This is a repair tool for those times when you and your partner are both triggered, seem to be stuck in a place of disconnection, and are saying to each other “How do we get out of here?” Although I am not a fan of cute acronyms I am resorting to that here, because reconnection can feel life saving, and it is worth remembering the steps. So I hope the acronym helps. Life B.O.A.T – BID, OWN, APPRECIATE, TOUCH.
This is a repair tool for those times when you and your partner are both triggered, seem to be stuck in a place of disconnection, and are saying to each other “How do we get out of here?”
The bid is when one of you has the presence of mind to suggest repair. You might do this by saying “I’d like to propose a round of ownership, is this a good time?” Remember, if your partner makes the bid and you are not quite ready at that time, be very specific about when you would be.
I suggest two rounds of ownership.
What ownership is: Ownership is taking responsibility for my part of the difficulty. It is in effect an apology. Remember this is a no blame paradigm so owning my piece does not mean the whole thing is “my fault.” The premise we work from is that every conflict and every episode of triggering involves contributions from both partners. One thing that makes this process safer is that the structure insures that both partners will own, so no one gets singled out.
And what do we mean by ownership? It is specific and it is what I did (a specific action or verbalization) that I regret. Detail helps, but don’t be wordy! When both of you are in a difficult emotional place, you want to be clear, precise, not monopolize, and keep the process moving. Including an actual apology can also be powerful. An example: “One thing I can own is that I was impatient and repeated my words with a sharp, nasty tone when you could not hear me. I apologize for that.”
What ownership is not: Ownership is not explaining. Ownership is not excuses. Ownership is not a veiled way of saying “You triggered me!” Ownership is not a trick to coerce counter-ownership! (i.e. a form of blame!)
In order to be potent ownership must be sincere, honest, and heartfelt. So make sure your tone and your face are congruent with the intention of repair!
See how two rounds of ownership feels. In particularly gnarly interactions, you may decide to do more. It is preferable for each partner to do the same number.
Remember to monitor your own reaction to your partner’s ownership. To comment on or critique it, or to show disappointment in it could compound the problem you’ve already got! This is hard when you are really hurt, and your partner does not own immediately the piece that most hurt you! Remember, you can enhance the depth and healing potential of the process by going deeper and further yourself. So focus on that.
By now you know how to do appreciations! Do two rounds of appreciations after the ownership. It is optimal to have the appreciations be related to the conflict or to the ownership process, but that is not essential. What is essential is that the appreciation be personal. For example it is much more meaningful to say: “I appreciate what a good friend you are to me, how you really listened to me when I needed to talk last night.”
That is more touching under these circumstances than to say: “I appreciate what a good friend you are, or what a good friend you to so and so; or what a good daughter and a good listener you are to your mom, etc.” Your partner needs to feel of value to you!
Specificity, depth, heartfelt feeling, and brevity all make for “connecting,” potent appreciations.
For many partners, touch is more connecting than words. So to end with some sort of caring touch integrates that component into the repair. It could be a hug, a stroke of your partner’s face or arm, a squeeze of the hand. See what feels most natural to the two of you. I suggest each partner offer a touch, so each feels as if something is being given. Touch can be very soothing; boost seratonin and oxytocin, and thus serve as an antidote to depression and disconnection!
Make sure the touch is safe and soothing to both of you!
After finishing all the steps check in and see how it feels between you. Let some time pass before you go back to the original content that the conflict was about. Perhaps some time later you will be able to talk about it calmly, utilizing what you each learned from the ownership.
“In normal, optimally interactive dyads, only about 30% of their time together is actually spent in the affectively positive, mutually coordinated interactive state. The rest of the time is spent in mis-coordinated interactive states, accompanied by negative affect, attempts to get back to coordinated states, and positive affect. There is a constant oscillation between matched and mismatched interactions, and back again. Tales of ecstasy are endless tales of failure. For always comes separation. And the journey towards the essential, fleeting unity begins again. As good as it gets is not some uninterrupted state of mutual bliss with perfect attunement; instead what obtains is some paradise, lost and regained as a result of focused efforts on the part of both partners.”
– Diana Fosha1
“Even the best relationships are really screwed up.”
– John Gottman
In his groundbreaking work Affect Regulation and the Origin of the Self,2 Allan Schore details the genesis of personal and interpersonal shame. In the first eight to nine months of an infant’s life, the primary function of the good enough mother or caregiver, is mirroring, and providing for the child’s many needs. It is in its ideal form, this phase is a love fest between them. When the child reaches the age of independent mobility, and also when exploration begins, the caregiver begins to have more varied functions, some of which include monitoring or even policing the movement and activities of the curious child. The caregiver may need to intervene or interfere with the child’s adventures in the universe, in the interests of safety, decorum or her own needs and sensibilities.
Wordlessly the communication is “I have done something bad and I lost you.” Swooning alone without a map of return to connection, the child sinks into darkness. The universal facial and body language of shame are dropped eyes, collapse and physical withdrawal. The loss of connection is deathlike for the infant. And the child who grows up without the template of repaired attachment, is at a terrible loss in the world.
The child may experience such interruption as a shock or a loss. Especially if it is an angry reprimand, the most painful part of it is the loss of connection with the caregiver. The good enough caregiver, once the dangerous or unwanted behavior has stopped, will comfort and reassure the child, and repair the ruptured connection. That child will have the experience that “regrettable incidents” or mistakes happen, and can be resolved. Relationships survive such occurrences and continue.
When the child receives the message “You are doing something bad!” with the accompanying rupture of connection, and there is no repair, the child withdraws into despair. This child is at a loss to restore the severed connection and does not know how. This is what Schore identifies as the early experience of shame. Wordlessly the communication is “I have done something bad and I lost you.” Swooning alone without a map of return to connection, the child sinks into darkness. The universal facial and body language of shame are dropped eyes, collapse and physical withdrawal. The loss of connection is deathlike for the infant. And the child who grows up without the template of repaired attachment, is at a terrible loss in the world.
Of course this is the experience of so many of our clients who come to us with relationship difficulty. Conflict is an inevitable fact of relationship life. When there is no knowledge of how to emerge from rupture back into connection, or even that such restoration is possible, clients adapt in all sorts of ways. They might avoid conflict at all costs, which may be at great personal cost to their own needs and integrity. They might simply submit to mistreatment. They might abandon or betray their own interests and seek to gloss over the conflict and have the relationship back, slowly disappearing within it. They may lose relationships as soon as there is conflict, accumulating a wrecking yard of abortive relationships and a belief that love cannot last. The variations are innumerable. But the result is uniformly tragic and lonely. We are wired for connection, and when it is lost or impossible, we suffer deeply.
The variations are innumerable. But the result is uniformly tragic and lonely. We are wired for connection, and when it is lost or impossible, we suffer deeply.
John Gottman is a researcher who has made a science of studying relationship. We recently had the privelege of hearing him speak in a special local appearance sponsored by the TPI Education committee. As he describes the elements of intimate partnership, he maps three major categories or “Blueprints” of relationship skills and qualities, essential to the life and health of the partnership. These are what he calls the “Friendship and Intimacy Blueprint;” the “Meanings Blueprint” and the “Conflict Blueprint.” All three require strength and depth for a solid partnership. In my work primarily with couples who come from histories of trauma and neglect, where they need the most help is with the conflict blueprint. From early on their experience was rife with Schore’s conceptualization of shame. Relationship was dangerous or absent, overwhelming or vacuous. Their transferences onto us as therapists are intense, as are their projections onto their partners. Often when these couples arrive in our offices, they appear to be shipwrecked and exhausted. Their cycles of conflict are like tempests and the storms may seem endless. They may be desperate for the skills of peace making, and perhaps hopeless. But by some miracle of faith, they show up. So how do we help them?
Seeing clients in this desperate state is a grave challenge for us. Especially as whenever there is an episode of conflict or traumatic activation, the body floods with cortisol, the stress hormone. Because cortisol and seratonin compete for the same brain receptors and cortisol always wins because it is survival related; each “cycle of escalation” as I call them, brings a seratonin dip or “hangover.” Each cyclone is followed by worse depression and despair, and still less energy or ability to restore hope or connection.
Gottman suggests principles learned from Anatol Rapoport, an expert in international conflict. Among them, he recommends, “Postpone persuasion until each person can summarize the partner’s position to the partner’s satisfaction.” The goal is not agreement, but the empathic ability to consider and see the other’s point of view.
The second main principle Gottman draws from Rapoport is the “Assumption of Similarity” which is distilled to: “if making a negative attribution to your partner, try to see this trait in yourself; and if making a positive attribution to yourself, try to see this trait in your partner.” These are invaluable practices and skills that belong in the armamentarium of all relationship therapists. My experience, however, is some of my couples who get caught in these terrible storms need something structured and radical to help them settle enough to even get back to the content of the conflict itself. So I developed a tool that I call the “Lifeboat.” The structure requires that both partners withdraw into self reflection, which takes the focus off the other and impels a shift into a cognitive mode. Because the understanding is that both partners will engage equally in all the steps, the burden of responsibility or the perennial fear of blame for the conflict, are obviated. I hypothesize that both of these factors serve to settle the body and nervous system somewhat, and as Gottman reminded us, when heart rate goes above 90 beats per minute, we are no longer able to think clearly.
This activity is not intended to resolve the content of the conflict. Rather it is designed to restore enough equilibrium and enough connection to have the conversation that went awry, in a different way. In effect, the intent is to arrive at the point where Rapoport’s principles become possible.
This is a repair tool for those times when you and your partner are both triggered, seem to be stuck in a place of disconnection, and are saying to each other “How do we get out of here?” Although I am not a fan of cute acronyms I am resorting to that here, because reconnection can feel life saving, and it is worth remembering the steps. So I hope the acronym helps. Life B.O.A.T – BID, OWN, APPRECIATE, TOUCH.
The bid is when one of you has the presence of mind to suggest repair. You might do this by saying “I’d like to propose a round of ownership, is this a good time?” Remember, if your partner makes the bid and you are not quite ready at that time, be very specific about when you would be.
I suggest two rounds of ownership.
What ownership is: Ownership is taking responsibility for my part of the difficulty. It is in effect an apology. Remember this is a no blame paradigm so owning my piece does not mean the whole thing is “my fault.” The premise we work from is that every conflict and every episode of triggering involves contributions from both partners. One thing that makes this process safer is that the structure insures that both partners will own, so no one gets singled out.
And what do we mean by ownership? It is specific and it is what I did (a specific action or verbalization) that I regret. Detail helps, but don’t be wordy! When both of you are in a difficult emotional place, you want to be clear, precise, not monopolize, and keep the process moving. Including an actual apology can also be powerful. An example: “One thing I can own is that I was impatient and repeated my words with a sharp, nasty tone when you could not hear me. I apologize for that.”
What ownership is not: Ownership is not explaining. Ownership is not excuses. Ownership is not a veiled way of saying “You triggered me!” Ownership is not a trick to coerce counter-ownership! (i.e. a form of blame!)
In order to be potent ownership must be sincere, honest, and heartfelt. So make sure your tone and your face are congruent with the intention of repair!
See how two rounds of ownership feels. In particularly gnarly interactions, you may decide to do more. It is preferable for each partner to do the same number.
Remember to monitor your own reaction to your partner’s ownership. To comment on or critique it, or to show disappointment in it could compound the problem you’ve already got! This is hard when you are really hurt, and your partner does not own immediately the piece that most hurt you! Remember, you can enhance the depth and healing potential of the process by going deeper and further yourself. So focus on that.
By now you know how to do appreciations! Do two rounds of appreciations after the ownership. It is optimal to have the appreciations be related to the conflict or to the ownership process, but that is not essential. What is essential is that the appreciation be personal. For example it is much more meaningful to say: “I appreciate what a good friend you are to me, how you really listened to me when I needed to talk last night.”
That is more touching under these circumstances than to say: “I appreciate what a good friend you are, or what a good friend you to so and so; or what a good daughter and a good listener you are to your mom, etc.” Your partner needs to feel of value to you!
Specificity, depth, heartfelt feeling, and brevity all make for “connecting,” potent appreciations.
For many partners, touch is more connecting than words. So to end with some sort of caring touch integrates that component into the repair. It could be a hug, a stroke of your partner’s face or arm, a squeeze of the hand. See what feels most natural to the two of you. I suggest each partner offer a touch, so each feels as if something is being given. Touch can be very soothing; boost seratonin and oxytocin, and thus serve as an antidote to depression and disconnection!
Make sure the touch is safe and soothing to both of you!
After finishing all the steps check in and see how it feels between you. Let some time pass before you go back to the original content that the conflict was about. Perhaps some time later you will be able to talk about it calmly, utilizing what you each learned from the ownership.
In the past ten or so years of burgeoning progress, the growing subfield of traumatology has come to identify and elucidate much about the physiology of trauma. From the start it was undeniably obvious that trauma was a “physioneurosis,” (van der Kolk, McFarlane and Weisaeth, 1996) directly afflicting the body even if there was no direct bodily injury or even bodily threat. We slowly began to comprehend the impact on brain and nervous system, and subsequently, endocrine, motor and muscular function in addition to the most evident psychological and emotional suffering. The increase in information is good news, not only in terms of compassion for sufferers long told their problems were “all in their heads,” or a weakness of character, but also because increased information has extended the range of treatments.
The amygdala is the little structure of the brain’s limbic system that evaluates the survival or danger significance of stimuli. It works like a smoke detector sniffing out danger cues. If danger is assessed, the amygdala activates the endocrine system to secrete stress hormones, non-survival activities like digestion or ovulation are suspended for the moment, and the body mobilizes for fight or flight. Attention narrows, becomes sharper and more focused. Mobilized by stress hormones, the heart and respiration quicken, muscles fill with blood and tense, ready for action.
