Should Therapists Be In Therapy?

I belong to a listserv for therapists and this is one of the topics that people have been discussing recently. It’s frequently a theme that raises ire amongst therapists, so here are my blogged opinions on the subject.

I remember in the halcyon days of Graduate School being amazed at how few of my student peers had actually been in therapy themselves and wondering how they were going to be able to empathize with the experience of their clients unless they knew for themselves what it felt like to be a client. I believe that it would be unethical to mandate therapy before commencing a graduate program, but there is a case to be made for strongly recommending that future therapists experience therapy for themselves.

I believe that my experiences in therapy have helped me begin to understand how it feels for some of my clients when they sit opposite me in session. Having been a client myself, I can empathize with the discomfort and vulnerability of showing one’s self, of displaying emotions that few, if any, people in one’s life will see, of talking about distressing and painful topics that may be rarely discussed with lovers, friends and family, of laying bare the challenges one faces in the world, the difficult decisions, the complexities of close relationships and so on.

But there are some clients whose life experiences and challenges are so far removed from my own, that it would be impossible for me to fully know from the inside out what they have faced in their lives, what it has meant to be that client. Does this mean that I would not be effective as their therapist? Walking a mile in somebody else’s shoes would definitely be a learning experience. But does a therapist need to have experienced and recovered from substance abuse in order to work with folks who are in recovery? What about able-bodied therapists who work with people with disabilities? Therapists who work with schizophrenics? Therapists whose specialty is working with people with autism? The list is endless. I believe that one of the most important aspects of a therapist having been in therapy themselves is that they understand the power of the therapeutic relationship from both sides of the couch, and understand the process of therapy.

Therapists should be in therapy if they need to be, but I don’t believe that we all need to be in therapy all of the time, and that the same holds true for therapists. What would be the point in requiring therapists to be in therapy that they did not need? Such a requirement would be tantamount to an assumption that all therapists are broken down and in need of “fixing” – this would be a huge, and inaccurate, leap in logic. In point of fact, very few of the people I see as clients are “broken” (and luckily neither do I perceive therapy as a process to fix broken people).

For licensed psychotherapists, our ethical mandate is to ensure that we take steps to be as effective and competent as is humanly possible and that we “do no harm.” We aren’t required to be perfect, merely to take steps to make sure that we follow our professional mandate. This requires us to either obtain supervision or refer out clients with whom we are in over our heads. In some cases, this might also mean that we ourselves pursue therapy in order to “tidy up” places in our life that get in the way of our well-functioning as therapists.

As regular readers of my blog already know, I consider supervision a necessity in my practice as a therapist. I also, when needed, am in therapy when it is needed. My daughter and I are just wrapping up some sessions of family therapy that have dramatically altered our relationship for the better: places that felt too messy for us to wade through alone became magically illuminated by Bunny Duhl's excellent clinical flashlight. I have a wonderful individual therapist that I am seeing at the moment to help give me perspective on a variety of issues in life, including how to handle my parents' aging and future deaths. I have read books on aging parents, being an adult child of parents, relationships between mothers and adult daughters, etc. Reading gives me instruction, education, insight and perspective. But it is therapy that allows me to internalize and experientially navigate what it means to be a 51 year old woman whose mother is aging and to have somebody witness the sorrow and grief I feel about that unavoidable, imminent and painful loss.

As somebody on my listserv wrote today, “If I need to place a Band-Aid on my finger, I'm able, but I can't seem to get my own proctology exam done - there's room for both self-care AND more objective care/therapy with professional assistance.” Few would argue that developing a healthy regimen for self care is not a good thing. Eating well, exercising, a spiritual life however you define it, nurturing and loving relationships with partners, friends and family, reveling in the delights of music and honest self-examination where needed – these are just a few of components of a vigorous, healthy life. Therapy is one such component - but a "when needed" not a "should."

The Fifty Minute Hour and Closure

I received some interesting questions via email about the practice of psychotherapy, and thought I'd respond to some of them.

