned earlier, everyone's situation and process will be different, but there are certain steps that can be gleaned from this that might be helpful to you or someone that you know.

Steps Towards Making Amends


Say That You Were Wrong:
For some people, saying, "I was wrong" or "I'm sorry" is one of the hardest things that they can do.

Say that You Were Wrong
Acknowledging to yourself and to the people that you hurt that you were wrong is a powerful first step. As previously mentioned, you need to use good judgment about this and make sure that if you're contacting someone to apologize, you won't do more harm than good. This isn't always obvious, but one possible example of many might be in a situation where your interjecting yourself back into someone's life might be too hurtful to them and their loved ones. For instance, if you've had an affair with someone who was married and contacting this person might place his or her marriage or family situation in jeopardy, it would probably not be a good idea to contact this person.

In all other cases, it's important that your apology is sincere. Express your remorse for what you did--without making excuses for your behavior. The minute someone senses that you're making excuses for your behavior, he or she will doubt the sincerity of your apology.

Now, making excuses is different from providing them with information about what was happening to you at the time--if they want to know. You can ask them if they want to know, and if they don't, you must respect that and not impose it on them. Above all, your intention should be to say you're sorry.

Say (and mean) that You Won't Do It Again:
For many people, when they hear someone apologize, the first thing that comes to their minds is the question of whether they can trust that person again. They might want to forgive the person who is making amends, but because trust has been broken in the past, they might be afraid to trust again.

Forgiveness and Renewal
When you're new to addiction recovery or to dealing with your mental health diagnosis, you might feel shaky yourself about whether you can live up to your words that you won't do it again. So, it might be necessary for you and the person that you're asking forgiveness of to put certain structures in place to help ensure that it won't happen again.

For example, if one of the things that you're asking forgiveness for is your compulsive gambling and that you spent the family's savings on your gambling addiction, one of the structures that you might put in place with your spouse is that he or she will handle the money. This can be an informal agreement or, if necessary, you might give your spouse power of attorney over the family finances, if this is appropriate. This can provide a feeling of safety for you and your family that even though you're sincere about not wanting to transgress again in this area, the particular structure that you've put in place will also support that effort.

Ask What You Can Do to Try to Make Up for Your Behavior:
Restitution is an important part of making amends. While you and your loved ones cannot go back in time to undo what has already been done, you can find out what your loved ones might want to help make up for the hurt that you have caused.

Ask What You Can Do to Make Up For Your Behavior
Even in situations where your loved ones can't bring themselves to forgive you and they are unwilling to allow you to make up for what you did, it can still be important for your own health and well-being to find ways to make restitution in your life.

This could mean that, when you've had enough time in your recovery, that you become a sponsor to people who are new to recovery to share your hope and wisdom, you volunteer your time to helping others, or that you find other ways to try to give back to others, even when you're unable to give back directly to the people that you've hurt.

Recognize that making amends is a process for yourself as well. You don't have to do it perfectly, although reflection and consideration before you start this process is an important step.

Also, recognize that other people don't always understand what it means to forgive. Some people might have the impression that by saying that they forgive you, they're telling you that what you did was all right with them, and they don't want to give you this impression. So, the people that you're asking for forgiveness from might have to go through their own process with this to understand what you mean and what it means for them.

When you first begin to recognize how much you've hurt others, you might only see the very top layer of hurts that go very deep. Over time, you might develop a deeper understanding of the implications of your behavior for yourself and others, and this brings its own challenges.

As previously mentioned, making amends can bring up a lot of feelings of shame and sadness, and I recommend that you find healthy support when you're going through this process.

I am a licensed NYC psychotherapist, hypnotherapist and EMDR therapist.  I work with individual adults and couples.

I have helped many clients to go through the process of asking for forgiveness and making amends.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up an appointment for a consultation, call me at (212) 726-1006.