One mechanism that is much better understood is the natural course of the fear response, and the aberration or overwhelming correlate to that, which is the natural course of the trauma response. Ordinary fear follows a typical bell shaped curve (LeDoux 1996, LeDoux 2002). It begins when, from a baseline state of relative bodily calm, a threatening stimulus is perceived via one or more of the five senses, by the thalamus. This initial stimulus activates an orienting response whereby attention becomes more focused in the direction of the stimulus and more information is gathered. The information is all sent to the amygdala for screening.
The amygdala is the little structure of the brain’s limbic system that evaluates the survival or danger significance of stimuli. It works like a smoke detector sniffing out danger cues. If danger is assessed, the amygdala activates the endocrine system to secrete stress hormones, non-survival activities like digestion or ovulation are suspended for the moment, and the body mobilizes for fight or flight. Attention narrows, becomes sharper and more focused. Mobilized by stress hormones, the heart and respiration quicken, muscles fill with blood and tense, ready for action.
Where the natural fear response curve takes place within a “window of tolerance,” the window within which our bodies are designed to respond effectively, the sympathetic arousal in trauma shoots well above the line, outside that window. In this state, traumatized people are scared “out of their minds,” unable to think or perhaps even know where they are in time or space.
Once action has been taken and the threat is either past, or turns out not in fact to have been a threat after all, (that is if the snake turns out to have been a stick,) the body calms down and the arousal resolves. The body is back to its initial baseline.
Meanwhile, the information about the threat is sent along its way to the hippocampus. The hippocampus is the brain’s filing system, a storage place for categories or files of information, that await being woven into the ongoing story of life. Information waiting in the hippocampus is not yet fully processed. Its complete processing takes place in the prefrontal cortex, or the part of the brain where “meaning is made.” The cortex knows what year it is, it knows location, and it has language for all of this. The cortex houses the locus of autobiography, and the cortex makes sense out of experience.
So if the stimulus is, for example, the sudden awareness that my wallet is not in its usual spot, I might momentarily have a rush of fear, especially if I am far from home. I forget everything else for the moment, and with heart racing and breath short, quickly search all other places where it might be. When I subsequently locate it in a different pocket than I usually keep it in, perhaps slowly remember why I put it there, my body readily settles back down and I continue on my way. When I arrive at my friend’s house I have a story to tell. The curve then is a heightening of arousal, a peaking out and a resolution. All of this takes place in what we know as the autonomic nervous system, the arousal being its sympathetic or energizing branch, and the parasympathetic being its calming down branch. This arousal curve is a natural progression. We share it with all mammals, and depending on their place in the food chain, they go through these ups and down continuously in the wild, throughout their stressful days (LeDoux, 1996).
With trauma, however, something different happens (van der Kolk et al, 1996). The stimulus is overwhelming and the natural fear response sequence is thus overwhelmed. The initial warning system is activated, stress hormones begin pumping away through the body, and the information makes it as far as the hippocampus, but the action of fight or flight is thwarted. The nature of trauma is that the threat is too great, the force of the danger cannot be fought or fled. A child cannot overpower an adult abuser, a driver cannot hold off an oncoming car, a gunshot victim cannot escape the bullet, a village cannot evade the bomb. The energy mobilized for fight or flight is frozen in a bath of stress hormones in the terrified person’s body. And the information gets stuck at the level of file storage, and not yet at the processing point where it can be verbalized, understood and integrated into autobiography. This is trauma.
Sensorimotor Psychotherapy has given us the “Modulation Model” as a map that illustrates in graphic form, the pathway arousal takes in trauma. (Ogden, Minton, 2000). Where the natural fear response curve takes place within a “window of tolerance,” the window within which our bodies are designed to respond effectively, the sympathetic arousal in trauma shoots well above the line, outside that window. In this state, traumatized people are scared “out of their minds,” unable to think or perhaps even know where they are in time or space. Or they might similarly dip beneath the window’s lower limit, into hypoarousal states, of frozen or numb blankness and paralysis. States on either the sympathetic and parasympathetic high end or low end may be “speechless” and “senseless.” And the worst of it is that, because the response is thwarted, it does not complete, it does not resolve and return to baseline. As a result, the experience does not end in either mind or body.
There are a number of reasons why the trauma lives on and on as it does. First of all, wired for survival, the amygdala is adamant about learning from experience and protecting the organism from another such traumatic episode. So it becomes hypersensitive to any stimulus that might even vaguely resemble the original one. For example if a child was beaten by an adult with an angry face, angry faces may become a “trigger.” If the smell of alcohol was part of a rape, the smell of alcohol might become a trigger, etc. The trauma response is readily re-activated by these triggers, and the body mobilizes into emotions and physical patterns that prepare it to fight, flee or perhaps freeze just like the first time around. The hyper alert nervous system behaves as if the danger is in fact happening again.
Because ordinary life may be filled with angry faces and alcohol smells and whatever else might be consciously or unconsciously associated with the trauma by the overly sensitized amygdala, the traumatized person’s body may be in and out of trauma states continuously, and the person bounced around between what may in fact be “real” dangers, and simply the over-reactions of the trauma-sensitive system. Needless to say this wreaks havoc in relationships and in life in general, where an innocent, passing angry face may bring on a cascade of seemingly irrelevant emotions and behavior.
Due to what we have also come to discover as a “kindling effect” (van der Kolk et al, 1996), the more often the brain is activated in these ways, the more easily it becomes activated. The circuitry of traumatic fear becomes more easily turned on. So being triggered, beyond its unpleasantness, chaos, conflict and confusion, is in effect deleterious. It strengthens its own circuitry and people get worse. We also know that the continuing flood of stress hormones that are part of the trauma activation have many other health eroding effects on the body. Some correlation has been discovered between trauma and hippocampal size and function (which are associated with memory processing;) autoimmune function, and depression to name a few of the potential health costs of trauma. It is not good to stay triggered or to stay in cycles of triggering!
Intuitively we know this and the body knows this. So another characteristic of trauma is the compulsion to avoid it. Survivors avoid reminders and avoid sensations, emotions: really anything reminiscent of the trauma. Depending on their level of sensitivity and the nature of their trauma, the list of what survivors avoid may be quite long. This is why many survivors never talk about what happened to them and simply “don’t want to go there” or even don’t want to do much. This is why many sexual trauma survivors do not want to have sex or truly believe they are unable. And it makes sense. To re-experience unbearable terror and helplessness, or to enter situations where one might be surprised by it, and to invite experiences that are known to have a long, unpleasant half life (i.e., it can take a long time to calm down after a triggering episode,) are things to avoid whenever possible. And in life, avoidance is not even possible that much of the time.
One final point about triggering and the body: research has shown us that very often at least some of the trauma information does not arrive at the prefrontal cortex of the brain (van der Kolk, Burbridge and Suzuki, 1997). This part of the brain is in charge of much of what we call “cognitive” processing. Cognition is knowing, so this is the thinking part of the brain, least developed when we are born, that develops slowly as we progress through childhood. Not only is it responsible for time and place location, logic and reasoning and speech, but it completes the task of processing experience into coherent memory. Information that is not processed in this part of the brain, therefore may not be cognitively “known” or remembered. This is why there is so much confusion about traumatic memory. Some survivors do not remember things cognitively, with clear picture and story-like sequences of what happened to them. They might have body reactions, behaviors and emotions that point to an event of which they have no clear recollection. This is also very confusing! Having intense emotions, sensations, strong reactions or extreme behaviors and not being able to link them to clearly remembered experience can make them uncertain about what is true or real; or make them feel as if they are crazy. Where in the past therapists emphasized the significance of traumatic memories, we now understand memory of trauma differently. For many, remembering and speaking of what caused all the havoc they are experiencing is not possible. We must explain this to them.
Peter Levine in his audio series “Sexual Healing” talks about “re-membering.” (Levine, 2003.) Where trauma brutally fragments or “dismembers” the body, soul and psyche; healing is the process of collecting the pieces, organizing and putting them back together again. It is a making whole of the person after having been blown apart by the overwhelming experience. This is how re-membering has been recast as the goal of healing.
Sensorimotor Psychotherapy, gave us a system for processing trauma called “sensorimotor sequencing” (Ogden, Minton, 2000). It is an exquisitely simple and brilliant method for healing the unprocessed trauma that continues to rumble in the body. Although Sensorimotor Psychotherapy is certainly not the only trauma therapy, it is a good one and a therapy that I like very much. In this approach, the story is not necessary or useful. As stated above, much as they try to avoid them, survivors are readily pitched into states of traumatic activation. I see it happen often when I work with couples, who are singularly skilled at triggering one another like almost no one else can. Even little stimuli can bring on the big reaction. What sensorimotor sequencing attempts to do, is make traumatic activation or re-experiencing bearable, in tiny bite sized increments, to help patients stay aware of sensation and allow the trauma response cycle to complete. In the moment of trauma and in the usual course of triggered activation, the natural reaction to overwhelming sensation is to “jump out of the body.” In lesser or greater degrees, survivors describe numbness and alienation from sensation, especially when triggered. They just do not feel, and are rather phobic of feeling, at least when trauma activation has produced the sensation. So staying present to the huge and frightening sensations and emotions must be a conscious, calculated therapeutic intention. In sensorimotor sequencing, with the gentle support of an attentive therapist, carefully paced and in small doses, the survivor is encouraged to drop the story or cognitions, and even set aside the emotions, and just track the physical sensations as they move through the body. In effect, the frozen unexecuted movement patterns of fight or flight, not allowed to manifest at the time of the actual trauma, are able to unfold and be expressed. But slowly! (Scaer, 2001).
In the late 1960’s and early 70’s there was a mushrooming of alternative therapy techniques that involved pounding pillows, yelling, using foam battacas to expressed unexpressed rage, and primal screams. We thought then that noisy, windy catharsis was good: a way to get feelings “out.” Although some people may have initially felt relieved or energized from the discharge of tension in the moment, we have since learned that these methods are not helpful and in many cases they were retraumatizing and harmful. And in general, in exercising cathartic methods survivors were no more present to their body experience than they had originally been. Sensorimotor sequencing and any safe somatic method of trauma healing is above all else slow and mindful. Slow in that it is carefully regulated to keep survivors in the window of tolerance as they move along; mindful in that the healing is in being able to feel the sensations and discover that they are not lethal, as they complete their interrupted course.
So what does Sensorimotor sequencing look like? In a recent session, Molly arrived pale and shaken. On her way to my office she had been involved in a minor rear end car accident. It was a tiny bump and there was no damage to her car and no bodily injury, but she was massively triggered. Molly has an extensive trauma history, which does not include car accident trauma. But being hit and helpless had her whole system in upheaval. After Molly only briefly recounted the story of the mini-accident and was clear that there was no real harm at all, I had her just drop all thoughts and focus on her body. We even gently postponed the emotions: the tears and fear until a later time. I reflected to her what I saw: her shoulders pulled back, tension in her neck, and she told me what she physically felt. Her breath was short and her heart was pounding, her stomach was in a knot. And I then asked her “and what happens next, what wants to happen next in your body?” And she kept following the movement of her sensations as they slowly progressed, lessened, changed and ultimately passed. The session lasted one hour and by the end of it she was completely calm and free of any tension or activation at all. We then talked about the accident and the emotions; how the emotions related to emotions from past events; and how she might take the feeling of calm she now had along with her into her life. We were not only resolving this upset, we were reworking a piece of the trauma that had been activated by it. When Molly came back the next week, she was amazed. It was her first experience of sensorimotor sequencing. The calm was a deeper calm than she remembered ever having experienced, and it seemed to last. She said, “Something is definitely different,” and she beamed.
Sensorimotor sequencing is not the whole story in trauma healing but it is a powerful tool. Careful attentive pacing, mindfulness to the body and its subtle changes moment to moment, getting acquainted with sensation and finding that it is in fact bearable, are powerful experiences that begin to alter the nervous system and reverse the kindling tendency (Ogden, Minton, 2000).
“The loss of the daughter to the mother, the mother to the daughter, is the essential female tragedy.”
– Adrienne Rich
On a dark November afternoon, I received an unusual phone message from a woman in Southern California. She had gotten my name from her daughter, and she wanted to come and see me. When I called her back, I heard an anxious, strained voice, “Thanksgiving brought it all up again, as the holidays do every year. There is a rupture in our family that tears me apart.”
For the mothers I have seen, being a mother had been their life, and having been a good mother a vital midlife concern. Their great fear is that they were not good mothers. It has been the norm to vacillate between extremes of guilt and defensiveness. Finally, what I have seen is that something about their childhoods has prepared them for the role of being caught in the middle, a role which they have played for years in the incest family.
She introduced herself as Betty and proceeded to tell me a bit of the story. Her daughter, after uncovering her sexual abuse, had broken off contact with Betty and her husband. This woman had not seen her daughter in four years; they had not spoken in almost two. She desperately missed her daughter, Sarah. Sarah, who had been in couple’s therapy with me some time ago, had asked her to call me to see about the possibility of their doing some work together.
I was intrigued. This woman was proposing to fly up weekly or biweekly, pay for the sessions, and work to heal their divided family. “She’s my daughter,” she almost wailed. Thus began my journey of mother-daughter work with women from families coping with incest.