How many clients do you have and how often do they come and see you?
The number of clients I have tends to fluctuate. At the moment I have 27 clients, and they include couples, families and individuals. This is about as many clients as I can see in any given week. If my practice is full and the potential client is not an emergency, I compile a wait list. If the length of time a client must wait is more than one month, I keep a referral list of other therapists that I recommend to potential clients. In the event of a client needing therapy immediately, I refer to other therapists as soon as I receive the call. Of this 27 clients about half are couples, with one or two families. The remainder are individuals. I generally work Tuesday through Friday. 25-30 hours of my work week is spent with clients face-to-face. I spend 5-10 hours per week attending professional meetings; I have peer supervision with colleagues and paid supervision with other experienced professionals; I conduct research into areas where my education is lacking; I talk with "collateral" agencies (this means other professionals who are involved in clients' lives, such as psychiatrists, other therapists, social workers, teachers, etc.); I market my clinical practice; I do my book-keeping and answer/return phone calls. When I started my private practice, I was determined not to burn myself out and decided that a four day work week was a more humane and reasonable approach to working. I pride myself on being a very conscientious therapist and spend a lot of time reading and researching on different issues that clients raise. This might mean educating myself about other cultures, religions or spiritual practices, learning about the stressors attached to various professions that clients have, consulting with other clinicians with a particular expertise, etc.

Most clients come to see me once each week for a therapy "hour" which is generally, but not always, 50 minutes long. For busy couples, especially those with children and the accompanying headache of finding regular babysitters, I usually suggest that they attend a 2 hour session every other week. Clients in crisis will often request extra sessions during the week, although unless the client is in an emotional crisis or is very depressed I usually suggest that they only come in once a week. While coming to therapy can be very helpful for people, and building a good relationship with your therapist enhances the quality of your therapy, becoming dependent on your therapist is not advisable. Encouraging clients to build supports into their lives in the form of friendships, communities, support groups and/or 12 step programs is a valuable adjunct to working in therapy. It doesn't take a whole village just to raise a child - adults need villages of caring support also.

Why do therapists have a 50 minute hour?
This is a fairly common question. The answer is that therapists, including myself, often need to have ten minutes before the next client. This allows time to jot down any notes that we need to remember, check messages and return any urgent calls and clear our heads before the next client comes in to the office. While a 50 minute hour works best for the therapist, in practical terms I will often allow more time if a client is dealing with a particularly challenging time in their life and would really benefit from an extra 10 minutes on the end of their “hour.”

How long do people stay in therapy?
There are as many reasons for people to attend therapy as there are people on the planet. Some people come and see me with a specific goal in mind: a parenting challenge; the death of a parent; a sexual problem; a miscarriage, etc. These people may spend 3-6 months in therapy and leave. Often they will come back in for a "refresher" later on, or they will return to therapy if another issue comes up that they think I could help them with.

Some people come in with bigger challenges: long-term depression; a marital crisis that has come about as a result of years and years of marital neglect and estrangement; families recovering from the effects of a family member's long-term alcoholism and new sobriety; people with a lifetime of struggle, who are just beginning to realize how much they have been affected by the family they grew up in and want to learn how to make different choices for themselves; men and women with histories of sexual abuse who want to learn different ways of being in the world. These issues are often more long term. I have some clients who have been meeting with me for 4+ years. Others stay for a year or more and then leave, possibly returning later if they feel it would help them.

Sometimes people come in to therapy and are not yet ready to do the work. I always leave the door open for these people to return. I know from personal experience that it can take time to pluck up the courage to sit and face your demons.

How do you know when you are done with therapy? Is it really necessary to have “closure” when finishing therapy?
In the best of all possible worlds, a client’s decision to terminate therapy would be because the problems or issues facing them at the outset of therapy are no longer present in their life. However, in reality a client’s decision to leave therapy may be simple or more complex: they may feel that the piece of work they came into therapy to focus on has been adequately examined and explored; they may not feel that they are benefiting from therapy; they may not feel that they are a “fit” with a particular therapist; they may have come face-to-face with some challenging feelings that they are scared to bring up with the therapist and see abrupt termination as a way out of that fearful place.

If it is the therapist who is driving the termination of therapy, they may suggest termination if the client is either unable or refuses to pay for therapy services; sometimes the therapist decides that the problems facing the client are outside of their particular expertise or competence; sometimes, despite a therapist’s best efforts, they can tell that a client is not benefiting from the treatment; sometimes the reverse is true and the client improves dramatically over time and is no longer in need of therapeutic services, leading the therapist to suggest termination; and there are times when a therapist is unable or unwilling to continue to provide clinical services, either due to illness, need for prolonged absence, or some other appropriate reason. Unless the client’s quality of life has improved to the point where they no longer need services and have decided, after discussion with their therapist, to terminate the therapy relationship, the therapist is at all times responsible for attempting to ensure that clients have access to other clinical referrals.

