Psychotherapy Perspectives

Sunday, August 08, 2010

Recovering After an Affair

by Margy Davis-Mintun

In the years of practicing couples counseling, I have found that one of the more common reasons couples come to counseling is to deal with a breach of loyalty in the relationship. While overcoming an affair is challenging and navigating the recovery difficult, the ultimate outcome through counseling can foster a healthy and hopeful experience.

Couples who are happy in their relationship do not have affairs; an affair is a symptom that something was already not working well in the relationship and enough space was created between them for a third party to step in. Sometimes I’ll hear one partner say that they thought everything was going well and felt blind sided, while the other one felt distant, ignored and lonely. Partners will talk about not being able to bring resolution to conflict and/or that resentment and anger had become the primary way of communicating. The withdrawal of one partner is another example where the pattern includes increased physical absence or emotional disengagement. The stories vary, however the common theme is that either one or both felt unfulfilled in some way in the relationship.

The initial phase of navigating the therapy process after an affair focuses on helping couples work with the feelings of betrayal and devastation. This phase is often the most volatile, where the emotional charge is intense and pain quickly turns to blaming and pointing fingers. Both partners feel the potential of loosing each other and the fear can quickly convert to anger. Difficult as it may be, it is important for the therapist to help channel these feelings so that partners can talk and listen to each other’s experience.

Once the couple begins to communicate, they also begin to evaluate their desire/willingness to restore and repair the relationship. Counseling at this point is critical so that the damage to the couple is contained and the destruction to the relationship minimized. At this point, couples may openly talk about their hurt, their ambivalence, and the fear that they cannot overcome the trauma to the relationship. Each partner has to make a decision about how much they want the relationship and how much they are willing to commit to work toward recovery.

As the therapeutic process unfolds, the therapist is charged with creating safety for the couple so that they can honestly look at the relationship and their own part in the instability prior to the affair. Here I will often hear couples talk about feeling lonely, ignored, and alone or resentful, angry, and invisible. There may be an external trigger, such as a death, a loss of job or financial stress, or internal patterns of poor communication, fighting without resolution, unmet needs and built up anger.
Regardless of the numerous factors that caused the relationship to become more fragile, or perhaps the relationship was never strong, the healing involves the couple taking stock of their contributions to this breakdown. This can be very difficult when one partner feels like an innocent victim of the other’s action. Here an individual can understand that, because they were not satisfied in the relationship, they maybe gave up, pulled back, exploded with anger, or felt overwhelmed or lost in the partnership.

It takes time for trust to rebuild, and the therapist facilitates steps toward recreating a trusting and strong relationship. This process is time consuming; while trust is building we are working with a leap of faith that trust can rebuild. It is a scary time and a hopeful time, thus it’s important for therapy to happen with regularity, for a period of months. In this phase the couple repairs old wounds, learns and practices new skills and begins to heal from the break created by the affair. Most couples are not successful in achieving a new level of functioning without professional help. It is not unusual for couples to bury the affair if they don’t get the help they need because the process is painful and the support and safety to do the work is generally not created without the expertise of a professional.

Once a couple gets to this point there is new energy and excitement between them. The new relationship is stronger than ever, the honesty and safety in the couple is firmly grounded and the skills to resolve conflict and attend to their individual and partner’s needs are an active part of everyday life. Couples will often talk about feeling important to their partner, feeling validated, and they enjoy spending time together; there is a flavor of new beginnings where the possibilities are numerous and they feel happiness with each other again, there is connection between them.

The affair resolution can also be a process in which couples thoughtfully decide whether or not their investment in the relationship is strong enough to commit to the expense and time it will take to work through the impact of the betrayal and the existing problem preceding the affair. Sometimes couples come to counseling to get help deciding whether or not they are mutually invested in the relationship and willing to move forward to save it or move forward by ending it. Partners are not always clear about whether they want to stay together and the professional can facilitate a safe dialogue to bring a resolution as to the next step for the couple following the affair. The option of ending the relationship can be facilitated with earnest discussion and understanding, rather than an abrupt ending.