As long as I have been working with survivors of childhood sexual abuse, I have observed that grief about the mother is among the deepest wounds to be healed. Along with rage at the mother, this grief tends to be far greater than any feelings about the perpetrator of the abuse. I have also seen the most extreme denial, and an urgency about trying to preserve an image of the ideal mother, including survivors saying barely tongue in cheek “My mother was perfect.” When they begin to see her more clearly, they feel truly orphaned. How could she not have noticed? Why didn’t she stand up for me? How could she have stayed with him? These questions haunt and torture them.
The complex mix of anger, hurt, longing, fear, love and desperate relief were a bittersweet variation on the Prodigal Son. It was the Prodigal Daughter, or the Prodigal Mother, and one of those privileged moments in psychotherapy that feel really too intimate as to include the therapist. It took my breath away.
The first session was with Betty alone, and it seemed to be an act of maternal heroism. This was the first time she had flown in an airplane by herself, and she navigated from the airport to an address in a strange city. She was a 50’s mom with the look of a farm girl. Active in her church and involved with her social service job, she was kindly and well meaning. She and her husband had been in therapy briefly when Sarah had originally raised the issue of the abuse, working with a therapist who had a decidedly “false memory syndrome” perspective. Betty was otherwise not particularly psychologically minded. She needed to check me out. She knew that I specifically work with survivors of trauma and she was not sure if I would view her as a villain.
The objective of the first session for me, besides building rapport, is to explore the motivation for the work and the nature of the hoped-for outcome. Some mothers are looking to make the problem go away. I need to let them know that this therapy will not be an argument about “what really happened”. It will not be a process for one or the other to make a case for what is the truth, and attempt to prove it. If that is the desired outcome, then we know right there to go no further. So far that has not happened. Betty said she was willing to “do anything to bring Sarah home.”
I described to her how I work. I use the same approach I use for working with couples, which involves a structured format called “Intentional Dialog” adapted from Harville Hendrix’s Imago Relationship Therapy. We also discussed logistics, how we might set things up to take into account the time and expense of her travel. We agreed to meet for weekly ninety minute sessions to start.
Betty and I seemed to make a connection, although I quickly realized that my neurological answers to her questions about traumatic memory were not what she really needed. Clearly, the process would be one of learning how to forgive one another and cope with having different memories and beliefs about the family’s truth.
What sort of women marry and stay with men who molest their daughters? Some themes have emerged over time through my work with these women. They tend to be children of neglect, often the unchosen among siblings. Betty was the “Ugly Duckling” among superstar sisters, although she never seemed to arrive at swan-dom. She suffered through her life within a brittle sense of worthlessness. Easily dominated, she was well prepared for a relationship of swallowing what she was dealt.
Often the women have their own experience of childhood trauma or witnessing trauma. Accustomed to neglect and minimizing of their own devastating experiences, they may resent or simply fail to understand why their daughter is “making such a big deal about the molest.” Spoken or unspoken, they may harbor a judgment of “I put mine behind me, why can’t you just get over it?” Yet for some reason they are here.
As is common with neglect, there may be a tendency toward some degree of dissociation. This may account for their capacity to not consciously know when the abuse was occurring. The mothers I have worked with have been strangers to their own feelings. Unaware of their other-directedness, they have to be taught how to talk about themselves, or how to even notice when they are not, let alone learning to become aware of their own emotions. They grew up in families where feelings were not discussed, so there was hardly a category for even feeling them. Betty was distressed and ashamed by her frequent tears in our sessions. To her it was a “breaking down” or “losing it,” that she would then apologize for.
For the mothers I have seen, being a mother had been their life, and having been a good mother a vital midlife concern. Their great fear is that they were not good mothers. It has been the norm to vacillate between extremes of guilt and defensiveness. Finally, what I have seen is that something about their childhoods has prepared them for the role of being caught in the middle, a role which they have played for years in the incest family.
In general, I have seen four core clusters of issues to be worked through in the mother-daughter therapy. From the daughter’s point of view they would be: You knew; You chose him; Do I really want to know who you are and understand how this could have happened; and the question of forgiveness. The first two, intimately entwined together, are the deepest wounds that survivor daughters tend to bring. They are incomprehensible and heartbreaking to imagine. Sarah lamented, “even if my kitten is under the weather I notice something is wrong. I was depressed, I cut myself, I was isolated and sad all the time, I didn’t eat and got emaciated. Even if you did not see the abuse, which is also unimaginable to me, how could you not have noticed that something was wrong?” It adds up to the most profound sense of annihilation and insignificance: “I did not exist for you. Invisible, I did not matter at all.”
Of course, if the mother did know then she clearly chose, whether actively or by default, to side with the father. If the daughter was significant enough or visible enough to be noticed, then the failure to protect, or the choice to turn a blind eye and maintain status quo, was intentional. Either is a profound rejection and unspeakable injury. Arriving at the point of being able to speak of such things is monumental. This is what the daughter has waited years to be able to say.
Finding words to describe these feelings, many of which have resided and ached within the survivor for decades, is Sisyphean at best. She both fears destroying the mother with them, or being ignored again. Either is tantamount to dying. The preparation is painstaking.
For Sarah and Betty, our work took some time. Our first session in which the two laid eyes upon one another for the first time in four years was a moment of awe. The complex mix of anger, hurt, longing, fear, love and desperate relief were a bittersweet variation on the Prodigal Son. It was the Prodigal Daughter, or the Prodigal Mother, and one of those privileged moments in psychotherapy that feel really too intimate as to include the therapist. It took my breath away. Sarah had dressed up, and looked more beautiful than I had ever seen her. Betty was a warrior woman having marched triumphantly in from the airport shuttle. The first session or two was a tentative, frightening and thrilling reunion, filled with looking at each other and catching up on news of their and their families’ lives.
From there it was a natural progression and important ground work for Betty to share stories with Sarah about her own childhood. As is generally true with neglected children, Betty did not even really know she had a story to tell. She certainly had no experience of the power and connection of sharing that story, especially with her daughter. She also told Sarah about the early years of her marriage with Sarah’s father, the financial pressure, the shame around the idea of a second divorce, the demand of Sarah’s disabled little sister on her time and reserves of patience and energy. Mother and daughter were creating a new connection which allowed them to get to know each other in ways they never had. For the purposes of the therapy, we were creating a context that might help Sarah ultimately make sense out of her mother’s failing her. It also created more balance in the therapy, depathologizing Sarah. If Betty’s story was also important to the work, Sarah felt less the “problem child” when she described her own. We were also creating a safe container, in the relationship with me and in the structure of the therapy.
Once under way, the work became difficult immediately. Betty had a strange suspicion of some sort of secrecy. Somehow she had unconsciously transformed the question “you knew” into a fear that Sarah suspected she was hiding something. She rather franticly tried to dispel this, but it was hard for Sarah to understand.
Sarah wanted for Betty to understand her feelings and how the trauma had affected her whole life. But somehow this sounded to Betty like a return to the argument about what really happened, and the court-like questions of blame and guilt. At this stage it seemed untenable to work less than once a week. There was not enough object constancy in the context of so much fear. The intense feelings, particularly Sarah’s emerging anger, would have been too much to hold for more than a week at a time, and there would not have been enough momentum to sustain hope for change.
There was another difficulty particular to this work. Betty went home each week to her husband, this same husband who had molested Sarah. For her it was like moving between one reality and another, one world and another. She struggled to keep her footing in both. Even though she was not discussing the therapy with her husband, she was returning to the world of denial, the world of his defensive, if unspoken, rage. It confused and ungrounded her.
With her inexperience with therapy and foreignness to feelings, Betty interpreted her frequent tears and Sarah’s and her anger as “the therapy not working.” As her hope waned, she began to complain about the trips and the expense. So, with some hesitation on my part, we began to meet once or twice a month for three or four hour sessions. Often my schedule did not allow full three or four hour blocks, so there might be a break of an hour or 90 minutes that gave Sarah and Betty a bit of a push to go out and do something together, have a meal or go shopping in my Rockridge neighborhood. When they began to return to the office with clothes and things that Betty had bought for Sarah, or doggy bags from enjoyable lunches, I began to see what an inadvertent and vitally important component these breaks were: they were structuring and dosing normal time together into the therapy session.
As time went on, both of their deepest objectives seemed organically, gradually to be met. What both really wanted most of all was to be seen. For Sarah, it had been, “Mom, I want you to understand me, and how my life has been.” For Betty it had been, “Sweetheart I want you to understand that I am not a bad person or a bad mom. I want you to see who I am and that I have really loved you.” This was happening quietly through the dogged exercise of the dialog, which by definition lands each momentarily in the other’s shoes. The incest was ceasing to be the focus of the connection and disruption of connection of these two women.
The role of Intentional Dialog in this work must not be underestimated. Daniel Siegel and Alan Schore, big names in current attachment research, are understanding more and more about the neuroscience of early attachment experience, and how the interaction between mother and infant affects the biology of the child’s developing brain. It is unclear what the possibilities are about healing early neurobiological attachment deficits later in life. Siegel and Schore are hopeful that it is possible.
Siegel cites research that identifies the primary cross-cultural element of healthy attachment and subsequent mental health as the good- enough mothering sequence referred to as “Contingent Communication.” In this sequence, there are four elements: when the infant emits a signal, the mother perceives it accurately, makes sense out of it, arrives with the appropriate response, and does so promptly. Contingent communication soothes and teaches self-soothing to the infant, and facilitates development in the structure of the brain where affect regulation occurs. It is simple attunement, and yet painfully rare among our traumatized and neglected clients.
The structure of Intentional Dialog, which involves mirroring, summarizing, making empathic sense out of, and responding in the same predictable format, essentially replicates the process of contingent communication. Perhaps, in effect, Sarah and Betty were repairing the dysregulated attachment sequence of both of their early lives. I like to think that is part of what makes this work so powerful.
As time went on, Sarah and Betty were e-mailing and phoning each other between sessions. Betty began to plan longer trips around our sessions, where she might spend a weekend with Sarah and her husband. They began planning a trip across the country for a relative’s wedding. It was becoming clear that they needed me less and less.
Interestingly, it is not unusual for the perpetrator to become curious around this time. Perhaps they want to “find out who this Ruth is,” or explore their own possibilities in the family healing. Sometimes I have met with them, and the process has continued. But that would be another story.
A last hurdle for Sarah, as for many survivors, was about letting go of the trauma. What does it mean to see how this could have happened? What would it mean to accept her mother as she is, her love with her failings, Betty’s own childhood injury with her massive betrayal as a mother? Would seeing her as who she is mean the abuse was OK? Does it excuse her from her part in Sarah’s lifetime of Post Traumatic pain and life disruption? Does it mean defeat? These are all questions that a survivor must contend with in this work. Is forgiveness a kind of denial, giving in, or might it be a loving, spiritual high ground? For each survivor and each mother-daughter pair, this question and its answers may be different.
For Betty, a final hurdle was about reintegrating Sarah into the family without a disavowal or a recanting of the “heinous accusation.” Would that mean that Sarah “won”? Would that mean that all the pain, rage and shame of the rest of the family would fade away like a war without a monument? What would it mean to allow the family to change? Would that once again be “Sarah controlling the whole family”? These are questions the incest mother must wrestle with, especially if she continues to share a life with the perpetrator. They are no small thing. I view this as profound spiritual work. There is no right answer. Sarah and Betty, and others I’ve seen, have been moved by love (and of course they are the select few that find their way into a process like this) to end a legacy of tragic unconsciousness and heartbreak.
“The brain is first and foremost an organ of action”
– Roger Sperry, Nobel Prize winner, 1981
For those of us who work with the traumatized, which like it or not is probably most of us to some extent, it is well known that trauma’s gravest and most painful sequelae are in the area of relationship. Even when the actual trauma is not interpersonal in nature, trust and safety in the world and in relation to others, tends to be shattered. The loneliness and anguish of this is what drives many of the traumatized into our offices, even if they themselves do not associate their isolation or relationship difficulty with their traumatic histories. Of course sexuality, already a delicate area for many people in the modern world, is hard hit. Couples where one or both partners have histories of trauma, often struggle and suffer with sex. Standard couple’s work or sex therapy may fall short in easing their distress and difficulties in functioning. Integrating concepts from relationship therapy, sex therapy and trauma theory is essential for helping them.
Healthy sexuality is very much about balance and flow. It is free blood flow that facilitates engorgement, erection, and erotic sensation. (Vasoconstriction or constricted blood flow is what the erection enhancing drugs are designed to alleviate.) Anxiety is vaso-constricting. In an anxious body blood vessels and muscles tense and tighten, blood does not flow freely.
Healthy sexuality is very much about balance and flow. It is free blood flow that facilitates engorgement, erection, and erotic sensation. (Vasoconstriction or constricted blood flow is what the erection enhancing drugs are designed to alleviate.) Anxiety is vaso-constricting. In an anxious body blood vessels and muscles tense and tighten, blood does not flow freely.
Both the sympathetic and parasympathetic branches of the autonomic nervous system are essential in sexuality. The sympathetic branch is responsible for arousal and activation; the parasympathetic branch is responsible for calming. Sex requires a balance or flow between relaxation and excitement. Without arousal, there will be no sexual activity, and a certain amount of calm is required for arousal to occur.
Most often in trauma, fight or flight fails. The child cannot escape or fight off the blows of the larger, more powerful adult; the driver cannot avert or overtake the oncoming car; the soldier cannot outrun or destroy the bomb. When fight or flight fails, the body resorts to a freeze response. This is a hypo-aroused or parasympathetic shutdown state. This is the analgesic state that an animal goes into to numb the pain of being eaten, or to “play possum” so that the predator will leave it for dead rather than eating it. Hypo-arousal can look like a deathly dullness, depression, or some of the range of dissociative states we are familiar with in our traumatized clients.