Also, see my article:
When Your Efforts to Make Amends Are Rejected




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Tuesday, June 15, 2010

Psychotherapy Blog: Developing Curiosity and Self Compassion in Therapy

One of the most challenging aspects of beginning psychotherapy for many people is learning how to develop a sense of curiosity and compassion for themselves. Many clients begin psychotherapy with such shame and a harsh and punitive attitude towards themselves that it becomes very difficult for them to get past their negative feelings in order to heal and grow from their experiences.


Helping clients to moderate and transform their punitive sense of self is one of the biggest challenges for a psychotherapist during the early stages of psychotherapy. Developing a sense of curiosity and self compassion is often one of the early goals of therapy so that clients can be more open to self exploration and healing.

Developing Curiosity and Self Compassion in Therapy

The following vignette, as always, is a composite of many clients with no identifying information about any particular client:

Ronald:
Ronald began psychotherapy because he was filled with guilt, shame and self blame about his father's death.

Developing Curiosity and Self Compassion in Therapy

His father died of a sudden heart attack when Ronald was eight years old. At the time, Ronald's parents, who had a contentious relationship, weren't speaking. They often communicated with each other through Ronald, who was an only child. When they were not speaking to each other, it was not unusual for Ronald's mother or father to say to him, "Tell your father that dinner is ready if he wants to eat" or "Tell your mother that I'm going out for a walk."

At a very early age, Ronald grew up taking on an adult role between his parents. Since he was expected to fulfill a role that was far beyond his developmental capacity at such a young age, he was often filled with anxiety and guilt. He learned to be vigilant in his home environment, trying to "read" the mood between his parents, and anticipate what he could do to fulfill their needs.

One day, during one of those times when his parents weren't speaking, his mother told him to call his father to the dinner table. When Ronald went into the bedroom to get his father, his father told him that he wasn't feeling well and he needed to lie down for a while. When Ronald told his mother this, she became angry and began banging pots and pans on the stove as she complained about how unappreciative Ronald's father was about all that she did in the household.

Ronald recalled that, as a young, nervous child, he was startled and flinched with the sound of his mother's banging and complaining. He kept trying to think of what he could do to patch things up between his parents, but he couldn't think of anything, and he blamed himself for the unhappy state of affairs at home.

Later that evening after Ronald went to sleep, he was startled to hear a commotion in his parents' room. At first, he thought they were arguing again and he put the pillow over his ears to drown out the sound. But then he realized that something else was going on. As he got out of bed, he heard the voices and footsteps of several people rushing around the apartment. When he opened the door to his bedroom, Ronald was shocked to see his father, looking pale as a ghost, being carried out of the apartment by emergency medical technicians and placed in an ambulance.

Then, Ronald heard his mother sobbing in the other bedroom. When he ran into the room to see her, she told him, "Your father is dead. You're the man of the house now, Ronald."

When Ronald recounted this traumatic event in therapy, even though he was in his early 40s, he experienced the sadness, self blame, guilt and shame as if it was yesterday. He also re-experienced his mother's words as a heavy mantle that was placed on his shoulders that he always carried with him.

As an adult, Ronald understood intellectually that he was only eight when his father died and that there was nothing that he could have done to save him. But there was such a disconnect between what he knew rationally versus what he felt emotionally.


Developing Curiosity and Self Compassion in Therapy

He carried this heavy emotional burden with him so that it affected almost all of his close relationships. He was often the one that his family and friends turned to about their problems. But having grown up as a parentified child, he felt so undeserving himself that he never confided in anyone about his own problems.

In many ways, it was surprising that Ronald came to therapy at all. It was only after he began re-experiencing overwhelming anxiety around the anniversary of his father's death that Ronald even considered getting help for himself.

During the early stages of psychotherapy, Ronald and I worked together to help him develop a sense of curiosity and self compassion. At first, this was very difficult for him. He was filled with emotions about what he "should have done" and "could have done" to save his father.