Regardless of how the couple decides to move forward, there are key steps in counseling that guide the couple through a very painful and complex situation. The negative impact of an affair has a long life for the individuals affected, so whether or not the couple decides to repair this relationship, the repair to the individuals is imperative so that each can successfully re-engage in a healthy relationship with each other or future partners. Trust is a theme that must be addressed in order to promote healthy intimacy in the future. Building trust has no shortcut; it is a journey of rebuilding that can bring great strides and positive changes if time and attention is given to this process. The devastation of a break in trust is pervasive and recovery means the difference between happiness and growth or repeated patterns of loss and loneliness.

It has been my experience that most couples I’ve had the opportunity to work with through this process of recovery have successfully rebuilt and enriched their relationship and have enjoyed a lasting experience of intimacy.

Thursday, December 17, 2009

EMDR—TWENTY YEARS LATER

By Amy Konkle, M.D.
May 2, 2009

(Accepted for Publication in the Spring 2009 Issue of the Indiana Psychiatric Society Newsletter)

This year marks twenty years since the publication of the first study of Eye Movement Desensitization and Reprocessing (EMDR) for the treatment of post traumatic stress disorder. This article attempts an overview description of the current status of EMDR: what it is, what the research says, and theories as to the mechanism of action. In addition I will share some observations and clinical vignettes from my own practice.

EMDR is a psychotherapeutic approach, rather than a technique or a protocol. EMDR’s underlying theory has two hypotheses: (1) much of psychopathology has its origins in experience implicitly or explicitly perceived as traumatic and (2) there is a block in the central nervous system’s innate ability to process, i.e., to adaptively access and integrate aspects of the trauma into a coherent and temporally updated context. Traumatic experience is understood to exist in a wide range, from a parent’s dismissive remark to an embarrassing childhood experience to the DSM Criterion “A” events that anyone would identify as major trauma. While EMDR appears to “jump start” this innate ability for processing which has become blocked, its mechanisms of action are undetermined and discussions remain lively around just exactly what is happening and what are the minimal essential components of EMDR. Although the preponderance of research looks at EMDR treatment of post traumatic stress disorder (PTSD), most EMDR clinicians perceive little difference in the effectiveness of EMDR in treatment of major trauma and in the reprocessing of the day to day traumas that may appear small but nevertheless shape self-perception, perception of the world, and ways of relating to others. When EMDR is used to treat the lifelong smaller events that shape personality, the duration of the treatment is longer than that of type I PTSD.

A typical EMDR session identifies an event experienced as traumatic by the patient and apparently related to the presenting problem. Even a recent event meeting criterion “A” definition may have an antecedent in childhood which affects the way in which the current event is processed. Components of the trauma—sensory phenomena, negative cognitions about self, emotions and somatic re-experiencing—are elicited. A protocol facilitates the activation of these components so that they are accessible for processing and integration. Desirable alternatives are identified, intensities are measured, and a ground-work is laid to follow progress. These traumatic components are activated and paired with some type of alternating bilateral or dual-attention stimulation, e.g., eye movements, auditory tones, tapping, or vibrating electrodes, which are applied in sets lasting about 20-30 seconds

For example, if eye movements are chosen as the type of stimulation, the assessment is completed as described above. The patient then holds in mind the image representing the worst of the trauma (“I see the truck crossing the median and coming straight at me”), the negative belief about self connected to that image (“I’m going to die”), and where the memory is felt in the body (“my chest, my throat, my shoulders. My whole body feels tense.”) The therapist moves two fingers rapidly from side to side approximately 20 to 30 times in front of the patient, who tracks the finger movement with his eyes. At the end of each set of eye movements, feedback is elicited as to change or lack of change in one or more components, essentially “What comes up now?” If processing is not progressing, that is if some change is not occurring, the therapist has a number of options to help get the processing going again, using the least interference possible. Processing continues until the memory is no longer upsetting, the negative self cognition (usually about safety, responsibility, or choice) is changed to a more positive one, and the body is cleared of disturbance. Ideally past, present and future anticipated triggers are processed to resolution. My experience is that successful processing is in general accompanied by lasting changes in the life of the client, such as decrease or elimination of symptoms, loss of diagnosis, or noticeable difference in life choices. Positive spiritual changes, such as a deep sense of peace, are not uncommon.