Satisfying sexuality involves a flow of energy between partners, an expression or communication passing back and forth between them that ideally would be physical, emotional and even spiritual. And finally, in good sex both individuals’ attention and awareness flow back and forth between themselves respectively, their own sensation; and the sensation or experience of the other. It is a quality of conscious presence that moves back and forth between the two.
What is the impact of trauma on all of this balance and flow?
In the last 20 years, our field has advanced dramatically in understanding how trauma affects the body, brain and psyche. Since the advent of neuroimaging technology, researchers have become able to observe in vivo what happens in the traumatically activated nervous system. This parallels the surge of information and understanding that occurred when Masters and Johnson began to study live sexual functioning thirty years prior. We have learned, that the traumatized nervous system, floods with stress hormones and goes into a state of acute anxiety or hyper-arousal. This, in autonomic nervous system terms, is a sympathetic state, where the body now in high alert prepares to fight or flee. Blood flows into the limbs, and constricts in all other directions. Functions non-essential to survival (like sexual functioning,) recede into inactivity. The cognitive part of the brain shuts down, and the more primitive limbic or emotional brain holds sway. The organism directs all of its intention toward staying alive.
Most often in trauma, fight or flight fails. The child cannot escape or fight off the blows of the larger, more powerful adult; the driver cannot avert or overtake the oncoming car; the soldier cannot outrun or destroy the bomb. When fight or flight fails, the body resorts to a freeze response. This is a hypo-aroused or parasympathetic shutdown state. This is the analgesic state that an animal goes into to numb the pain of being eaten, or to “play possum” so that the predator will leave it for dead rather than eating it. Hypo-arousal can look like a deathly dullness, depression, or some of the range of dissociative states we are familiar with in our traumatized clients.
What this means is that trauma may involve wild extremes of sympathetic and parasympathetic arousal. By definition, trauma is overwhelming experience. It is more intense stress than the organism is designed to bear; and the traumatic stress response is an effort to adapt to circumstances that are not tenable. The residual post traumatic symptoms are evidence that although the attempt to survive succeeded, the attempt to adapt failed, and the body continues to struggle to find emotional and physical equilibrium.
We have also learned that once the nervous system has been shaken by a particular experience, the limbic brain is adamant that it will not happen again. It becomes highly sensitized to stimuli even slightly reminiscent of the original event, and responds to them as if the cataclysm is about to happen again. So even vague cues, often well outside of awareness, can activate the full blown trauma response. It is the limbic brain that prevails in trauma and the limbic brain has no sense of time. A traumatized veteran hearing a helicopter will not know the difference between 2006 in Berkeley and 1968 in Vietnam. The organism responds as if it is happening again now. And as the analytical prefrontal cortex shuts down in trauma activation, the pre-recovery veteran cannot readily be talked out of these feelings.
Post traumatic stress as we have all doubtless seen involves the swings between hyper and hypo arousal, or “intrusion and numbing.” Survivors may swing between being bombarded by traumatic memory and stimulation; and an even amnesic dullness or numbness. The inability to self regulate is the bane of the trauma survivors existence. They are as if batted around by their overly sensitized nervous systems and often cope by utilizing any imaginable means of avoidance and escape. The world is a jungle of unpredictable stimuli and traumatic cues. Safety and trust are elusive, the body and emotions may become a kind of minefield.
Obviously the delicate balances required by sexuality may be dysregulated at best. Or individuals seek adaptations to the dysregulation in one way or another: sexual avoidance, substance abuse, sexual compulsivity to name a few. In one couple I worked with for quite a while, one partner when she became erotically aroused would go into a full blown panic attack. The experience of sexual excitement was a trauma cue that activated her whole system. Her partner, also a trauma survivor, generally defended himself with a hypo-aroused, numb state and consequently had little or no sexual sensation or functioning when with her, although he functioned just fine when alone. Their intimate life had been an agony. And although the emotional relationship was not easy, they loved each other deeply and wanted to get married and have a family some day. They were wracked with distress about their sexual dynamic. So how do we help?
Effective relationship work is obviously essential. The dynamics of extremes of hyper and hypo arousal make for difficult enough emotional and interpersonal dynamics as do the vicissitudes of “triggering” of spontaneous trauma activation. As stated, relationship is difficult! And the emotions and emotional patterns that develop around the challenging sexual relationship may begin to take on a life of their own too. Given that trauma overpowers and has no regard for a person’s feelings or wishes, traumatized individuals may be highly sensitized to issues of control, or feeling unconsidered. Cycles of fear and rejection are a common theme in these couples. John Gottman the relationship researcher found that on the average, couples wait six years before showing up at our doors. By the time they get to therapy the patterns of pain and anger, fear and hurt may have substantially coagulated and hardened. So careful couple’s work that teaches both about empathy and trauma, is the necessary first phase. The couple described above, worked hard to create understanding and emotional safety before we even broached the sexual interaction.
1. “World Without End”
Again, the limbic brain has no time sense. Part of the terror of the trauma state is the feeling or the fear that it will never end. There may be either a sense that this torture is infinite and endless, or that the end is near, i.e. “I am going to die.” Both produce a terrible anxiety. The understanding that time passes, events resolve and life goes on, are advanced functions of the cognitive prefrontal cortex, which is inoperable during trauma. One of our tasks with the traumatized is to introduce the notion that time does pass. Given that the reasoning function may not be available to work with at all, a powerful way to begin this process is with awareness of the moment to moment changes in body sensations.
When a person in a trauma state shifts the focus of attention to the body and simply tracks the movement of sensation, it becomes possible to notice moment to moment sensation changes. By asking the client to pay attention to what happens next and what happens next, we introduce the concept of time. Time passes, things change, things pass: flow. With the focus on sensation, ultimately the body settles. The individual then becomes more available verbally and cognitively; and the sensory experience can be cognitively grounded and re-enforced by talking about it. Slowly through experience, the individual begins to learn both limbicly and cortically, about time. We are helping to get the various parts of the brain working together again, and also to make sensation and experience less threatening.
2. “Being Here and Not There”
Post traumatic stress is dominated by the loss of capacity to pay attention to current experience. One is catapulted willy-nilly into the past, or into a zone of hypo aroused unconsciousness. Part of what we need to help the traumatized to do is to be fully here. One brain area most activated during traumatic flashback is the thalamus, or sensory relay station. Its function is to integrate fragments of sensory input from any given experience. In trauma, where recall is predominantly sensory, these inputs may be scrambled and disorganized. An important goal in trauma recovery is integration: integrating the sensory fragments into a coherent narrative, and integrating dissociated brain functions.
Part of how we can work with this integration is with naming, putting words to the experience of both emotion and sensation. The prefrontal cortex, which is the part of the brain capable of self-reflection also has the ability to inhibit the amygdala, (a key player in the limbic system,) and regulate emotion. Calling upon the individual to simultaneously experience and observe experience, to use one part of the brain to attend to another, is a way of enlisting the prefrontal region. Helping clients and couples begin to speak precisely about experience, to articulate aloud and to each other what is happening, facilitates a shift from sensory gales to narrative; and strengthens prefrontal function. It also enables the client eventually to experience and to feel more control.
3. “Mediating Visceral States”
The vagus nerve is a long and very important nerve extending from the brain stem to the far reaches of the body. It relays information back and forth from brain to body, the information whereby we “know” what we “feel.” Interestingly, 80% of the information carried by the vagus is “afferent” meaning that it carries the information from the body to the brain. Only 20% of the information runs in the other direction. Using this advantage, there is a potential for the body to effect changes in the brain. Method actors know this, as do the researchers who study facial expression. Method actors who configure their bodies in the positions associated with particular emotions begin to powerfully feel those emotions. Manipulating facial expression can have a similar effect.
In the trauma experience, natural physical defense functions and movements fail. The lasting visceral memory is of powerlessness and defenselessness. The feeling of potency and the capacity for self protection can be slowly re-introduced through movement. An individual who begins to experience the strength and ability to push against or push away, natural defensive functions, will come to feel safer and more confident in close proximity with another’s body. Coaching couples to experiment, for example, with pushing against one another in a structured and contained way, may begin such a process. Mediating or modulating visceral states we get a new outcome. Again working with the body is a path to self regulation as well as relationship safety.
4. Breath
Breath is a powerful vehicle of affect regulation. It is certainly evident in the sexual interaction. The inhale is activating or autonomically sympathetic. The exhale is parasympathetic or calming. Of course whenever we are addressing anxiety disorders of which post traumatic stress is one, utilization of the breath for calming is an important skill and habit to teach. And of course calming breath facilitates the blood flow requisite for sexual sexual activity.
Helping couples to make use of their breath in the service of their own respective body calm as well as getting in synch with each another, is important work. Synchronized breathing is one of many activities borrowed from tantric practice that helps couples begin to move between their own and their partner’s body rhythm and sensation, while also calming themselves. It also slows everything down, which facilitates a sense of control and safety. Awareness of breath is another element of the attention to sensation, all of which serves to bring clients into present time. I like to tell them “Right here, right now, everything is OK.” And they generally admit that that is so.
Sex therapy technique, such as adaptations of sensate focus, continue to be invaluable with these couples, as does much sex education about both healthy sexuality and “garden variety” (ie non-trauma–related) sexual difficulties. Many couples need a fair amount of in-the-office help with the relationship and the trauma activation patterns before they feel comfortable doing sensual or sexual homework. This needs to be normalized. Given that both hyper and hypo arousal takes individuals out of the moment and out of presence with one another, all of our practice at staying present, naming emotions, moving between contact with the other and contact with the self, are “money in the bank” for when the overtly sexual practice begins. Presence is perhaps the most crucial element in satisfying sex, and a challenge for these folks to achieve. All our work in that direction is essential.
The task at hand in working with traumatized sexuality is more than anything the work of integration: integration of dissociated brain functions; integration of fragmented experience; integration of body, emotion and brain. For the therapist it requires an integration of trauma theory and practice, sex therapy and sound relational work. It also requires a good deal of patience, probably time; and a hefty measure of love that keeps everyone hanging in there.
It was almost two decades ago when I stumbled across a most remarkable video. In it, a circle of women, all naked; and their group leader, a woman in her seventies, also naked. They were pre-orgasmic, and she was teaching them how to have their first orgasms. I was immediately transfixed. My years of work had brought many women who had never had an orgasm or whose orgasms have been lost to them for one reason or another. I had always wished to be able to help them acquire or restore the longed for magic. I later learned that this was Betty Dodson, and the video was a one hour distillation of the legendary women’s BodySex weekend workshops she had been leading since the early 1970’s. I proceeded to buy all her videos and pore through her books, and continued to wish for the opportunity to sit in the circle and see how she does it.
She came to rely on masturbation to sustain herself, discovering a powerful feedback loop between her art and her self pleasuring. Her orgasms energized and inspired her art and her painting turned her on. It was a perfect marriage.
Fast forward to 2018. I find that although Betty has gotten older as I have, she has met and joined forces with a young business partner, Carlin Ross, who is helping her to offer the workshops again. I have a chance to realize a bucket list dream. July of 2018 I fly to Manhattan from my home in San Francisco, to find myself sitting in the circle.
Betty was born in Wichita, Kansas August 24, 1929, the second of four children in a low income farm family. Her mother, Bessie, attended school through the third grade, just long enough to learn to read and write. Betty considers her mother to be one of the wisest people she has ever known, and with her wealth of “horse sense” perhaps the greatest, most profound influence on her as a person, a woman and a sexual being. She was profoundly “fair” and in a culture of completely segregated racism and highly religious sexual conservatism and sexism, an enlightened voice of equality and sex positivity. She was normalizing and relaxed about childhood sexual curiosity, and also taught and modeled a strong minded parity with men unique for her day. Betty grew up to be fierce, telling a story of going after a family friend who attempted to sexually molest her best girlfriend when the girls were 11 years old, chasing the man breathless out of her house at knifepoint. He never tried anything like that again. Bessie patiently answered and encouraged her questions about her sexuality from early ages, which probably laid the groundwork for the remarkable maternal skill Betty has for teaching women of all ages about theirs. Indeed Betty, who never thought of herself becoming a mother, considers the BodySex workshop to be her baby.
It was increasingly dismaying and then infuriating to her that wives continued to be subject to the pleasure of their husbands, their then only legitimate male partners. There was virtually no awareness, interest or consideration of women’s pleasure. She viewed marriage as a tyranny in which both self-pleasure and partner sex relegated women to second or third class citizen status.
The other thing Bessie did right from the start, was convince Betty of her talent and brilliance as an artist. From an early age, Betty loved to draw, grabbing a crayon at every chance she got. She was in fact quite an extraordinary artist, and by the age of 18 was contributing significantly to the family income by working as a fashion illustrator, her drawings appearing regularly in newspaper and magazine ads. With dreams of becoming famous in the fashion world, Betty worked hard as she completed high school in Wichita. She especially loved drawing lingerie.