Therapists often disagree about the benefits of taking time to “close out” a therapy relationship. Some therapists prefer that several sessions be devoted to the termination of therapy. Others don’t see the necessity of a lengthy termination procedure, and still others, like myself, think that it really depends on the client, how long they were in therapy, what kinds of issues they were working on, and how invested they appeared to be in the process. If a client comes to therapy wishing only to work on a short-term goal, the issue of closure is less important. However, in the event of a long-term relationship between therapist and client, the issue of taking time to say goodbye to the relationship takes center stage in the final treatment sessions. Few of us have had the opportunity to say a proper goodbye to a relationship, and that opportunity is enshrined in the closure sessions between client and therapist. This is the chance to “do it right.”

The manner of terminating therapy is one of the most crucial aspects of therapy. All relationships should have a good ending and a good beginning and therapeutic relationships are no different in that respect. While licensed psychotherapists are bound by the ethical standards of their professions to follow appropriate termination procedures with their clients, clients are not bound by the same rules and ethics. I always hope that my clients will terminate therapy with me in an honest and straightforward fashion, but this is not always the case. Some people would rather drink drain cleaner than say goodbye! This shows in the way they terminate the relationships. For example, refusing to answer a therapist’s phone calls is not terminating therapy. That is hiding out from therapy and is not an honest approach to closure. Getting “too busy” in your personal life and not having time to attend therapy is also not closure. That is running off and is not the same as taking time to say goodbye. If a client is furious and/or upset with their therapist and is too scared to tell them, leaving therapy rather than dealing with their feelings that is not closure – that too is running.

On balance, the most effective way to terminate therapy is to talk about it. It is an opportunity to review where you are in your recovery path and to understand, with some perspective, where you have come from, where you stand and where you still might need to go in the coming years. Even a short term therapeutic relationship can benefit from one such session. It is a great opportunity to take stock of strengths and to pat yourself on the back for your hard work (both therapist and client!)

Before the Wedding

I seem to be becoming the "expert" on Wedding Day jitters! I was just interviewed again for an article on Wedding Day Discord, for "Elegant Wedding" magazine. So, here are my thoughts on how to survive family discord at weddings. In fact just recently, a young couple has been coming to see me for pre-marital counseling. Among other issues they wanted to talk about was the anxiety and tension that was continually surfacing over mounting family discord (on both sides of the bridal couple) during the planning of the wedding, and how this was affecting the couple as their wedding day draws nigh. While therapy can be, and often is, a deeper examination of the origins of one person's complex inter- and intra-psychic issues, three weeks before the wedding is probably not the time to do critical or long term psychological digging. This is the time for understanding, solution-focused dialogue, clarity and clear-cut pragmatics.

Let's face it - weddings require huge amounts of preparation and planning around family and personalities, especially if the couple come from very different family backgrounds. Any time you bring together two groups of people with differing opinions on marriage, religion, culture and values, there's the potential for sparks to fly!

Problems? What problems?
For a start, in view of the divorce statistics, there is a high probability that the in-laws are separated, divorced or remarried which presents the problem of multiple combination of parental couples and dynamics, all with opinions and thoughts on how they would like their role in the wedding preparations and ceremony to play out. Here in Massachusetts where same-sex marriage is (happily) legal, homophobia will often rear its ugly head in the planning of the wedding and decisions over the presence of family members who will undermine the joy of the event creates a dilemma for couples.

There's a distinct chance that the couple, and therefore their families, represent different religious, ethnic/cultural backgrounds. Oftentimes, long simmering family feuds raise their ugly heads at weddings, with the specter of emotional clashes and uncomfortable disagreements arising on what the couple hopes will be their special day. Weddings also bring up social class issues and differing opinions and beliefs about money and how much or how little is available and how it should be spent. There are often disagreements, spoken and (often more dangerously) unspoken about how the wedding should be organized and how traditional or non-traditional it should be. In other words, weddings are potential powder kegs of family discord, and much of the anxiety created by bringing families together invariably ends up being carried by the couple.

What choices can a couple make and how can pre-marital therapy help?
The number one most crucial aspect of planning a wedding where there is a potential for family discord is communication between the couple. Marital therapists, trained in family systems and experts on family dynamics, are well placed to guide couples through the swirling vortex of pre-marital confusion. Marital therapists know that if the couple aren't on the same page, chances of smooth sailing become less likely. Now is the time to get to grips with the wedding day issues as a couple, being clear on the problems that each half of the couple has identified, being respectful of each person's fears and anxieties and being clear on the direction you are going to take together, and how you will communicate this resolve to family members. As an impartial observer, marital therapists can provide outside-the-box thinking on how to approach family challenges. One of the things that I usually suggest is that the couple create a "wedding support system" - one or more people from outside the couple's respective families, who are the designated "go to" folks for complaints and/or conflicts during the planning of the wedding. I typically suggest that this person or team is present at the couple's conflict-resolution planning sessions, either with me present, or in the planning the couple does outside therapy, so that everybody is clear on how the couple intends to approach potential or actual family conflict.