Approximately twenty randomized controlled trials exist which positively compare EMDR to antidepressant medication, exposure therapy, cognitive behavioral therapies, and other psychotherapies in the treatment of PTSD. Many treatment guidelines, including the American Psychiatric Association, the International Society for Traumatic Stress Studies, and the Department of Defense, have rated EMDR at the highest level of evidence-based effectiveness in the treatment of PTSD. Numerous meta-analyses show no difference in effectiveness between EMDR and CBT treatments for PTSD, although EMDR requires no homework. The findings in a few studies indicate that it may require fewer sessions than CBT. Although some positive research exists for EMDR’s effectiveness with veterans, children, disaster survivors, and adults abused in childhood, and many clinicians report success with these types of clients, more research is needed for these specific populations. In my own practice childhood abuse survivors have expressed deep gratitude for the transformation that EMDR has brought to their lives. Others have described feeling a “lightness” to life previously unknown.

Although EMDR’s efficacy has been established in the treatment of PTSD, research is still in the preliminary stages for its treatment of other disorders. For example, while EMDR has successfully eliminated secondary depressive symptoms in many PTSD studies, no published study has yet investigated EMDR treatment of primary depression. Similarly, research on EMDR treatment of panic disorder (with agoraphobia) has had uncertain results. It has been suggested that anxious patients may need lengthier preparation before targeting distressful experiences. For example, a recent case study with a woman who had suffered for 12 years from panic disorder with agoraphobia, provided 6 preparatory sessions and 15 EMDR sessions, with complete remission of symptoms and maintenance of positive behavioral changes at one-year follow-up. A clinical series of 4 patients with generalized anxiety disorder were provided with 15 EMDR sessions to each participant to treat etiological memories. At follow-up, two patients were still symptomatic, but all had lost the diagnosis.

There is also some indication that EMDR may be helpful for somatic symptoms with traumatic etiology. Several case studies provided preliminary evidence for EMDR treatment of phantom limb pain. In one case series, 5 patients with chronic (1-16 yrs) phantom limb pain, previously treated in both inpatient and outpatient settings, received 3 to 15 sessions of EMDR. Post-EMDR, there was a significant decrease or elimination of phantom limb pain, reduction in depression and PTSD symptoms to sub-clinical levels, and significant reduction or elimination of medications related to the phantom pain. There are also promising studies of EMDR as adjunct treatment for chemical dependency, conduct disorder, and sexual offense.

Current theories as to how EMDR works include the following: (1) synchronization of the two hemispheres, (2) de-conditioning caused by a relaxation response, (3) “jump-start” of a process similar to that of REM sleep, (4) the initiation of an orienting response, (5) the promotion of thalamocortical temporal binding in 40 Hz neural oscillation range which helps to integrate somatosensory, sensory, cognitive and affective material, and (6) the activation of the cerebellum, setting off a sequence of information processing which activates the thalamus and eventually the frontal lobes, increasing dorsolateral and orbitofrontal processing. Neuro-imaging studies pre- and post-EMDR show changes compatible with any successful treatment of PTSD but do not really clarify the mechanism of EMDR. Dismantling studies which have attempted to demonstrate whether or not eye movements are an essential component of the treatment, have significant methodological flaws and so far add little information. Numerous studies have shown that eye movements reduce the emotionality and vividness of distressing memories, produce physiological relaxation, and enhance episodic memory recall. While research has yet to investigate the effects of the other forms of bilateral or dual-attention stimuli (auditory tones, tapping, etc.) most clinicians report the various stimulation modalities to be equally effective, although they may prefer one over another.