At 19, fearless, Betty moved alone to the fashion center of New York City, rented an apartment and got a job as an illustrator. Her father’s younger brother, her Uncle Howard whom she had never met, was a twice divorced, fiftyish, good-looking bachelor, who lived in the City. Like Betty’s father, he was artistic himself. Shortly after meeting, Betty proudly showed Uncle Howard her portfolio. With a cursory look he said to Betty, “You are pretty good, but if you want to make it in this town, you need to go to art school.” Betty with the grandiosity of youth was affronted, thinking she had nothing to learn. Uncle Howard offered to take her to the Museum. Betty had never been to an art museum before, went with him to both the Modern and the Met. Although unimpressed by modern art, the first painting Betty set eyes on in the Metropolitan Museum of Art, was Caravaggio’s huge canvas, Mars and Venus, which portrayed the exquisite nude body of Venus showing Mars how the stars of the galaxy had been created by “expressing milk from her perfectly formed breasts that came out in dazzling little stars. The combination of beauty and sensuality knocked me out. I knew I wanted to paint like that.” She took Uncle Howard’s advice and proceeded to go to art school. And although he was opinionated and had old world gender role attitudes, he was kind and generous, helping Betty get settled in New York where she proceeded to work her way through the prestigious Art Academy.
Betty was and still is outraged and enraged by the seemingly impenetrable sexism of the art world. The little I knew of it was from the story of Georgia O’Keefe who relied on her husband Alfred Stieglitz to open doors and facilitate her gaining her earlier opportunities to exhibit her work, even though she was “pretty good for a woman.” That of course complicated for O’Keefe, what would become an increasingly difficult dependency. Betty still snarls about it. As Betty moved into her thirties, in New York of the 1950’s she had decisions to make about her own life. It was expected that women marry and have families, and although she knew fairly young that she was not cut out for motherhood, her “ticking clock” drew her to marriage as she approached 40. She married a handsome, kind, seemingly perfect Jewish art benefactor named Fred with whom she had a relatively harmonious, bland and sexless marriage. The sexless part being unbearable to a woman as sexual as Betty, she came to rely on masturbation to sustain herself, discovering a powerful feedback loop between her art and her self pleasuring. Her orgasms energized and inspired her art and her painting turned her on. It was a perfect marriage. Often she would come home from the studio to her more mundane, literal marriage, spent, her husband not knowing she had been wildly masturbating all day long. This placid arrangement lasted a decade, with Betty’s art becoming increasingly erotic during that time until one day Fred came home and racked with shame and remorse, confessed to Betty that he had fallen in love with his secretary and wanted a divorce. And although Betty now claims she effectively played the role of heartbroken, betrayed spouse, she was secretly hugely relieved to be “off the hook”and free of the stifling prison of a monogamy bereft of partner sex. This happened in a world slowly awakening to women’s and sexual liberation.
Liberating Masturbation
The early 1970’s brought women’s “CR” consciousness raising groups, where women gathered at regular intervals to talk about their lives and relationships, feelings and ideas, with other women. Betty’s art, sexuality and political sensibilities seemed to be three harmonic branches of the same tree, growing, expanding, flowering and then beginning to bear extraordinary fruit. Perchance she discovered “sex parties,” a kind of latter day orgy, where participants were free to explore and experiment with sex free of serious, sacred or relationship trappings, but rather as fun and play. Permission for such an approach to sex which since time immemorial had been the accepted purview of men, was novel, refreshing and freeing for women. And Betty began first to attend and then host such parties, which grew in notoriety and size as time went on. They were drug and alcohol free, sex being the social lubricant, (although there were plenty of cigarettes in those days, and Betty admittedly still loves to smoke.) Her repertoire and philosophy about sex continued to evolve and she continued to paint about them. Soon thereafter, she met Grant, the “great love/hate of her life.” An intellectual and accomplished university professor, he was a wonderful play mate for partner sex, and a great proponent of her work. The hate was because he was “depressive, unpredictably angry, moody and unbearably possessive.” Their involvement as non-exclusive sexual friends however, spanned 40 years until he died. It was Grant who encouraged her to write.
Betty became increasingly politicized by the burgeoning women’s movement of the 1970’s. Her unique and special interest was around women’s sexuality. It was increasingly dismaying and then infuriating to her that wives continued to be subject to the pleasure of their husbands, their then only legitimate male partners. There was virtually no awareness, interest or consideration of women’s pleasure. She viewed marriage as a tyranny in which both self pleasure and partner sex relegated women to second or third class citizen status. Raising consciousness about women’s pleasure, and introducing women to self pleasure became Betty’s passion, mission and great contribution.
In 1974 Betty was invited to write an article about women and masturbation for the then foremost national feminist magazine, Ms. The editors, finding it perhaps just a bit too hot, the article was slashed to a perfunctory three pages, with the parenthetical caveat that interested readers could order the full unabridged 18 page monograph by sending a check for three dollars. Within four weeks, Betty’s mailbox had been deluged with literally thousands of three dollar checks. Incredulous, she proudly told her mother she had collected close to $10,000 in three dollar checks, no small sum in 1974 currency. Betty busily Xeroxed and stuffed envelopes over the next several months, and then set to work on her first book. Clearly there was an appetite and a demand for a new female sexuality. Speaking engagements soon followed.
From there, her increasingly bold openness about masturbation and a new female sexuality, and Betty’s finding a niche in the women’s CR groups, organically sprouted the BodySex workshops. She named them BodySex as they were about something free of morality, roles, heaviness, sacredness or even love. They were about freedom, organicity, nature, self care, pleasure and joy. The workshops were about restoring our nature. And they evolved organically like a piece of art. “I never planned them, just like I never plan a painting. Just as the painting seems to appear spontaneously on the canvas, so the workshops “shaped themselves. I didn’t know what I was doing,” Betty declares, “I just made it up as I went along.” And somehow over the decades, hundreds, and then thousands of women. came.
Decades later Betty’s work is formational and transformational in what is now the world of sexology and sex therapy, research and practice. Betty earned a doctorate and in addition to the BodySex workshops has taught and presented around the globe. Over the years I have heard her speak and teach dozens of times in different conferences and venues. I was thrilled that she granted me an interview and welcomed my writing this article/
Betty and her work seemed never to get old even as the world has changed around her. Her books now number in dozens and have been translated into many languages. Her legacy grows. It was a great thing when in 2004 she met up with Carlin, a thirty-something attorney. And the timing was perfect. The age of electronics was upon us and Betty was mystified and cowed by it. Although savvy to its inevitability, she was neither inclined nor interested in pursuing it herself. Upon meeting Carlin ,she sensed immediately a quick and brilliant mind, and an innate generational technological ability. It was a perfect match. Carlin also proved to have the unique quality of being willing and gracefully able to operate behind the scenes as not the main event herself, but the invisible facilitator of the main event presenting flawlessly. It is a rare absence of egotism and narcissism, that portends an amazing self confidence and humility. An extraordinary blend. Carlin also has the patience, compassion and presence to graciously and respectfully fill in for Betty’s failing ears and memory. “I am deaf!” Betty declares “although I can read lips and bodies.” Carlin seamlessly knows when she needs to loudly repeat something that Betty has missed. Standing in for Betty’s sometimes spotty memory, she can say with humor and gentleness, “Yes Betty, we just did that.” They are a wonderful team. Carlin is an unsung hero, that has enabled us to have more of Betty when she seemed to be winding down. She is also a great archiver, documentarian and organizer, all a great complement to Betty’s artistic temperament, as well as a creative sexual being in her own right. We are fortunate to have her. Fifty years later, I arrive at the door of the same downtown Manhattan apartment where the first BodySex workshop was born.
It is a steamy July afternoon in New York City where Betty still lives in the classic rent controlled apartment she lived in with her husband Fred. It is beautiful, and the sign downstairs says “all guests must announce themselves.” The young man at the desk takes one look at me and says “Betty Dodson?” and points to the elevator. Clearly he has seen hundreds of women trooping in and out to see Betty, even in the young years he may be employed there. I am greeted at the door by Carlin who is completely naked. It seems utterly natural to take off one’s shoes and leave them in the entryway, and to take off one’s clothes and hang them on the hooks.
I am not the first to arrive and the other women, who have already begun to situate themselves in a circle on the floor, are completely naked. The room is beautiful and light, clearly the home of an artist entranced by Renaissance art and the human form. Huge drawings and paintings grace the walls, most prominent of all being an exquisite nude of Bessie, Betty’s beloved mother and mentor. There are also beautiful sculptures, warm textiles and candles, and many artistic representations of vulvas. Shelves of books cover several walls, gentle music plays, and there is both a quiet, tense excitement, and a remarkable sense of comfort, ease and safety. It is rather like the mysterious blend of arousal and relaxation required by sex. (Betty adamantly declares however, that “orgasm is NOT about relaxing but about GOING FOR IT” I guess I am just amazed by how comfortable I already feel, if perhaps somewhat pinching myself. Is this is actually happening?
Where often coming from San Francisco, I am the farthest traveler in a group, in this group women have journeyed from all over the globe: two from Australia, one from India, one from Chile, one from Berlin and two from China, with a smattering of new Yorkers and one other West Coaster besides me. We are the world. And we are every shape and size. There are women who are at least twice my weight; the range of pronouns and orientations are represented. The youngest is 27 and the oldest (besides Betty) is me at 63. I am vaguely conscious of my age, but mostly to be moved and somewhat emotional about the crop of young women who are up and coming in this historical time.
We begin with an un-hurried round of introductions, each woman saying something about herself and what brings her. People are there for a range of reasons, to restore an orgasm lost or damaged by surgery or trauma; to learn how to have orgasms for the first time, and to learn how to do what Betty does and help other women. We all have a story, and each is captivating. I feel moved and privileged to share and be let in to this deeply personal and usually private realm. By the time we complete the circle, 14 women plus Betty and Carlin, most of whom just met for the first time, are very much a group.
Show and Tell
The main event of Day One is “Show and Tell.” This is where each participant has a chance to sit next to Betty who with her 50 year old hand mirror, gives each person a guided tour of her own vulva, and the whole group comes along. Betty names the various structures: “This is your clitoris, these are the outer and inner lips, the “pee hole” or urethra, and the vagina. We are all amazed by how different we all are, that vulvas are as varied as faces. The colors, the shapes, sizes of the various structures. And because of our different ethnicities and ages we are that much more diverse. Some have pubic hair and some are waxed or shaven. Some have thick or textured pubic hair that resembles the hair on their heads, on others it is thinning or greying. Some have been injured giving birth, or experienced sexual assault and are scarred by that. And each has a story, often including shame, the shame that comes of never having been told “there is nothing wrong with you.” It is remarkable how shame dissolves by bringing the vulvas and their stories out of hiding. Carlin takes a photo for each woman of her vulva.
The pinnacle of the weekend is what Betty has named the “Erotic Recess.” When we arrive on Day Two, at each woman’s spot on the floor, is a towel with a one pound stainless steel “barbell” dildo, a bottle of lube, and a vibrator. After doing a breathing exercise and some warm-up movements, Betty has us all lie down with our feet toward the center of the circle. It is a large and airy room , there is plenty of space. She instructs us to lube up and insert the barbell, biting down on it. Orgasm is a uniquely healthful activity, Betty teaches because it combines 4 essential human functions: breath, muscle strength, movement and imagination. Betty considers the integration of these four powerful elements as being the secret to longevity and health. She prioritizes regular orgasm, with or without a partner with good nutrition, sleep and going to the gym. At 89 she still has a regular masturbation routine, and she recommends it to all of us lifelong. She emphasizes, “you don’t need to have a partner.” Betty gave us simple instructions for each element, attention to breath, thrusting movements that curl toward ones own body rather than arch away, using muscle to grip solidly to the barbell, and let fantasy fly. Then she, as she has in this room and many others around the world over the past 50 years, she invites us all to go about it. For the next timeless hour or so, the room is a symphony of ecstatic sound as 14 women plus Betty and Carlin, generate multiple, multiple orgasms. Betty believes that women’s orgasmic energy will rise and heal the planet. I was amazed to be so un-distracted and comfortable in a way I had never imagined, well not for me anyway.
Once we all began to wind down Carlin brought out bowls of huge, ripe strawberries, chunks of wonderful cheese; and pitchers of ice water with lemon slices. A relaxed glow settled over the room.
After a break, came one more activity. The group massage. This was where Carlin split us up into two groups of seven, and we each had a turn at being massaged front and back, by six pairs of hands at once. Not erotic, it was calming, and a delicious culmination of our extraordinary day. What remained was closure, where we had a chance to share our gratitude, and any other insights or discoveries we had gained. Many of the women wanted to g out to dinner or hit the new York clubs, but I was ready to settle in and reflect on this remarkable weekend. I had become part of the 50 year legacy.
On August 24th Betty turns 90 years old, still going strong and continuing to make her indelible mark on the world. Countless women and men have a happier life because of her work. And she also teaches that the best way to promote sexual health is to be like her mother Bessie: open, interested and encouraging of children’s sexual curiosity and impulse to masturbate. Teach them to be safe and informed, and let them explore.
Thank you Betty for your life’s work and legacy. In New York you are a local treasure and in the world you are one of a kind! Happy Birthday and many more! And as I know you would say to all of us, “Happy Orgasms!”
“Two country people were fishing in a river. As they fished and talked, they saw a child floating down the river dangerously close to the rushing waterfall. Fearing the child would drown, one of them jumped in the river and brought the child safely to the bank. But soon there was another child floating down the river, then another, and another. Soon the river was filled with children all heading toward the whitewater and waterfall.
Both of them rushed to save as many children as they could, but there were too many children, they would never be able to save them all. One of the two jumped out of the river and started running upstream along the bank. The other yelled “hey where are you going? we need to save these children.” The first yelled back “I’m going upstream to stop whomever is throwing them in.”