Weddings bring up people's romantic hopes and longings. For those relatives present whose marriages did not endure, weddings bring up feelings of sadness, of hopes, dashed, and bitter-sweet memories of their own weddings. Unless you are lucky enough to live in Massachusetts, USA, Canada or Spain, you are probably not living in a country or place that allows same-sex couples to marry, so if you are a gay or lesbian wedding attendee, weddings can be painful reminders of how you are denied access to such ceremonies due to civil rights issues. The wedding support team, as well as the couple themselves, can help smooth ruffled feathers by taking the time and being willing to listen to people's thoughts, hurt feelings and disappointments. But then calmly, but respectfully explaining their choices. Establishing a clear boundary that this is your wedding day and and that you retain the right to at all times reflect your choices and desires is important.

If the wedding is uniting two families of different religious or ethnic backgrounds, ask the families to submit a list of three religious symbols or ethnic/cultural customs that are important to them and then ask if they would be willing to have you pick the one that fits best with your wedding. This helps families feel that their beliefs and values are important and included.

Find an area of organization that family members can co-create, i.e. a table with a joint family album, or framed photographs from both sides of the family. The symbolism of having all these photographs on the same table or united in the same album will not go unnoticed as a statement by the couple and can be a strong symbol of unity that is effective in framing the wedding as a bridge to a new beginning.

I usually tell folks to get creative! If folks are fighting about who is going to walk down the aisle, have ALL parents walk! If you can't come up with a solution alone, consider taking representatives of each family for a family therapy appointment with a licensed marriage and family therapist. We are trained to handle a room full of disappointed and possibly irate people (and I have found that most people can agree to disagree if it's just for one afternoon!!) Bear in mind that for a formal wedding, seating arrangements can be made so that the paths of warring factions don't cross. I also usually remind the couple that the officiant at their wedding should be apprised of the situation if there are dissenting factions. Even if they don't have specific recommendations on how to handle the situation, they will at least be aware of the tensions and can better support the couple on their special day.

Is Therapy Private?

When a prospective client first contacts me about therapy one of the first things I do is to send out a copy of my HIPPA (Health Insurance Portability and Accountability Act) Privacy Notice and a couple of pages (oh-so-poshly called my "Statement of Practice") that describe my clinical practice. The Privacy notice, as of April 2003, is a "must have" in any clinical practice and therapists are legally required to present one to their clients. I have one of the best written privacy notices EVER because my spouse was HIPAA Compliance officer at a major hospital a while ago, and made sure that I dotted my i's and crossed my t's! I know of many therapists who don't provide one for their clients, and are treading on a legal minefield as a result. Essentially what this notice says is (1) how information about you, the client, can be used and (2) how you, the client, can access your personal information. On my particular privacy notice there is a handy-dandy tear off sheet on the back. Most client dutifully tear off the sheet, sign it and return it to me where it is filed away for posterity, proof that I gave them the document. Only one client has ever had a conversation with me about privacy, thus proving that they actually read the privacy notice! As boring as it is, I wish more clients would take the time to read. It's frequently taken for granted and shouldn't be.

The very first session with a new client, I have a checklist of things I review with them. First one on the list is the limit to confidentiality. Here's where I inform my client that if they plan on beating up the wife, abusing their kid (or any other kid for that matter), wacking the next door neighbor, slow-poisoning an ex-boyfriend or killing themselves, I am duty bound to warn the appropriate authorities. This is the meaning of the phrase "mandated reporter," and there is no therapist in the USA who can circumvent this. The law is the law.

When all is said and done, most people, and by people I mean clients, can see the wisdom in this arrangement; after all most of us want to protect children, and most of us understand that people need to be protected from those few poor souls who want to hurt, maim or otherwise disrupt our lives in painful ways, even if this does mean revealing our confidential records. So, I typically explain that I would in most cases attempt to contact and talk with the client first, before making the call if I am about to break what I consider to be a sacred trust between therapist and client (their privacy) they deserve to hear it straight from the horse's mouth.