He blamed himself for not calling the doctor when his father told him that he wasn't feeling well. He blamed himself for being asleep when his father had the heart attack and died. He also blamed himself for not being able to console his mother after the father's death.

Ronald's own sense of loss for himself after his father's death was suppressed, buried underneath all the negative feelings that he had for himself. The weight of those feelings was often palpable in the therapy room.

Talking about it did little good. Ronald would often say that, as an adult, he could look back now and see that there was nothing that an eight year old child could have done. But that intellectual insight did nothing to ease his emotional burden.

Using clinical hypnosis, Ronald and I worked to help him to access that younger part of himself that was the repository for much of his emotional pain. Slowly, over time, Ronald began to let go of his negative feelings so that he could develop more self compassion and a sense of curiosity about what happened to him.

Once he was able to develop self compassion and curiosity, the healing began. His intellectual insight developed into deeper emotional insight, and he forgave himself and his parents. For the first time, he mourned his father's death. He also mourned for that younger part of himself for what he didn't get emotionally as a child.

Freed from this emotional burden, Ronald was able to open up to a fuller and richer life. Although he maintained a sense of compassion and altruism for others, he no longer felt that he had to "fix" them or resolve their problems.

Developing Curiosity and Self Compassion in Therapy

I often hear people say that they don't understand how psychotherapy can help them because they "already know" what their problems are and what they should be doing to resolve them. It's often difficult for people who are not in therapy to understand that intellectual insight is not the same as emotional insight and it's often not enough to integrate trauma and create healing and transformation.

Regular talk therapy, although very useful in many situations, often is not enough when trying to work through trauma. Talking about a traumatic incident, where talk remains intellectual, is often not the same as working towards healing and integration through a mind-body oriented psychotherapy like clinical hypnosis or EMDR.

Many clients, who go from one form of talk therapy to another, come away with important intellectual insights about their problems, but they're not healed. Nothing really changes.

As a psychodynamically trained psychotherapist, I value the psychodynamic talk therapy process for many issues that clients bring to therapy and it informs my work. But I also know that regular talk therapy is often not enough and it's important for psychotherapists to have a variety of tools to use with their clients.

Getting Help in Therapy
If you are struggling with a traumatic event in your life, it's important to get professional help with a licensed psychotherapist who has experience working with trauma.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist.

I work with individual adults and couples.

I have helped many clients to overcome trauma so they can lead more fulfilling lives.

To find out more about me, visit my website:  Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (212) 726-1006 or email me.















Thursday, June 10, 2010

Relationships: When There's Loneliness and Lack of Intimacy in Your Relationship

Loneliness and lack of intimacy in relationships is not unusual. People who are lonely in their relationship usually don't like to admit it, except, maybe, to their closest friends or their psychotherapist because there is often a lot of shame associated with this.

People who feel lonely in their relationships often feel that loneliness only occurs among people who are, well, alone, and that if you're in a relationship, you shouldn't be feeling this way.

But there are lots of reasons why relationships that start out well can, over time, devolve into relationships where one or both people feel lonely and the emotional and sexual intimacy go out the window.

Relationships: When There's Loneliness and Lack of Intimacy in Your Relationship
Let's look at the following vignette which, as always, represents a composite of many different people, so that there is no identifying information that represents any one particular person:

Steve and Susan:
When Steve and Susan met in college, they fell in love with each other almost from the start. They had a very passionate one year relationship before they got married. Both of their parents wanted them to wait a year or two before they got married to give them time to get to know each other, but they couldn't see any reason to wait, so they got married right after college and moved into a small apartment in Manhattan.

A year into their marriage, Steve began to feel that there was "something missing" in his relationship with Susan. He wasn't sure what it was and he didn't even have words to describe it, but he knew that something had changed. He and Susan both had demanding jobs, so they spent almost no time together during the week. On the weekends, they were often both exhausted and too tired to go out, so they spent a lot of time watching TV. Whereas they had sex a few times a week during the first six months of their marriage, now, they only had sex a couple of times a month, which concerned Steve because he and Susan were still in their early 20s.

