Statistically, committed relationships are no easier to maintain now than in bygone days. The specific nature of the problems may have change, but the complexity remains. Relational issues, historically, often focused around: roles, child-rearing decisions, extended family, fidelity and how to allocate time and resources. Today's couples still struggle in these areas. Additionally, modern life seems to generate both new opportunities and new challenges. Some of the common dilemmas presented by couples today revolve around: lack of shared enjoyment, chronic conflict, problems that never fully resolve, pervasive negativity, power struggles, and lack of shared interests or vision. These culminate in an overall lack of fulfillment, generalized dissatisfaction and a subsequent turning away from the relationship as a source of comfort or inspiration. Sometimes, people become resigned. Others leave, only to find similar stumbling blocks resurfacing in the next relationship. Some attempt to apply wisdom from other arenas of life – where they have been given quite successful -- to the relational sphere, only to find it creates even greater discord. Likewise, relative to sexuality, old issues remain relevant, but are eclipsed by some originally less frequent that now permeate culture. Forty years ago, the most commonly presented issues were erectile or ejaculatory problems in males, and pain with intercourse or lack of orgasm in females. These have not disappeared. Currently though, with (1) the availability of Viagra and Viagra-like drugs, (2) the more extensive use of prescription medications which, while rectifying one medical problem, create the unfortunate side effects of dampening or eliminating sexual desire or arousal, and (3) the ever-present accessibility of the Internet, inhibited sexual desire (ISD) now competes with compulsive sexual behaviors for predominance in presentation.
When a relationship is already generating a high degree of stress and distress, one session a week can be insufficient. With one weekly session, too often, whatever is initially learned and applied unravels in the course of the ensuing week. Each week can feel like starting over. This cycle can create heightened hopelessness and lessened motivation, even when a couple starts out highly committed to a change process. We have found, over the last 25+ years of working with couples, a more intensive format has the potential togenerate greater momentum towards change. At a minimum, two sessions per week is preferable. Ideally, depending on what couples' schedule affords; a week-long intensive can offer great potential for making crucial neededprogress. These initial shifts can facilitate the foundation required for implementing further change – often with a greater sense of teamwork, even where previously lacking. During the inattentive, the couple create a vacation from as many other commitments as possible, are seendaily, with "homework assignments" done together between sessions. Alternatively, given the nature of the problems to be addressed, a 4-day weekend intensive, followed by continuing outpatient sessions, may help tojump-start the process of change, creating greater clarity about what is likely to be possible or desirable going forward.
Working in an intensive format also allows for couples to come from out of town and complete a signification piece of work that can be integrated in to their on-going therapy back home. This approach can be particularly useful when a couple requires a very specific adjunctive component to their on-going therapeutic work, or when progress has become stalled. Often, couples, where one or both are themselves therapists, find leaving their geographic area of practiceuseful in order to focus on their own work with therapists outside their immediate community of colleagues.
Another way, in which our approach differs, is our preference for using a male/female co-therapy team. We find in this way, attention is maximized for each client, both as individuals, as well as relative to the issues andgoals they present as a couple. Many couples, whether male/female or same sex, find it useful to have both a male and female collaboratively work with them in a therapeutic team approach.
The Monterey Peninsula – Carmel, Monterey, and Pebble Beach up to the Redwood Forests of Big Sur — provide some of the most stunningly beautiful geography on the continental U.S. Hiking, golfing, dining, kayaking, bicycling, shopping or quiet solitude in nature are all readily accessible. Quaint seaside B & B’s alternate with hotels that include spas, dog-friendly inns and houses for short-term rental by the sea. Natural beauty alone doesn’t cure relational problems – but it certainly provides inspiring backdrop.
Addiction and Recovery
Chemical Dependency is a term that may encompass addiction to alcohol or drugs. There are many paths to becoming chemically dependent, but ultimately, reliance on a mood-altering substance begins to negatively impact and createimpairment in multiple areas of life. A hallmark of addiction in denial and minimization, so it is often as hard to acknowledge the reality of the problem as it is to get adequate help. For some clients, to become abstinent safely requires a period of detox and stabilization in either a designated residential facility or hospital unit.