In my own clinical experience with EMDR over the past 12 years, I find it to be a highly effective treatment approach. As with any treatment, EMDR is not appropriate for everyone. However, I have used it with good results in a wide range of patients, including veterans, rape victims with and without significant childhood trauma, accident victims, those witnessing the traumatic death of a loved one, patients with medical traumas such as awaking during surgery, men with anger-management problems stemming from their own childhood abuse, women with childhood physical, sexual and emotional abuse, selected patients with borderline personality disorder and still others with dissociative disorder.

Most (approximately 75 to 90%) of single-episode adult traumas in an otherwise relatively healthy person can be adequately resolved in one to three 90-minute sessions. The greater the number of traumas and the younger the person at the time the traumas occurred, the greater the care required in the stabilization and preparation phases of treatment, and the greater the care required not to “flood” the person with their traumas, resulting in destabilization and re-traumatization. “Fractionation” of the trauma, i.e., processing one aspect of the trauma at a time, may be required. Treatment in those with complex trauma histories, heavy reliance on dissociative defenses, and involvement of the structure of personality formation remains a lengthy process. However, for a number of such patients, therapy can be shortened significantly with the judicious use of EMDR in the hands of a skilled therapist. For many with fewer traumas even if they are severe, and with basically good ego strength, EMDR can produce results which are rapid and dramatic, unlike anything I have seen with other modalities. Results tend to be long-lasting, and positive effect may actually increase with time.


Amy Konkle, M.D.
May 2, 2009

Wednesday, November 04, 2009

Emotionally Wired and Addicted to the Computer

by Garth Mintun, LCSW, ACSW, CSW-G


There has been an awareness of a sharp increase in addictive behaviors to computers, as well as Blackberries, iPhones, etc., in our psychotherapy practice in Indianapolis. Many young adults, older adults and children are wired in and don’t know how to quit. Because of this, some people are jeopardizing their relationships, losing their friends, losing their jobs, and/or flunking out of school. There is an increase in sedentary lifestyle, and the sacrifice includes physical health as well as emotional wellbeing.

We have see couples coming in for marital and relationship counseling because of the significant time a partner is spending (upwards of 17-20 hours per day) playing on the internet. The internet games and interactions (role play games) have begun to replace the real life relationships. Partners and family members are feeling ignored, sacrificed, and replaced. The wired person is so into his/her virtual role that sometimes they struggle to distinguish the line between their real world self and the roles they play (which may include changing one’s age, gender switches, animals or fantasy creatures, etc.) on their internet virtual world. Family members complain that an addicted person spends more time with their fantasy relationships than connected to life with the people in their household. In the absence of contact, some partners have resorted to join them in their virtual world as a means of having a relationship.

It is not uncommon for relationships to be broken and couples to separate over the loss of communication, contact, and engagement from the one who is plugged into the computer.

Internet games are not the only way people are wired to their computers. With the convenience of palm computers and/or laptops, work has now become a 24/7 phenomena. Families now have to compete with work and online entertainment in order to have any engaging interaction with their loved one. This behavior condones and promotes work addiction. The Blackberry and iPhone light up for each email, enticing and compelling a response to work when at home, on vacations, or in other spare time. The poor economy exacerbates this when employees are stretched thin and there are plenty of competent unemployed folks who are ready to replace them.

With easy access to technology, Twitter, Facebook, instant messaging, text messaging, ebay, social networking, gambling, and dating sites, one can become compulsive and ultimately addictive, much like drugs and alcohol. An individual may have a full blown addiction and might need an inpatient hospital treatment due to the decline of one’s health and family relationships. In these cases, an individual may be literally in danger of harming themselves due to their compulsion with the computer.

Like food addiction, we cannot give up computers or the internet. We need to be wired to live in this modern world; technology is not the problem. However, like food, we need to moderate our use or we become a slave to it. We can overdo anything, even healthy foods, and/or technological applications. It becomes a compulsion or an addiction when we cannot stop it and/or when we have knowledge of its destructive influence in our life and our family.