As time went on, Steve began to feel lonely and disconnected from Susan, even when they were spending time together. He often felt that when she was with him, she "wasn't there" emotionally. He felt that it was as if they were "going through the motions." Whereas he used to feel excited and alive when he was around Susan, he now felt bored and that the relationship had gotten into a rut.

Steve tried to talk to Susan about his concerns, but Susan was not someone who liked to talk about what she considered "negative feelings." So, whenever he tried to talk to Susan about it, she dismissed his feelings and told him that all relationships settle down after the first year or two and he shouldn't expect that they would feel the same kind of passion that they felt when they first met.

But Steve knew that there was more to it than that. He didn't feel close to Susan any more, and he was concerned and upset that he felt lonely around her. In the past, when he was single, it wasn't unusual for him to feel lonely, but he couldn't understand why he would feel lonely when he was with Susan.

As Steve's concern grew, he continued to try to talk to Susan about their relationship. But the more he tried, the more annoyed Susan felt and the more she avoided talking to Steve about his concerns. And the more Susan avoided talking to him about their relationship, the more Steve sensed that Susan was putting up an emotional "wall" between them that seemed to be growing thicker by the day. He knew that he still loved Susan, but he wasn't sure if he was still in love with her. And he resented that she refused to discuss their relationship, as if there was something wrong with him for having these concerns.

As time went on, Steve felt more and more distant from Susan. They had friends and they socialized, but Steve began to feel that his marriage was a sham. He felt that there was a disconnect between what he felt internally and how he felt he was expected by Susan to behave with her.

One day, when one of his coworkers, Laura, began to confide in Steve over lunch that there were problems in her marriage, Steve felt himself opening up to Laura about his own worries. Laura seemed to understand completely. She said she felt the same way in her marriage, and her husband refused to talk to her about it too.

This was the first time that Steve had a chance to tell anyone about his problems, and it was a great relief to feel heard and understood. Soon after that, Steve and Laura began having lunch more frequently, and Steve felt an attraction building for Laura. He knew that she was also attracted to him because she began flirting with him. He liked that she laughed at his jokes and that she admired him at work.

So, after a few weeks, when Laura told him that she had a friend who would let them use her apartment during their lunch break or after work, Steve was not surprised. Although he was flattered and he felt a strong sexual desire for Laura, especially since he and Susan were hardly having sex any more, he was not prepared to start cheating on Susan, so he gently and tactfully declined the first time that Laura suggested that they get together sexually. But as he continued to feel more and more emotionally and sexually frustrated in his marriage with Susan, he told Laura that he was ready to spend time with her at her friend's apartment.

On the day when he was supposed to meet Laura at her friend's apartment, Steve had a change of heart. He really didn't want to ruin his marriage, and he decided to try to talk to Susan one more time and, if that didn't work, before he began a sexual affair with Laura, he would rather separate from Susan first and think about getting a divorce.

That night when he went home, Steve told Susan that he thought their relationship was in serious trouble and if they didn't go for marriage counseling, he didn't think they would survive. Usually, Susan put up a wall whenever Steve tried to talk to her about their relationship but, somehow, he got through to her that day, at least enough to get her to agree to go for marriage counseling.

When Steve and Susan came for their first marriage counseling session, Steve was very open about his feelings and concerns. He talked about feeling lonely and disconnected in their relationship and how disappointed he felt that there was almost no emotional or sexual intimacy between them any more. Susan sat next to Steve and stared straight ahead. Whenever Steve looked at her to tell her how he felt, she continued to stare into space.

When it was her turn to talk, Susan had a lot of difficulty expressing her feelings. With some encouragement, she began to talk, but all she could say was that she wasn't sure what she felt any more, and people in her family almost never talked about their feelings and they certainly never went to marriage counseling to talk to "a stranger" about their feelings about their marriage. Not only was she anxious and angry, Susan also felt deeply ashamed to be sitting in a marriage counselor's office.