– Prevention Parable
For three decades the voices of #MeToo have echoed off the walls of my psychotherapy office. What a long overdue and welcome relief to hear them resound at long last, even be believed in the larger world outside. Gratified and hopeful though I am that the issues of exploitation, abuse and sexual injustice are getting wide mass and mainstream attention, I find myself thinking more deeply about its causes and prevention. Policy and punishment appear to be beginning and changing, and much more is needed than that, to interrupt a pandemic that is daily proving to be even more ubiquitous than we may have thought. I am interested in adding to our responses the major categories of education and treatment for perpetrators and all boys and men; and locating sexual health in all of its ramifications as a public health issue for all children and adults in our country. I for one, am old enough to remember the “false memory” movement where victims and their therapists were blamed and villainized for “fabricating” stories and symptoms of sexual trauma, attempting to drive it back into darkness and silence. We must all work hard to keep that from happening again, and prevent this devastating reality from slipping back under its cloak of denial into hiddenness and complicity.
A new perspective is emerging in the larger sexuality field. There is a budding movement to redefine the concept of sexual health from one that is value, moral, culture and pathology laden, toward a more thoughtful and subjective criterion that emphasizes consent, pleasure and self-regulation.
As awareness grows, we see the beginnings of progress toward changing attitudes, policy, and education about gender, power, sexual harassment and abuse. That is heartening. However, while the #Me too movement shines a much-needed spotlight on gender and power inequality, it is also an aspect of a far more complex web of problems. By looking a little wider, at more of the issues in play, casting a wider net may garner a better shot at success. Awareness of exploitation and abuse of women and children is imperative, as are sanctions and consequences for perpetrators and sexual opportunists of all kinds, I propose that we also guard against solutions that are too simple, or become a contest that further divides men and women. Perhaps this pandemic of out of control sexual behavior, reflects a cultural crisis involving sexual health, that we may have a public health crisis on our hands, As in yet another parable, of the blind men and the elephant, viewing the parts in isolation, does not convey an accurate enough big picture, and will certainly fall far short of our goals. We need to sort and study in depth the various issues, integrate them, and then put the mosaic together. While with certainty for many men who exploit, abuse and intimidate women, sanction and punishment are the only appropriate response. I also see a fundamental imperative to put sexual education and sexual health through the lifespan on the national public health agenda.
Still, however, sexuality in the larger world, and even in the relatively progressive Bay Area, continues to be sensationalized, commodified, pathologized, mystified and globally titillating, with there being a poverty of information. Although it has become routine to see advertising for sex enhancing medications and other products, most people have a limited understanding of what is sexually realistic or “normal.” I am repeatedly dismayed by clients’ reports that the oncologist treating their cancers; the psychiatrists treating their depression; even their couples’ therapists do not educate, inform them, or do not inquire about sexual function and satisfaction. Because their helpers do not initiate the dialog, they conclude either that it is wrong to ask, or that they are simply supposed to know.
My career began in the 1980’s when the Women’s Movement had recently given voice to violence against women and children. My work with sexually traumatized women took me down an unexpectedly winding road. Realizing how difficult relationship was for my clients, I became a busy couples therapist, then sex therapist. Sexuality was so difficult for so many of these traumatized women, that it became a focus of my attention and my work.
The advent and rise of the Internet brought with it what every “new” technology and medium of communication historically had: it became a vehicle and a new commercial avenue for sex. Pornography in every imaginable and unimaginable iteration appeared, and it became a widely discussed and often sensationalized topic, in the world and in the field of sex therapy. It certainly began to show up in my office, with partners or spouses wondering or worrying about what it might mean. Is porn use cheating? Is it patholological or damaging? How much is too much? Due to “Accessibility, Affordability and Anonymity” people could spend inordinate amounts of time watching it and many did. A literature and treatment industry soon mushroomed around pornography in both professional and mass public realms, with little agreement or data supporting it. In my office, I witnessed the pain, suffering, shame, humiliation, confusion anger and despair of couples, where one partner, (in my practice usually male) repeatedly hurt and betrayed a spouse he truly loved. Both were baffled and desperately dismayed that he would not or could not stop. Then I began hearing about other activities: affairs, sex for money, anonymous sex with strangers, empty “hook-ups” and all taking place without explicit agreement between the two who sat in front of me.
The specifics of the sexual behaviors varied, but the consistent element was what came to be described as a kind of split self. Essentially the sufferer (or perpetrator) was of two minds: there was a part of the self that did not want to engage in the behaviors in question, were even repelled and ashamed of them; and another part that irresistibly did. I saw this often in my practice, and it is an experience known to most of us where the warring pull of temptation versus a commitment, value system or priority seem to agonizingly tear the individual apart. The battleground of the two parts in this case was the body and sexual behavior in question, be it infidelity, or some other variation on betrayal. I have seen, a broad range. The problem was often less the specific behavior per se, than the drive to repetitively do something in spite of its impact, its consequences and against one’s better judgment. Often these individuals were betraying their own deeply cherished values and morals, and rather shocking themselves. For myself, I struggled and searched for an understanding and an approach that would help both clients and their partners make sense out of what seemed incomprehensible, and maybe even find a way to navigate through it together. No small feat, especially as often the impact on the betrayed partner is many faceted and profound.
2015 brought the seminal work of Doug Braun Harvey, who with his co-author and collaborator Michael Vigorito wrote a groundbreaking book on what they termed Out of Control Sexual Behavior or OCSB. They brought a different lens to the problems of sexual harassment, opportunism, exploitation and abuse, building a coherent and dignified conceptualization, and a treatment approach. The centerpiece of their work is a concise definition of sexual health, which is also its heart and soul.
Sexual health consists of a framework of six essential and non-negotiable principles. Within the frame of those principles, individuals and couples determine for themselves what their sexual activities are to be. For many individuals and couples, these concepts are astonishingly new and they have never thought about them or discussed them. In fact it is remarkable how many couples have barely if at all talked about sex, or their sexual relationship. We live in a world where we are bombarded with sexual stimulation and sexual myth, and information is at a minimum. Doctors and surgeons, prescribing physicians and psychiatrists, teachers and even therapists more often than not fail to speak or educate about sexuality. The majority of clients I have seen over the decades, if they have had any relevant sex education at any time in their early or adult lives, it was pitifully lacking. So I found the six principles to be a surprisingly useful teaching tool.
First and most important of the six principles, is Unambiguous Consent. By unambiguous consent we mean, beyond “No means No!” that unspoken “deals” must be spoken about. If he buys me an expensive dinner, what do I “owe” him? Is it true that revealing attire means “I am available?” Is it “fair” to change my mind? What is the impact of mind altering substances on consent, even if the substance use itself was consensual? And power differentials are a game changer. “What will it cost me if I don’t do what you want?” And “What do I want to do about that?”
Consent is a huge, complex and multidimensional topic, and I view it as a vital component and expression of care and empathy. I teach couples to practice “informed consent” about most anything; as a way that we acknowledge, honor and create equality around differentness. Even something as fundamental as when we discuss any difficult or personal matter, is a point for consensual agreement. In the larger world, consent is complicated by many factors, the most obvious of course, is power.
The other five principles are:
Non-exploitation: This of course means a commitment to being ethical, thoughtful and respectful of the integrity, rights and preferences of all parties to the interaction. It also considers what might be a power inequality between the two parties that could complicate the question of consent. I have also found that as with so many concepts, definitions of what constitutes exploitation, vary widely. Some individuals view pornography and paid sex as categorically exploitative of the sex worker. Others do not. Again, individuals and couples must elaborate and agree on their terms.
Protection from HIV, STI’s and Unwanted Pregnancy: Shared responsibility for safety and equality in all its forms.
Honesty: A commitment to transparency. So often the worst injury in sexual predation and betrayal stems from deceit, of intention, motivation and meaning. I have certainly also seen couples disagree on “lying by omission,” which also needs to be explicitly negotiated.
Shared Values: Sexuality is tied to a vast range of diverse philosophical, moral and religious meaning systems. Gender, exclusivity, sexual frequency, even preferred sexual acts for example, are all personal and subjective, and must be known, negotiated and compatible.
Mutual Pleasure: Not to be forgotten, with the emphasis on mutual.
If the whole world operated on these principles, OCSB as well as the entire #MeToo phenomenon and all its abusers, would pass into grim history.
Beside the Six Principles, the authors detail the problem of “split self,” of being of two minds, which can result in unwanted sexual behavior, and the emotional and relationship difficulties and disasters that it can bring. Numerous devastating examples of have flooded into my office over the years. Braun Harvey and Vigorito developed an approach consisting of individual, group and couples education and therapy, emphasizing accountability, self regulation and relational integrity. I found their framework to be of great use to me, and many of my struggling and suffering couples.
Self regulation is a concept that is becoming more and more a part of the mental health lexicon as we finally come to better understand the role of the brain and nervous system in human psychology and health. It would seem like a “no brainer” that the brain profoundly shapes the mind, but it has been a long time coming. Self regulation boils down to maintaining balance and control, a fundamental ability that is most noticeable in its absence.
Regulation is the balance between energy and rest, intensity and ease, excitement and calm, sympathetic and parasympathetic: the ability to rev up when appropriate and then settle down. As children we rely on caregivers to oversee or manage these functions. Under the best of circumstances, children are soothed and comforted by parents, their fears and worries are eased, their frustrations and anger tempered or contained by a good parent. As children, we need first to be taught to identify, name and effectively express impulses and feelings. With maturity, we ideally learn to manage our energy, our activation, our impulses ourselves, to self-regulate. A “regulated” nervous system, is one wherein individuals can control and choose how to behave. Rather than rely on external rules, we ideally become able to trust an internal mechanism of control. Of course none of us do it perfectly. We all have the occasional emotional outburst we regret, the impulse to overspend, the one too many brownies.
The same is true for sexual feelings. Pioneer sexuality educator Betty Dodson teaches that parents’ normalization and acceptance of children’s sexual feelings, and helping them to understand and manage them, are the fundamental building blocks of later sexual health. In the world of sexuality what can feel like a runaway train to an adolescent, becomes manageable to a regulated adult.
In a world where couples rarely talk about sex with each other, let alone their children; and sex education in schools is minimal at best, this is all too rare. However regulation, within a solid sexual health framework, provides a foundation for individuals and couples to thoughtfully, honestly and intentionally evolve and negotiate their arousal and their own erotic palette. That would be a worthy goal.
Bill Clinton rose out of a matrix of parental alcoholism and violence, to become a Rhodes Scholar, and Yale Law School graduate. He went on to become the youngest governor in the nation at 32, an age when I was barely emerging from drugs, sex and rock ‘n roll. Elected president in 1992, at just 46, he was arguably the most powerful man in the world, a success story at the pinnacle of success. Why would he risk it all on scandalous, wanton sexual behavior with someone who apparently meant little to him?
Bill Cosby has dominated the sexual predator stage for some years, with one after another of his alleged victims speaking out before his conviction this month on three counts of aggravated indecent assault. But before that downfall, Cosby was also another great American success story. “The Cosby Show” was TV’s biggest hit of the 1980s, earning him the moniker “America’s dad.” He also earned a doctorate in education from the University of Massachusetts, and became a widely followed civil rights activist, Popular, rich and famous; with a beautiful family, he appeared to have it all. Why would someone like this have to drug women to have sex with them? Or why would he want to have sex with unconscious women?
Al Franken, Kevin Spacey, Anthony Weiner, Charlie Rose, Eric Schneiderman, Woody Allen… What is wrong with these men? And how many men, famous or not, powerful or not, “good souls” or “good” spouses or not, are fractured by split selves, and out of control? With the statistic that one in three women are victims of some kind of abuse, harassment, rape and other unwanted sexual attention, it is clear that these men are but a fraction of those who perpetrate.
As a trauma therapist, I have seen the gamut of wildly dysregulated sexuality, from frozenness in seemingly endless sexual impasses, to erotic extremes of every imaginable and unimaginable ilk. I see plenty of “split self” sexuality in the traumatized. Braun Harvey and Vigorito, agree that trauma may be a factor in Out of Control Sexual Behavior some of the time, but certainly not in all cases.
I asked Braun Harvey, “What do you think about this #MeToo phenomenon from an OCSB standpoint?” He replied that sadly, for the most part men do not talk about sexual health, unless they have either been victimized or have themselves already perpetrated. Men’s conversations about sex tend to be limited to what our president referred to as harmless “locker room banter:” competitive, posturing, vapid. Beyond that, even though bombarded with Viagra advertising, most men know very little about what is really “normal” and what other people are doing. Couples commonly don’t talk about sex in any meaningful way. It is time to begin a national discourse about sexual health.
Braun Harvey continued that consent as a concept is largely not broached until it becomes part of a conversation about sexuality, and even then not nearly enough. The broader implications of mutuality, consideration and equality are weak at best in our culture, which was been built largely on the motifs of self-reliance and rugged individualism, not to mention slavery.
In 2001 our then Surgeon General, the enlightened David Satcher issued a “Call to Action to Promote Sexual Health and Responsible Sexual Behavior.” Not that different from Braun Harvey’s formulation, it went as far as to place sexual health among both our nation’s values and rights. Education, policy and accessible services must make sexuality as safe, just and dignified, as all other matters of health.
“A major responsibility of the Surgeon General is to provide the best available science based information to the American people to assist in protecting and advancing the health and safety of our Nation,” Satcher’s call proclaimed. “This report represents another effort to meet that responsibility… These challenges can be met but first we must find common ground and reach consensus on some important problems and their possible solutions. It is necessary to appreciate what sexual health is, that it is connected with both physical and mental health, and that it is important throughout the entire lifespan, not just the reproductive years. It is also important to recognize the responsibilities that individuals and communities have in protecting sexual health. The responsibility of well-informed adults as educators and role models for their children cannot be overstated. Issues around sexuality can be difficult to discuss-because they are personal and because there is great diversity in how they are perceived and approached. Yet, they greatly impact public health and, thus, it is time to begin that discussion… We need to appreciate the diversity of our culture, engage in mature, thoughtful and respectful discussion, be informed by the science that is available to us, and invest in continued research. This is a call to action. We cannot remain complacent. Doing nothing is unacceptable. Our efforts not only will have an impact on the current health status of our citizens, but will lay a foundation for a healthier society in the future.