In the USA, computer addiction is not acknowledged as an addiction or illness. Other countries, such as China, Taiwan and South Korea, take computer addiction as a serious mental health problem. Internet addiction is becoming more recognized in this country. For example, there is a residential program in a suburb of Seattle, Washington (Fall City) which treats individuals addicted to the internet. Hilary Cash, Executive Director for RESTART Center for Internet Addiction, states that three of the following symptoms suggest abuse and five or more suggest addiction:

Increasing amounts of time on the internet
Failed attempts to control behavior
Heightened euphoria while on Internet
Craving more time on Internet; restless when not there
Neglecting family and friends
Lying to others about use
Internet interfering with jobs and school
Feeling guilty or ashamed of behavior
Changes in sleep patterns
Weight changes, backaches, headaches, carpal tunnel
Withdrawal from other activities.

Psychotherapy /counseling help people and families recognize and heal from the fall out caused by “wired in” behaviors. Self awareness, recognition of the patterns, and the use of human supports to help break the compulsive pattern are necessary components of individual psychotherapy. There are also many kinds of support groups ranging from 12-step programs to Smart Recovery programs designed to help regain balance in a person’s life. If the person is in the early stages of neglecting self and the family, often an intervention in therapy to recognize the destructive nature of the compulsion and limit the amount of time on the computer per day can help. Repair of the broken relationships is also needed in the early stages of therapy, which requires finding alternate ways of coping with stress.

The computer and the internet are wonderful in moderation. We all need balance in our lives, and we can achieve that balance if we ask for help from our families and mental health counselor/psychotherapist. We all need other people, and in our “real time” relationships we can experience love and belonging.

Thursday, September 17, 2009

When Symptom Relief Happens, Counseling has Only Just Begun!!

By Garth Mintun, LCSW, ACSW,CSW-G

You and/or your spouse have been engaged in counseling for a few sessions. It is your first time in psychotherapy and you have expressed yourself, you have been heard, you begin to have a fresh look at yourself and your life… and you are starting to feel hopeful; things can be great. Your anxiety is decreased, your relationship with your spouse has improved, and/or your child is remarkably better. Perhaps you are experiencing work to be less stressful now. Maybe you have some relief from depression. You are not in the midst of a crisis anymore, so you think about quitting the counseling. After all counseling is expensive and you feel better now, so why not quit?

This belief is often attached to the notion that it is time to quit because you feel better. Weeks or months go by, however, and the problems not only come back, but seem to get worse. What happened? Was therapy not effective?

As a new client (especially as a new client who is in psychotherapy for the first time), it is important to understand the following:

1. When you start counseling, often you feel better quickly because you feel symptom relief.
2. Symptom relief is good because it often means that there is awareness of old patterns of problems and therapy begins to solve the surface problems.
3. Symptom relief does not heal the underlying deeper problem/patterns; that process takes a longer time.
4. If you quit too soon when you experience the first symptom relief, you will not undo the fundamental patterns, therefore new symptoms or old symptoms often return more forcefully. This is because you have not yet changed the deeper systemic nature of the problem.
5. It is best to stay long enough to work on the deeper pattern, so you will substantially decrease the likelihood that the old problem will reemerge in other aspects of your life. It may take a little longer, but in the long run it saves money and creates a higher degree of success.

When the initial symptom relief occurs, it probably means that you have just started therapy and feel good about your work, but your work is not yet done. Now the real work starts, which often involves grappling with the underlying issues, such as old fears and traumas. At first this next step may create a little angst; you might feel a bit uncomfortable accepting that is part of the healing. Yes, the painful process starts after the initial symptom relief. Therapy helps you uncover fears, sadness, grief, and trauma that you may have previously ignored. Furthermore, therapy helps you make the connections between patterns and problems, so that you can get to the root or source of the problem and explore new behaviors and beliefs. This has the potential to enrich your experiences.

So, roll up you sleeves, take a deep breath, and know that you are in a safe and supportive environment which will help you address the issues that keep you stuck in old familiar and destructive patterns. You can now begin to make lasting changes that will create a healthier sense of yourself and help your relationships to thrive and be more resilient.

Keep up the good work, because you are not in crisis mode! Continued counseling pertaining to underlying patterns will enable you to avoid continued years of emotional pain. This may be hard work in the short term, but it will be beneficial for many years to come.

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