During the first few marriage counseling sessions, Susan continued to have a lot of difficulty identifying her feelings and talking. She retreated behind a wall and she seemed greatly relieved when the therapy hour was over.

It was only after Steve admitted in session that he was beginning to have feelings for his coworker, Laura, at work, that Susan's wall began to crumble. Steve told her that for a long time he had been feeling that maybe there was something wrong with him that he felt so lonely and empty whenever he was around Susan. But, he said, when he realized that he had sexual feelings for Laura and he felt close to her, even though he had not been sexual with her "yet," he realized that what he was feeling was a problem between him and Susan and not something that he alone was going through. He also told Susan about how he almost went to Laura's friend's apartment to have sex with Laura.

Steve told Susan that he still loved her and wanted to repair their marriage, but if she wasn't willing to do the work too, he was considering leaving her and having a sexual affair with Laura because he wanted to feel "alive" again.

When Susan heard this, she looked like she had been struck in the face. She began sobbing in that session and told Steve that she was terrified of exploring and talking about her feelings. She said that during the early stage of their relationship, she felt carried along on a wave of passion and love, but once their relationship settled down, she began to feel too afraid of the emotional intimacy of everyday life together and she shut down.

This was a breakthrough moment for Susan. After that, Steve agreed not to spend any more time with Laura, and Susan agreed to enter into her own individual psychotherapy with another therapist at the same time that Steve and Susan continued to come to marriage counseling.

During the course of their marriage counseling, it came to light that Susan and Steve had very different experiences in their family of origins with regard to expressing feelings.

Steve's family was very open to expressing their feelings. And Steve's mother and father had a close, loving relationship.

Susan's family was more reserved. Her parents never showed any affection for each other around Susan, and they almost never talked about their emotions. When Susan was growing up, whenever she tried to talk to either of her parents about anything that was bothering her, Susan felt like she was being a nuisance. Her mother often told her, "No one likes a whiner." So, she learned to stifle her feelings.

That's why Susan was so surprised that she felt the depth of feelings that she did for Steve during the early stage of their relationship. When it was new and exciting and they were getting to know each other, she felt carried along by the excitement. But she felt uncomfortable with the growing emotional intimacy that was developing after they got married, and she realized that she had shut down emotionally to protect herself from her own feelings of vulnerability.

Susan also realized that her emotional shut down lead to Steve's feeling disconnected from her and lonely when he was around her. And this was only made worse when Steve tried to talk to her about his feelings and she avoided these discussions.

And, for his part, Steve also realized that by acting out with Laura and almost having a sexual affair, he was also checking out emotionally from his marriage and putting up his own emotional barriers with Susan. He realized that even though he and Laura never had sex, they were starting to have an emotional affair because they were confiding in each other a lot and comforting one another. He also realized that even though Laura excited him, any affair that he had with her would have been motivated more by anger towards Susan than any sexual or tender feelings he felt towards Laura.

Steve and Susan remained in marriage counseling for two years. During that time, they learned to improve their communication with each other. Through the marriage counseling and in her own individual therapy, Susan began to feel more comfortable expressing her feelings with Steve. A few sessions with a sex therapist also helped them to revive their sexual relationship.

It wasn't easy but, over time, their relationship improved. As the emotional and sexual intimacy improved in their relationship, they both felt more connected to each other and more satisfied in their relationship. Steve no longer felt lonely when he was Susan, and Susan stopped defending against her feelings by shutting down emotionally.

If you and your spouse are experiencing problems with loneliness and lack of intimacy in your relationship, you're not alone. Many couples go through this.

The important part is to admit that there's a problem and get help with an experienced marriage counselor.

I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist.

I have helped many individuals and couples to revive their relationships.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up an appointment, call me at (212) 726-1006.

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