So, here's the irony for me in giving out this darned Privacy notice. Here I am, doing everything I can to provide a safe environment in which people can unload and unburden themselves of their deepest, darkest pain and yet I am required to hand out this blurb that essentially says that people have less rights than they think they have (if they were to think about it for more than 3 seconds that is!) In point of fact, clients who self-pay for therapy and don't rely on their insurance (and these clients account for 99.9% of my client base) have many more protections than clients who use their health insurance to cover their mental health costs. Health Insurance companies place great premium on being able to have access to mental health providers' files. In fact, they have the right to review ALL clinical files, even those of clients who are not members of their insurance plan, if they consider or suspect that the therapist is providing improved coverage and better standard of care to self-pay clients.

I was talking with my friend Kelly about privacy and confidentiality this week, and told her about this blog, and about the philosophical dilemma I am in each time I hand out the privacy notice. Kelly and I have spent endless hours discussing organizational psychology and the importance of a shared vision and mission in working with groups of people in collaborative efforts. Kelly works in a senior position at an urban multi-service center working with poor and homeless people and I used to be director of a large agency that covered five cities, and the mission of the agency (which also focused on poor and working poor people) was the central organizing principle for me with every facet of the work I did. This applied whether I was supervising staff, directing the various projects I implemented, or even down to the way I related to the people who delivered sandwiches to our agency site at lunch time. So, during this particular conversation Kelly told me the following:

"I was doing orientation this week with a new hire and told her what the mission statement of our agency is. Then I said that the mission statement for most people and organizations in the country is to make as much money as possible in the least amount of time. So if violating privacy makes money then that is what they do. I explained to her that mission statements are about what comes first over all else. At our agency the dignity of the guests comes first over everything else, including money, property, staff, etc. For you, your clients come first. Perhaps you could write your mission statement or a blog about what that would be... and how important it is to determine the mission of any person or organization that you deal with, so that you know where you stand with them, first or secondary to something else."

Hearing this from Kelly was like having a light bulb go on over my head. I have been short of a mission statement, a simple phrase that is my current organizing principle that comes first and foremost above all else! So here it is.

Jassy Timberlake's central organizing principle as a psychotherapist is to provide a safe, welcoming and supportive environment in which any information shared is regarded as sacred and private and not to be revealed unless severe physical or emotional harm to another human being would result.

Yep, that about sums it up.

Attachment Parenting (and Finding a Therapeutic "Niche"!)

There are many kinds of specialties in psychotherapy: some therapists only work with individuals and focus on depression and anxiety; some work only with couples and focus almost entirely on marital/relationship issues, with little focus on sex and sexuality; some therapists work almost entirely with individuals and couples with sexual disorders and challenges; some therapists have a specialty of working with families, with a sub-specialty of doing play therapy with young children; others have a particular skill in working with adolescents and the list goes on.

The methods by which therapists come to develop “niches” in their clinical practices are many and varied. For example, some therapists feel drawn to working with people who have substance abuse histories, either because the therapist him or herself has substantial recovery from, and understanding of, substance abuse, or was raised in a family where there was alcoholism or drug use. In this case, the “niche” was chosen and made complete sense given the therapist’s own unique history. Still other therapists maybe interested in the larger issues around substance use and abuse, while having no particular experience of addiction to a substance, but discover that they are particularly skilled in working with this population of folks.

I happened into one of my therapeutic niches quite by accident.

One day I received a telephone call from a young couple who were looking for a couples’ therapist as they were having problems in their marriage. The couple, eschewing standard child-rearing practices, felt strongly about raising their child using attachment parenting practices, and had encountered problems locating a therapist who was supportive of, and wouldn’t pathologize, their parenting style. Parents’ decisions to practice attachment parenting have been “blamed” on various factors: they are told that they chose AP as a result of their own (theoretical) experience of feeling detached and disconnected from their own parents; they are told they are scared of intimacy with adult partners and use their children to avoid this; they are told that they are over-indulgent and don’t know how to set appropriate limits or “discipline” correctly, and the list goes on. As a result of these kinds of therapeutic catastrophes, a stream of parents subsequently contacted me, seeking couples’ therapy which would take into account their attachment parenting (AP) methods.

I raised my child under somewhat alternative circumstances, strongly influenced by reading John Bowlby’s books on parent/child attachment during my pregnancy. Committed to nursing (and despite many negative comments from friends and family), I breast-fed my daughter until she sadly weaned herself at the age of 16 months. Although my daughter only had brief periods of being home-schooled, I was supportive of home-schooling as a choice and felt strongly that children should be primarily parented and taken care of by their parents and close loved ones. I “wore” my daughter everywhere, carrying her in a sling until she began walking at the tender age of 10 months, and even then until she reached one year old. I still carried my daughter in the sling if we were out running errands.