Dr. Satcher cited in his 2001 report:
A 2007 federal study on abstinence education found that these programs had no impact on the rate of teen sexual abstinence. Rather, teens in states that prescribe abstinence education are actually more likely to become pregnant. 1 in 4 teens in the US receives information about abstinence without receiving any information or instructions about birth control. Among teens aged 18–19, 41% report that they know little or nothing about condoms.
The chilling rates of child sexual exploitation have not changed much. In a 2015 report:
Clearly it is time to dust off and revisit Dr. Satcher’s call, and resuscitate sex education that will enable boys and men to make sense out of, and speak about confusing sexual feelings; or desires and impulses they don’t know how to manage before they perpetrate. Girls too, besides learning about consent and equality need to learn about what problematic and out of control sexuality look like. In others and in themselves. Identifying a problem and ready access to help that would not be shaming or stigmatized, might prevent a lot of damage to self and others. These discussions might begin in the elementary grades.
None of this is in any way intended to let #MeToo offenders off the hook, or excuse sexual harassment, abuse or violence. Quite the opposite. I believe we must continue to make the policy and legal changes that will stop the Harvey Weinsteins, and Larry Nassars (the Physician who abused generations of young gymnasts entrusted to his care,) and protect and prevent children and adults from any unwanted and/or exploitative sexual attention or activity. Parenting classes might expand to include sexuality and sexual health as important parenting responsibilities. And besides making it safe and effective for children and adults to report their experiences, we need sexuality education that covers both wanted and unwanted sexual activity, and the nature of out of control feeling and behavior. Rather than hide and continue it, those afflicted will be able to recognize it; and know that help is available before they do harm, or more harm. And we need to make sure that help is readily available This means training health care and mental health professionals including school counselors and other key adults at schools, about diagnosis and treatment that are positive, sex positive and effective.
When the infamous pussy grabbing video burst on the scene in 2015, I thought for sure candidate Trump was finished. As a professional, a woman and a civilized human being, I just could not fathom that a man who did and said such a thing could become the president of the United States, there was simply no way he could continue to advance toward the White House after such an affront.
I was shocked and horrified to see how wrong I had been, and that men still impress and amuse each other with “conquests,” and not only in locker rooms. That furor died down. Other shock and horror has followed. And I am concerned about the real change that needs to take hold. I don’t want our cat-eared pussy hats to migrate to the back of the drawer. I don’t want the cries of #MeToo to fade again into silence without the essential response: a response that will include sanctions and reparations for wrong-doing,
The renowned neuroscientist Antonio Damasio, in his most recent book, tracks human evolution back to the earliest bacteria. He posits that it is feeling, the experience that something is “wrong,” something is out of balance with wellbeing and preservation of the species, that impels the organism to find the correction that will restore health. That, in conjunction with natural selection, brought us from our forebears – those early bacteria that were even without nuclei – to the conscious, complex-brained, and hopefully self-aware beings that we have become. Damasio seeks to create more respect and value for feeling as being fundamental to the advance of healthful life. We need to teach young children to recognize the feelings associated with “good touch” and “secret touch;” older girls to recognize and understand the feeling of unwanted or exploitative attention; and sufferers of dysregulated arousal and sexuality to identify the feeling that something is awry in their bodies. All of this before injury and shame has calcified in these young, and older bodies. It is my fervent hope that we can use the outrage of the #MeToo movement in that direction. This would include parents, teachers, coaches, employers, managers, employees, chefs, bloggers, celebrities, policy makers and of course all health and mental health professionals, all speaking up for sexual health. I guess that is most of us really.
Lately it is not uncommon for me to get an emotional phone call, where the breathless voice on the line says “I’m a sex addict! My partner threw me out! Can you help me?” The anguish is palpable and my heart goes out to both the caller and the partner. Of course I want to help. This article is an attempt to elucidate my thoughts on the subject of “sex addiction.”
Sex therapist, physician and author Charles Moser’s main complaint about the “sex addiction” designation is twofold. First he believes it is that it is a catch-all term for all sorts of behaviors, completely lacking in diagnostic precision. For some it may be an expression of OCD, a set of ritualized behaviors to manage anxiety and inner chaos, and in effect self soothe. For others it may be an expression of ADD (attention deficit disorder,) or a way to stimulate, focus or wake up the brain. It may reflect an anxiety disorder or depression. Or some other possibility. Moser’s complaint is that all these diverse diagnostic categories that call for different approaches to treatment, are lumped together under one unflattering umbrella label. Precision in treatment of the actual problem is lost. It’s lousy medicine.
What is “Sex Addiction?” That is the $64,000.00 question. No one knows. Is it looking at pornography on the internet? How much looking constitutes addiction? How do we define “pornography?” Is it compulsive pursuit of prostitutes? Serial affairs? Is it about quantity of sex? Is it about specific sexual activities? Risk taking? Or simply about not being able to stop? What do we mean by this term? As of yet, science has not given us an answer.
The “sex addiction” treatment industry has an answer. (And quite an industry it is, that has mushroomed around this “diagnosis” in recent years.) Programs offer both inpatient and outpatient treatment, largely in the image of chemical dependency treatment. They charge a lot of money for their programs so they stand to gain significantly by having the public buy their definition.
Chemical dependency or substance addiction has over the last 50 or 60 years, been studied and precisely defined. Prior to this time, alcoholism was viewed as a terrible moral flaw and character defect. In the 1950’s a pair of brilliant and desperate alcoholics discovered that although they seemed to be unable to stop drinking on their own, together they managed to do it. They then found that if they went on to help still other alcoholics to stop drinking too, it helped them to stay sober. They developed a program that evolved into what we now know as the 12 Steps of Alcoholics Anonymous (AA.) This was truly the best and most effective method ever to come along, for people addicted to alcohol to become sober. It quickly spread around the world. Before long it became apparent that the 12 Steps as they were utilized by alcoholics, were equally effective for those addicted to other drugs. So Narcotics Anonymous followed in the footsteps of AA, and similar miracles and transformed lives followed.
Obsession is an agony as is behavior that one cannot control. Sexual problems create a very particular kind of relationship hell. It is easy for partners to take it personally when pictures on a screen, prostitutes or other people compel the sexual attention and time of their mates.
On the heels of AA and NA came true scientific research about addiction and what it actually is. Science began to uncover a whole physiology that went along with the much observed psychology and behaviors of addiction. We got a precise definition, and a precise “phenomenology.” Phenomenology means a picture that is objective, based on observable characteristics from many angles. It specifically leaves out the subjective, or perceptual biases based on morality, religion, philosophy, culture or personal taste or point of view.
We also got a precise nosology, (nosology is the branch of medicine that deals with the classification of diseases.) making alcohol and drug addiction diagnosable by known specific criteria. This did not happen overnight of course. But by the middle 1980’s there was a sophisticated and growing field of study in both medicine and psychology about addiction.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official text for diagnosis, utilized by health care providers and insurance companies. Being at least allegedly research based, it evolves with history as culture and the general knowledge base grows and changes. For example barely thirty years ago, homosexuality was listed in the DSM as a diagnostic category, and practitioners were working hard to “cure” those “afflicted.” Young people born after these changes might find it absurd or hard to believe that being gay was considered a “mental disorder” not that long ago. Those of us who have been around for a while, lived through the changes and perhaps even witnessed the effort required to remove homosexuality from the DSM. This is a clear example of how science blurs with politics and morality in the murky world of diagnosis. Bessel van der Kolk, veteran researcher, clinician, academician and author says it plainly “Diagnosis is a political instrument.”1
In the DSM, there is a precise list of criteria for the diagnosis of Substance Dependence, the clinical jargon for addiction. The list includes: tolerance, which means progressively increased amounts of the substance are required to achieve the desired effect; withdrawal, which is a characteristic syndrome of physiological and psychological symptoms that appear when the substance is removed; persistent desire (ie craving) and unsuccessful efforts to cut down substance use; much time and preoccupation spent on obtaining and using the substance, even to the neglect of important social, occupational or recreational activities; and continued use in spite of consequences.2 Although there is a lengthy chapter detailing variations on these themes, there is a uniform, agreed upon diagnostic tree that clinician or client can consult to ascertain whether the diagnosis fits.
Alcohol and drug treatment programs assess and diagnose with precise criteria, and generally treat the addiction with a combination of detoxification, which means safely withdrawing the person from the substance with medical support if needed; drug and alcohol education so clients have a clear understanding of the nature of addiction and recovery; individual and group counseling or therapy; general healthcare including good food, exercise, sleep perhaps supplements, and attention to whatever health deficits may have resulted from the addiction. A major component of most programs is 12 Step which is still considered to be the most effective path to recovery and certainly a centerpiece of the “aftercare” plan.
Relapse prevention is of course an important aspect of the education component in addiction recovery, as relapse is one of the most insidious aspects of chemical dependency. Shorter-lived returns to substance use are referred to as “slips” and relapse is the full blast return to active use. It is essential to learn how to guard against either.
The last 20 years brought the internet, and with it the proliferation of widely available erotic and sexually explicit materials of every imaginable and unimaginable stripe. No longer did anyone have to skulk naughtily or shamefully into an “adult” bookstore or video store to find “girly” magazines or movies. In the comfort and privacy of one’s own home, virtually everything could be had. Al Cooper coined the term “the Triple A Engine”: Anonymous, Affordable, and Available, to explain what appeared to be a new order of magnitude of its use.3 As technology advanced so did the complexity and variety of available services and visual opportunities. We all began to hear stories of individuals spending numerous hours of day and night (often while on the clock at their places of employment,) engaged with these materials. Money was spent, relationships jeopardized. Therapists began to get the desperate calls.
In the psychology and the sex therapy field there is much debate about whether in fact there is such a thing as “sex addiction.” One key expert in the sex therapy field, Eli Coleman in his brilliant, brief article “Compulsive Sexual Behavior: What to Call It, How to Treat It?” makes a strong case against the language of addiction. Says Coleman “Although the term ‘addiction’ may be an interesting metaphor, it obviates the essential understanding of the etiology of compulsive sexual behavior.”4 He views sexual compulsivity as a “disorder of regulation,” physiologically very similar to OCD (obsessive compulsive disorder).
By disorder of regulation, he means the nervous system is in effect “wired” too high or too low, with anxiety and/or depression. Self-regulation is the attempt to manage emotion and arousal such as to get comfortable in one’s skin. Disorders of regulation can be caused by physiological irregularities, life experiences, or both. This means trauma, neglect, genetics, medical factors, or some combination of them all, may add up to the irregularities. The impact is a greater or lesser urgency of the need to calm down or breathe life into the nervous system. Some people use alcohol or drugs to this end, some use food or work, exercise, gambling, shopping, thrill seeking, sleep, etc. Some like the OCD sufferer use rigidly ritualized, uncontrollable behaviors. The possibilities are limitless. Coleman sees what he calls “compulsive sexual behavior (CSB) as being within this spectrum.
To Coleman Using the rubric of addiction suggests “once an addict, always an addict,” which as of yet is an unanswered research question about CSB. It also implies that the only solution is a rigorous spiritual program like AA. Perhaps most significantly, however, the world of addiction treatment and recovery has traditionally been strongly biased against medications. Coleman’s research shows that sufferers from CSB often respond quite favorably to pharmaceutical treatments, often those used for OCD, ADD or depression. In many cases medications can be decisive in who does and who does not succeed at putting the unwanted behaviors to rest.4 I have indeed observed pivotal impact and success with medications in many of my clients as well.
Sex therapist, physician and author Charles Moser’s main complaint about the “sex addiction” designation is twofold. First he believes it is that it is a catch-all term for all sorts of behaviors, completely lacking in diagnostic precision. For some it may be an expression of OCD, a set of ritualized behaviors to manage anxiety and inner chaos, and in effect self soothe. For others it may be an expression of ADD (attention deficit disorder,) or a way to stimulate, focus or wake up the brain. It may reflect an anxiety disorder or depression. Or some other possibility. Moser’s complaint is that all these diverse diagnostic categories that call for different approaches to treatment, are lumped together under one unflattering umbrella label. Precision in treatment of the actual problem is lost. It’s lousy medicine.
Secondly, in order to understand, diagnose and treat safely and effectively we need to consider not only the behavior itself, but its context and meaning. From there we can determine a diagnosis and treat that. Behavior alone, taken out of context does not yield a diagnosis. Himself a busy physician, Moser says he might easily wash his hands fifty times a day, between patients and between procedures. In some cases washing one’s hands 50 times a day might be the symptom of an irrational fear of germs or a ritualized OCD behavior. In that case the problem is not really the handwashing behavior itself, (although to be sure the behavior may be distressing). The real problem to be treated is the irrational fear and the anxiety. For the busy physician with a seemingly identical behavior, there may be no problem to be treated at all. Moser views the sexual addiction recovery model as falling short in this way. It lacks an understanding of context, meaning and therefore a treatment approach that addresses the real issues.5
I agree with both Coleman and Moser. I think I would add that the designation of “sex addiction” has a tone of shame that other obsessive and compulsive afflictions don’t, or at least not as much. Perhaps it is my own association. Perhaps not. I believe the archaic prejudices about weakness of character, or sordidness associated with the word “addict,” linger.