For many, AA and similarly based 12-step programs – including meetings, step-work, sponsorship and support – are crucial in maintaining sobriety. In addition, there may be very distinct underlying contributors to the original “need” served by the use of the drug(s) and/or alcohol. Sometimes, a mental or physical health issue such as depression, an anxiety disorder, including PTSD, bi-polar disorder or chronic pain has led to what might be considered an attempt at “self medication” that soon takes on a life of its own, creating deepened pain and hopelessness where relief was sought. Sometimes the “function” an addiction originally arises to address creates more than one dependency. In such instances, clients find that as one addiction subsides, a dormant or lessor addiction begins to become prevalent.
People sometimes settle for the least lethal or the least obvious addiction (i.e. workaholism rather than alcohol.) Yet, the underlying dynamics remain and continue to undermine the quality of life. The root causes, never identified, are never resolved, and in time, the original primary addiction often reasserts itself. Additionally, where addiction has reigned, there has typically been collateral damage – to self-concept and esteem, as well as to their relationship with others. Often, patterns of relating have formed around the addictive behaviors and over time, have become entrenched. Maintenance of recovery, once symptoms are under relative good control involves revising self-awareness, rebuilding trust, and repairing relational habits that no longer serve. Recovery is not about restraint, but about broadening and deepening to create a life worth living.
Sexually Compulsive Behavior
Sexual addiction has become an epidemic since the development of the Internet. Due to its relative accessibility and anonymity, the web has become a ready alternative to distressing relationship experiences. As with other addictions, tolerance can set in, and more and more is needed to achieve the same high. As sexually addictive behavior increases,dating becomes less frequent, or the activity increasingly displaces a couples’ intimacy. The computer screen comes to feel like a pseudo-affair to the partner of the addict.
Treatment Process for Sexual Compulsivity
Treatment for sexually compulsive behavior usually begins with abstinence. The individual most often will need to learn how to deal with emotions such as loneliness, sadness and anxiety in more effective ways. Sometimes a major psychiatric disorder underlies the problem. For a subset of clients, sexual arousal patterns may be atypical; the desire is not for a person they would find physically attractive and for whom they might feel affection.
This is a disorder of intimacy and is most often a result of a history of complex trauma (multiple overlooked childhood experiences that are difficult to integrate.) In such cases, the therapy focus includes trauma integration. For other clients, the couple needs to change the structure of their marriage to include more passion, fun and creativity. Marital therapy, even when the compulsive issues pre-dated the marriage, is an essential component. The solution to sexual compulsivity is rarely simple, and the individual needs to be committed to an intensive phase of therapy with outpatient follow-up.
In addition to issues of addiction, other common mental health issues faced by many include depression andvarieties of anxiety disorders, including: generalized anxiety, social phobia, PTSD, Obsessive Compulsive Disorder(OCD) to name a few. Often, mental health problems co-occur. Examples include anxiety disorders and alcohol abuse or depression, social phobia and OCD, alongside an eating disorder. In treatment centers where there exists a narrow specialization, a person might find excellent help for one oftheir mental health issues, and no help for any but that one. Some mental health issues can be treated sequentially. Some require a more simultaneous approach, for as one declines, the other may increase. For example, as an eating disorder, such as anorexia nervosa remits, a client may find their OCD worsening.
Though eating disorders fall in to a distinct diagnostic category, they have elements in common with their other addictive disorders. Specifically, the behaviors of bingeing, purging, and restricting typically escalate overtime: more is necessary to achieve the temporary “relief” originally attained by less. Likewise, secrecy, minimization and denial routinely accompany, as eating disorders behavior escalates. The purging that occurs with bulimia, many take multiple forms that include extensive, even dangerous levels of laxative and diuretic use, exercise that grows increasingly compulsive, and vomiting that can become habitual — anytime food is consumed.
To break patterns that have become severe and chronic requires higher levels of care, including a period of inpatient or residential care. For some clients, day treatment (PHP) or intensive outpatient (IOP) may provide the containment necessary. Where there is the possibility of a strong support system that the client will allow, to provide needed help, outpatient treatment alone may be sufficient.