For most of my daughter’s early life I was a single parent, reliant on child care and schools to “help” with the education and care of my child and I was therefore not, by strict definitions, an AP parent. I nonetheless supported the philosophical ideals and values of AP. My own experience with some of these practices meant I was more understanding of the challenges which AP parents face.

So, what is Attachment Parenting?

By way of an overly brief description, Attachment Parenting is a term coined by Dr. William Sears. He proposes a parenting style that focuses strongly on the quality of the relationship between infant and parent, and suggests the following tools to cement early attachment. (Please note that this is not an exhaustive list. For more information, please visit http://www.attachmentparenting.org/ or http://www.askdrsears.com/ .)

1. Create a solid early connection with your newborn infant.
2. Pay close attention to an infant’s cues, staying close at all times.
3. Breastfeeding (preferably until the child self-weans).
4. “Wearing” your baby, by using slings and carriers so that your infant is close to you at all times.
5. Sharing sleep (Some parents create a “family bed” with all family members sleeping in the same bed; others use bed extenders, etc.)
6. Maintain balance in family life

Sears encourages parents to recognize that their child’s dependence is a psychosocial, developmental need that needs to be factored into any and all parenting strategies. His belief is that if this need is successfully met it will provide a solid foundation for a child’s developing sense of self, and create a close, affectional bond between parents and their children. His emphasis on loving, respectful, thoughtful parenting is the hallmark of his ideology.

This sounds wonderful for children, but how does this labor and time-intensive method of child-rearing work for the couples who still need time to focus on their emotional and sexual intimacy?

Let me first of all stress that most of the issues facing AP couples are no different than for those confronting any other couple, but there are specific situations that do require creative solutions for AP parents. AP parents often come to my office reporting that while their children are flourishing in their AP household, the romantic/affectional side of the couple’s relationship often suffers. While maintaining balance in all aspects of family life is one of the ideas enshrined in the principles of attachment parenting, negotiating the complexities of an intimate couple relationship is hard to do given the intense hands-on aspect of AP.

Some of the challenges are:

* While they remain committed to sharing sleep with their children, the sleeping arrangements often create challenges to a couple’s attempts to initiate sexual intimacy, and there is frequently a down-turn in a couple’s ability to be sexual as much as they would otherwise choose.

* In practical terms, AP usually requires at least one parent to be present with their child or children throughout the day and night. This also requires that an infant has unlimited access to nursing, a role usually falling to the parent who can or is willing to breast-feed. Sometimes hurt feelings surface for the parent who spends less time with the child or children, as children tend to exhibit a preference for the parent who spends more time with them. This can lead to tension between the couple and arguments and bickering often ensue.

* Breast-feeding mothers often report that while they are committed to nursing their infants until their children self-wean, there is often a diminished identification with their bodies, and in particular their breasts, as erogenous zones. It is not uncommon for women who have given birth to temporarily lose interest in having sex. Also, ironically the very hormone, Prolactin, that stimulates milk production, is also the very same one that curbs testosterone and estrogen levels. Lower levels of Estrogen are also responsible for vaginal dryness which can make penetrative sex very uncomfortable and sometimes downright painful. Low levels of testosterone leads to low desire. Low-desire in one partner often leads to feelings of rejection, anger and sadness in the other.

* Given that there are relatively small numbers of people who are attachment parents, it makes life difficult in terms of creating real supports for your AP family. What this means is that unless you live near supportive family members and/or other AP friendly or practicing families, your AP family will have few places to turn for respite from non-stop parenting and the tasks and chores that accompany this. For most AP parents, this translates into having little or no “down time” or alone time without the children.

I’m not going to go into solutions for the above challenges, given that it would make for an even larger blog than this one. Suffice to say that addressing practicalities and coming up with strategic solutions is one aspect of the focus of many AP couples’ sessions. The biggest initial clinical challenge as a therapist working with attachment parents is finding time when I can meet with them without their children, which is exactly the problem facing AP parents as they try to find ways to focus time on their relationship. Parents who have nursing infants have an even greater challenge on their hands. I aim to be as flexible as possible with AP families, offering to come to their homes if they are in a position, financially and otherwise, to pay for my travel time, and being willing to have infants stay with them in my office if they have no other options. (I do not recommend this option if the couple is having serious problems, particularly when they are very angry with each other. Infants readily pick up on their parents’ anger and distress.)