This sense of prejudice extends into some of the other language used in the “sex addiction” world. Bulimia is another compulsive disorder. When a bulimic has a recurrence of the problematic behavior it is viewed as a relapse. When a “sex addict” practices the unwanted behavior it is referred to as “acting out.” In my childhood, “acting out” was a term used with unruly children being told they, or their behavior are “bad.” In the mental health world, disturbed people displaying their feelings in dramatic misbehavior rather than words are described as “acting out.” Again, the language is pejorative, unsympathetic and smacking more of a moral defect than a painful difficulty. For me these add up to prejudices that do not help the person struggling with sexual compulsivity, and definitely contribute to partners believing “My partner is a pervert. What is wrong with me?”
Dopamine is one of the predominant neurotransmitters or brain chemicals. Where many people are familiar with serotonin, they might be less so with dopamine. Seratonin is the chemical more associated with a sense of well-being. Dopamine is associated with excitement, pleasure, reward, and also seeking behaviors. Dopamine is stimulated by some of life’s pleasures like eating and of course sex. Some thrilling or risk taking activities activate dopamine.
Irregularities of the dopamine system may impel behaviors that will stimulate or increase it. For some people gambling, shopping, sky diving or activities involving uncertainty or excitement are used to attempt to self regulate this system. And the dopamine rush may be self re-enforcing. That is to say the linkage between a behavior and the pleasure of the dopamine reward, may inspire the impulse to continue the behavior.
Individuals who spend time looking at erotically stimulating materials and masturbating may get a dopamine surge at orgasm. The practice of looking and the pleasure of the dopamine high may get wired together in their brains or psyches. The dopamine reward may impel the urge to do it again, and even again and again and again. Does this constitute addiction?
As an endurance athlete I get very high from intense exercise. I love to ride my bicycle and I usually know exactly when the dopamine kick will hit. I go back again and again for that joy. It is not the only thing I like about riding my bike, but it is a definite perk. When I go on a long ride, I get as high as a kite, and I know I can count on riding to change my mood. So I repeat these activities as often as I can. Although I have had a couple of serious accidents, I have always returned to riding, more careful perhaps, but undeterred. And admittedly sometimes I take unintelligent risks. For example, the first time I rode 200 miles in one day, the temperature was 105 degrees. I was not willing to give it up. Am I an addict? Some might say a resounding yes. Some say they admire my “discipline!” I know it is certainly not that. Others just think I’m a nut. And what am I addicted to? Dopamine? Bicycling? Is it even compulsive?
All these questions come to my mind as I contemplate the loose and incomplete logic and definitions around the question of sex addiction. Clearly dopamine is involved and often a pivotal factor in compulsive behaviors. Compulsive sexual behavior is no exception. Does it add up to meeting the criteria for addiction as defined in the DSM?
None of this is to minimize the pain and suffering of compulsive sexual behavior. Obsession is an agony as is behavior that one cannot control. Sexual problems create a very particular kind of relationship hell. It is easy for partners to take it personally when pictures on a screen, prostitutes or other people compel the sexual interest, attention and time of their mates. As with most compulsive activities, the world of the compulsion is compartmentalized and hidden from the rest of life. Often in these relationships there is a snowballing deceit so there is a terrible dynamic of betrayal and guilt that spans many levels. Because compulsions may be relentless and difficult to disarm, often a couple goes through more than one go-around of confrontation or “coming clean,” attempting to stop, and the patterns silently and insidiously creeping back.
My belief is that disorders of compulsivity are painful and destructive, and definitely hard to beat. In our culture anything related to sex is likely to carry an additional weight of shame, guilt and disgust. I prefer to use language that is precise and unstigmatizing. I work hard to understand specifically what is the context and meaning of the behavior, and of course to help clients clearly connect the behavior with its impact on their own lives and the lives of significant others. And we attempt to tailor treatments very specifically to the real problem.
We begin with a careful assessment, taking into account the whole person and the person’s whole life. What is the unwanted behavior? What are the patterns? When did it start? Is it related to trauma? Anxiety? Depression? Or something else? We seek to piece together the context and meaning. Is the behavior an attempt to calm down, to escape, to feel alive, to relate to others? Is there a sexual problem that it is an attempt to bypass or compensate for? A relationship problem? An attachment disorder? There are so many possible diagnoses that may lead in different treatment directions.
Of course we seek to link the behavior to its to consequences. One of the hallmark agonies of compulsivity is how behaviors persist in spite of the havoc they wreak. Somehow the person or the brain fails to learn from experience. It is essential to face up to the damage, and in most cases stop the behavior.
In general a solid treatment net includes individual therapy for deep self-exploration. Whatever the specific diagnosis, the deeper layers need to be uncovered and processed. Often medications are a tremendous help. Again a precise diagnosis is required. For some people, antidepressants are the medication of choice, and often the SSRI’s (the Prozac family of drugs) which also have libido suppressing properties, are a welcome relief. For others who are more in the anxiety/OCD spectrum, it is anti-anxiety medication that helps manage the compulsion to self-soothe with the unwanted behaviors. For still others, the behaviors may be a symptom of Attention Deficit Disorder, and an attempt to enliven the nervous system. In these cases the ADD medications may be a godsend. As I’ve said, sometimes the right medication makes all the difference.
Couple’s therapy is essential for those who have partners. Often relationship is an area of great difficulty for the CSB sufferer anyway. And as the compulsive sexual behaviors persist and “progress,” relationship and family takes a strong hit, with dishonesty, distance, often sexual problems or impasses in the partnership, etc. However, I have never yet seen a couple who did not have other problems besides the problem of sexual compulsivity between them. Perhaps both believe that all their conflict is a result of that but I have never seen this to be true. It is however a very hard sell, as generally the CSB sufferer feels so much guilt, shame, remorse and fear; and the partner feels so much betrayal, rage, hurt and righteous indignation, that both are entrenched in that belief. There are many couple’s dynamics to sort, process and renegotiate, in the course of repairing the broken trust. This is no small feat. And as I said, it is imperative.
Group support is also tremendously helpful. The benefit of 12 Step recovery is that it is imminently available and free. It is excellent for breaking the isolation which is endemic; coming out of “hiding” among others who may have similar stories and feelings; and facilitating the process of self examination and self reflection. The 12 Steps are compassionate while also directly confronting the damage to self and others that the compulsive behaviors wreak. My complaint about the 12 Step application to sexual compulsivity is its rather moralistic stance, and its adherence to the language of addiction. Yet for many it is the core of a successful recovery package. If not 12 Step groups, some other supportive therapy group around the issues of sexual compulsivity are a necessary treatment element.
Of course general self care around health is important: good nutrition sleep and exercise. Sexuality like perhaps nothing else is at the interface of body mind and relationships. We must carefully attend to all of them!
The rest is an unrelenting commitment to honesty and growth; a willingness to make recovery the centerpiece and top priority of one’s life for a good while; and time. It may be the hardest thing one ever undertakes, and unquestionably the most valuable.
Currently the DSM is up for revision, as it is every few years. There is wide disagreement and debate about whether to create a new diagnostic category of “sex addiction” in the new tome, expected to appear in 2012. Experts are working hard, attempting to come to agreement and also answer these tough questions. As van der Kolk says, we want the DSM to reflect the best and the most current science.6 What do you think?
Last month one of my client couples gave birth to a child. Always a joyous event, this birth had particular significance to me. When I first started seeing this couple, just over 2 years ago, they had had virtually no sexual relationship in some four years. At that time the wife, a survivor of childhood sexual abuse, longed for a baby. The husband pined and bristled for a sex life. Both seemed a distant dream. Restoring a regular, reliable and satisfying sexual life was a primary goal of the therapy and achieving it a major milestone. This baby brought a new meaning to the term “love child” and was one of those awesome rewards of the difficult work we do.
At its essence the experience of childhood sexual abuse is annihilation. The feelings and humanity of the child are disregarded, the perpetrator being preoccupied with self-gratification. The child is in effect used and discarded, often treated as if nothing unusual has happened. Overwhelmed and uncertain, this child grows up with the core beliefs “I am unsafe in the world,” and even more importantly “I don’t matter.”
Sexuality is among the most challenging issues in recovery from sexual trauma. When I first ventured into that area, I was dismayed to find that the literature reflected the same major oversight as had the early theory and practice of general sex therapy. Somehow it did not see fit to address the relationship as either a significant factor or potential resource in the maintenance or healing of the sexual problem. The books I read focused on the trauma survivor, who was saddled with the responsibility for the problem and who got all the attention. The non-sexually abused partner was essentially entreated to be supportive and patient, and wait. What this translated into for the average couple, was that the abuse survivor got all the blame and all the help. The partner got off the hook in terms of personal work, but received little else. Getting to know these couples, I rapidly discovered that the persistence of the sexual impasse is decidedly dynamic and relational.
Once in the room with survivors of sexual abuse and their intimate partners I made two major discoveries. First of all, survivors of childhood sexual abuse invariably partner with survivors of childhood neglect, at the very least emotional neglect. These children of alcoholic, depressed, mentally ill, overwhelmed, deceased or otherwise absent mothers in effect seem to have raised themselves, perhaps their siblings too. Often the sexual trauma survivor partner has a neglect history as well; and often the neglect survivor partner has experienced childhood trauma. But in each couple is one whose primary wound is trauma and the other for whom neglect is primary.
At its essence the experience of childhood sexual abuse is annihilation. The feelings and humanity of the child are disregarded, the perpetrator being preoccupied with self-gratification. The child is in effect used and discarded, often treated as if nothing unusual has happened. Overwhelmed and uncertain, this child grows up with the core beliefs “I am unsafe in the world,” and even more importantly “I don’t matter.”
The child of neglect grows up in an environment of deprivation. These children are left to fend for themselves in fundamental ways, and learn early not to think of other people as resources for them. They tell heartbreaking stories of finding ways of registering themselves for school in second grade; climbing on a chair to get themselves food; never ever having anyone interested in knowing how they feel. They are self reliant, resigned, and deeply anxious and conflicted about it. These kids grow up to believe “I will never get what I need in relationship.” Often unaware that they even have a story to tell, they think of the trauma survivor partner as the one with the pain.
My second discovery was the dynamic interaction of these core beliefs between the partners in the couple, which generally goes as follows: “Partner A,” the neglect survivor driven by the belief “I will never get what I need,” perceives or fears that needs will not be met, and becomes anxious, possibly angry.
“Partner B,” the trauma survivor, compelled by the belief “I don’t matter,” experiences that anxiety as demand, and fearing coercion/annihilation, withdraws. A experiences the withdrawal of B as proof: “my needs will be thwarted or ignored,” and becomes more anxious. B experiencing the heightened anxiety as increased demand withdraws yet further. A cycle of escalation ensues that goes on and on and on.
This dynamic is glaringly evident in the realm of sexuality, as sex is perhaps the one need that the neglect survivor might acknowledge or feel entitled to put forward as requiring the participation of another person. But in fact the dynamic is threaded through the entire fabric of the relationship. The two may keep each other thus triggered virtually all the time, their life together becoming a living minefield of their re-enacted childhoods. For this reason couple’s work may be essential to both of their recovery or even to keep them from getting worse.
Once identified, this dynamic provided both a starting place and a map for relationship work with survivors of trauma and neglect; and most specifically a way to approach the sexual conundrum. In effect, the work came into crystalline focus and what before seemed an insurmountable tangle became simple. Simple while also perhaps being the hardest thing all three of us, clients and therapist, will ever do.
Over time, both partners learn to recognize their reactions to each other as being largely expressions of their past. Blame and defensiveness are gradually replaced by compassion and safe connection. Sexual intimacy, rather magically emerges ultimately from that safety.
Research, theory and practice around trauma has burgeoned in the last 10 years. We now understand that core elements of post-traumatic stress are dysregulations of affect and attachment. Trauma, overwhelming the nervous system, disrupts its capacity to process experience and maintain a baseline physiological and emotional equilibrium. The system swings between hyperarousal, (anxiety and preoccupation with danger;) and hypoarousal (depression and dissociation) without the capacity to modulate. Interpersonal, particularly familial abuse distorts existing and future attachments, while also destroying the most powerful potential resource for soothing and safety when it is most needed. The wounding around relationship is perhaps the most tragic and severe of the sequelae of abuse. Research about neglect is nascent, with attachment theory having much to contribute, and findings are similar and parallel.
I find the theory and structured dialog of Harville Hendrix’ Imago Relationship Therapy to be exquisitely suited to this population. Grounded in attachment theory, Imago theory views current relationship difficulty in light of re-enacted or projected childhood experience. The structured dialog lends order and predictability to the potentially frightening task of expressing feelings, rendering it safer. The emphasis on coming to understand one’s partner’s world without necessarily agreeing, facilitates differentiation and boundary. And the rhythm of the dialog, the ebb and flow of understanding and being understood, appears to ease the dysregulated nervous system, and quiet the bodies of both partners.
The couple’s work consists of psychoeducation about trauma and neglect; and dogged conversation in dialog. Although there is no substititute for solid trauma work, much trauma processing also goes on in the couple’s work. Over time, both partners learn to recognize their reactions to each other as being largely expressions of their past. Blame and defensiveness are gradually replaced by compassion and safe connection. Sexual intimacy, rather magically emerges ultimately from that safety.
A necessarily cursory introduction to the most challenging work I have ever done, leaves much to say. Not for the faint of heart, this is undoubtedly the most awesomely rewarding work I do.
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