Since DSM V has included the diagnosis of Binge Eating Disorder, an increasing number of clients are seeking treatment for this long-neglected struggle with food. The critical component of intervention is creating an individualized, balanced, non-restrictive meal plan concentrated on re-establishing hunger/fullness cues and addressing cravings. This step is achieved with the assistance of a dietitian. The emotional component of bingeing requires attention to the particular contributing factors for each individual. Issues of loneliness, socialisolation and relationships may require attention and intervention. For others, complex trauma or PTSD can be a causative agent. Other factors may include long-standing patterns or double binds related to perfectionism, anger, social anxiety, impulsive or obsessive traits, shame or self-loathing. The goal of treatment is to develop and implement alternative coping responses to binge-related triggers as cravings and urges decrease. Additional work maybe important around originating, maintaining or concomitant issues to achieve lasting symptom remission.
Anorexia and Bulimia
With anorexia and bulimia, sooner intervention can yield better prognosis. Due in part, to the debilitating effects of malnutrition, descent into an eating disorder can create the precise circumstances that make it increasingly difficult for a person to accurately register the level of debilitation or danger their continuing behaviors pose – to both physical andmental health. Part of the complexity is that greater symptom stabilization may need to precede insight, yet insight is required for the person to accurately assess the realities and derive adequate motivation from that realistic assessment.
In order to optimize the client’s ability to acquire control over the addictive process, initial phases of treatment are typically coordinated with a dietitian and psychiatrist. Once the symptom is initially stabilized, the client often experiences more intense emotions that the eating disorder was being used, in part, to suppress. At this point, dialectical behavioral therapy (DBT) and mindfulness work can be useful for what we call establishing “affect tolerance” and fostering the “emotional intelligence” requisite for creative problem solving. Once the eating disorder symptoms decrease, some clients likewise experience more anxiety and fear. It can be as though the symptoms, while ultimately life threatening, provided, temporarily, the ability to push through certain life challenges or put aside persistent fears.
Work with a life coach to master experiences that have been previously overwhelming often can be of benefit. Where past trauma or overwhelming developmental experiences have contributed to the development of the eating disorder or to an underlying depressive or anxiety disorder, trauma resolution and grief and loss work are often useful.
Post-traumatic Stress Disorder (PTSD)
PTSD can occur in response to extreme experiences that overwhelm and individual’s coping resources. The nature of such events typically involves a sense of threat to a person’s life or physical integrity. Often there is a sudden and destructive onslaught that a person cannot process at the time. Later a person may experience intrusive thoughts, images or recollections of the experience – while awake – or in dreams. Sleep is often disrupted. The person may begin to avoid circumstances that remind them of what happened as so their lives become constricted.
Depression and anxiety may accompany; also irritability, rage, and guilt. It is not unusual for individuals to actively seek to blunt the intensity of the trauma-related feelings and also develop a secondary substance abuse issue. Without treatment that allows a person to work through and integrate the experience, avoidance tends to grow, creating an increasing narrowing of a person’s life. Exposure -based therapies allow the individualto master the overwhelming experience(s) with reduction of anxiety, depression and other trauma-related symptoms.
Complex trauma is a relatively new term that recognizes individuals whose difficult life circumstances cumulatively create an ongoing or recurring state of feeling overwhelmed. The experiences that culminate in this state of overwhelm, may cause the individual to be highly self-critical, perfectionistic, self-hating...to be over or under dependent with others and constantly anxious about safety. When there is also a PTSD response to past experience like violence, war-related events, child abuse – the symptoms of anxiety and depression can be compounded.
Therapies that allow for processing and integration of the painful and overwhelming events must also include revising one’s sense of self to increasingly change self-blame in the direction of self understanding, and hopelessness in to meaning making and the ability to move forward. If self-destructive or addictive behaviors have become a way of coping, the primary focus is to create a longer term plan to manage symptoms while allowing the person to take charge of their life and move it in more functional and fulfilling directions.