One of the wonderful and exemplary aspects of attachment parenting is parents’ commitment to their children and to creating a family life that is loving and child-centered. Prioritizing your children’s growth and development is a noble and worthwhile philosophy, and the challenge for attachment parents is often the struggle to determine how to maintain responsiveness to a child, while at the same time honoring the individual adult’s needs and, even more challenging, the growth and development of the couple’s romantic and affectional relationship. This is, at the end of the day, the challenge facing most couples with children. In all the exhaustion and preoccupation with focusing on the parental relationship with the child, the adults’ romantic relationship all too easily gets lost in the shuffle. The relationship that they have with their spouse or partner will form the template that their child will use for creating and maintaining his or her own relationships in later life. I don’t remember the genius who said this, but there is a famous quote that says something to the effect of, “Marriages are like sharks. If they don’t keep moving forward, they die.” Continuing to develop your intimate “love map” with your partner is a central and crucial task for any couple; this intimacy and connected friendship is the life blood for any sexual relationship. Such a task is almost impossible to achieve unless you find creative ways to carve out time for yourself and your partner, despite the challenges.

Central to the clinical work I do with AP parents is the eliciting of their general philosophy of child rearing, and to define what they mean by being an “attachment parent.” I ask each parent to develop a list of adjectives that define the nature of the relationships they have with their children, the specific ways in which they relate to their children, the kind of human being they hope their child will grow up to be and what they see as their particular and individual strengths as a parent. Where do they see themselves as needing some help?

I then ask them to create a similar list, but this time using the concept of being “attachment lovers.” What is their general philosophy for being a couple? What would they mean by being an “attachment lover.” What adjectives would describe their preferred relationship? What words would describe their preferred way for relating to each other? What are their hopes for their “attachment lover” relationship and what do they aspire to have it grow into? What are their particular and individual strengths as a lover, as a friend and partner? Where do they see themselves as needing some help with their “attachment lover” self-concept?

In developing a relationship "compass" as we begin our work together, the most helpful part of my work with AP parents is the development of their own unique blueprint for both their parenting style and their intimate relationship.

Explosions in London

I awoke on that eventful day this week to the news that Al Quaida had detonated bombs in several sites on the London Transit system. While bombings are nothing new to us Brits - we survived two world wars worth of bombings, and years of IRA attacks - I am stunned to recognize that national stoicism runs more deeply in my veins than I had thought. Here's why...

My family lives far enough away from London that I feel reasonably secure in the knowledge that they are all safe. Displaying my famous "glass is half full" personality, I put off calling home until lunch time EST, (5:00pm UK time) at which point I placed a call to my mother - she has always known where everything and everybody is, being the center of the known universe as I know it. Mum informs me that my sister went to London to see a play last night and has not returned home. She then proceeds to tell me that my sister Alison, who is joined at the hip to her "mobile" as they refer to them in the UK, is not picking up her phone and that my mother cannot reach her. I do not feel reassured. I have read online and heard on the news that cell phone lines are jammed in and out of London. In my vivid imagination, my sister is lying broken and bleeding somewhere in a London hospital or, worse, a London morgue, while her cell phone buzzes plaintively inside her copious (and ubiquitous) handbag.

I try to call my sister's home phone number before heading into the office to see clients and there is no answer.

Several clients ask me in concerned tones whether I have been impacted by the news from London. I find that I have to tell them that my sister appears to be missing. They look shocked and confused, and express concern and good wishes. I can't decide whether telling them is a lapse in clinical judgment on my part or not - but the truth is out. Interestingly, I get a very different response from friends and neighbors. They laugh and smile with embarrassment when I tell them my fears about Alison. Flustered, they apologize for smiling and explain that it's such serious news, they don't know how to process it. I understand their response, or leastways I have an explanation for it. Despite the out-of-the-ordinary sharing that I did with some of my clients about my sister being missing, the sharing was done in an environment that invites affect, emotion and feeling, even if there was a tables-are-turned quality to the sharing. Neighbors and friends are not expecting the information. Standing on our respective stoops with groceries and house-keys in hand, they are unprepared for the information, and not sure what response they should have and what is permissible in terms of displays of emotion.

Throughout the week, I notice that I am "spectatoring" my own responses, and pay attention to the feeling of tension that I notice in my body, the irregularity in my breathing and the tightness in my shoulders when I am think about Alison. I'm most definitely having physiological stress responses to my sister's "disappearance," it's just not surfacing into my consciousness. As I often instruct my clients to do, I tell myself that I can most definitely tolerate these feelings, as uncomfortable as they are, and I continue with my work week. I try to reach my mother several times throughout Thursday and Friday and have no luck. Finally, this morning I reach her. Alison is fine. My mother just didn't think to call me, as she assumed I'd realize that Alison would be okay (is this the therapist-as-mind-reader assumption at work again?). My mother's news is received by me with equanimity - actually, my mother was right. I did just know that my sister would be okay. I also find myself forced to identify to with a facet of British stereotyping that I've strenuously suppressed in myself for years - I am WAY more stoic than I like to think. Are optimism and stoicism the same thing? Hmm..I have some interesting things to think about. How will my optimism (or stoicism) affect my work with clients? I feel a blog coming on...

The Joy of (Psychotherapy) Blogging

I do declare! I've had much fun writing this blog thus far. So, here are some general thoughts on my experience of blogging. To begin, I've received emails from folks in the UK, France, the Southern United States, Germany and Japan. While this presents problems in terms of maintaining more email relationships, it's fascinating to realize that by simply writing down a few thoughts, I am able to make connections with people, both therapists and non-therapists, in various parts of the globe. I have so much enjoyed hearing from everybody and hearing their opinions (although I also would LOVE it if people would post comments as well as writing emails to me). I love to write and this has satisfied my desires in that direction.

Some people have written to ask me if I find it hard to think up blogs to write about, but the business of thinking up blogs isn't that hard. I am constantly adding to my already long list of wiating-to-be-written blogging topics. A far larger problem is finding time to do this. By the time I get home from my day at the office, the last thing I want to do is sit in a chair and type, when the couch, my ever-growing pile of books, family members and my puppy, Ziggy, are all calling to me loudly. And then of course, there's the Monday through Thursday infusion of Jon Stewart's Daily Show - to my mind the most reliable news source! While purchasing an air conditioner has definitely increased the comfort level in my study, it is my time-management skills that could do with some focus.

My other continuing challenge, as mentioned elsewhere on this blog, is the problem of "audience." For example, an unexpected result of doing this blog is being told that I have current clients reading the blog relieved that they are not "revealed" on the site, and I've had clients reading the blog who tell me they are disappointed that they are not mentioned. (Waving "Hi" to those folks - you know who you are.) I have spent the last couple of weeks writing a blog (not yet published) on how therapists find their "niche" clients, and about a particular niche of mine, which has been working with Attachment Parenting folks. I've taken so much trouble over this blog, that I've tied myself up in knots, compiling huge amounts of text, but not achieving much. It feels a little like wading in molasses as I struggle through it. I hope it will be the next blog I post after this one and then all will be revealed. I realize that the issue of self-disclosure is omni-present. I want there to be enough so that I don't disappear behind a mountain of psycho-babble, and not too much to present clinical dilemmas. It is my hope that everything I reveal about myself is strategically positive.

There is a little of a "should" quality to perpetuating a blog, particularly once you develop regular readers which appears to have happened already judging by the emails I receive. I'm conscious when a few days go by that I haven't written anything new. The last gap of two weeks was a huge challenge - I became fixated on writing the Attachment Parenting blog, and forgot that I could write something a little more lighthearted.

Up until now, I have written nothing about sex. I am after all a sex therapist and a marriage and family therapist. I love writing about sex, reading about sex, and talking to people about sex. However not everybody wants to read a sex blog and I'm trying to be mindful of the dizzying array of blogging possibilities; I'll put my mind to coming up with an interesting sex therapy blog in the near future. What is sex therapy? Who comes to sex therapy? Any suggestions, folks?

After the Vows, the Reality!

Yesterday I received a call from a writer called Rebecca Delany. She was working on an article for “Elegant Wedding” magazine, put out by the same folks who give us the illustrious “Boston Magazine.” Ms. Delany left a message asking if I would be willing to talk with her about the feelings of let-down and depression that brides feel after the excitement of their wedding day has passed. This was an interesting topic and it got me thinking. I suspect that it's not just brides who have this feeling, but is something that crosses gender.

Anyway, the fact is that usually by the time I see couples, the wedding day has long since passed and disillusionment and unhappiness have well and truly set in. While I have occasionally been called upon to do Pre-Marital counseling, by and large couples appear to wait until they are in crisis before pursuing the horrors of couples’ therapy. Oh, how much easier my job would be if they came in to see me before walking down the aisle, going through their commitment ceremonies, moving in together or having their first child!

The decision to join your life with that of another, regardless of one’s gender or sexual orientation, whether you seal your commitment with a wedding ceremony, a commitment ceremony or a civil union, heralds the beginning of a whole new challenge for a couple. Weddings and ceremonies are very exciting and usually drenched in romantic imagery and symbolic gestures. Physically exhausting to plan and carry out and emotionally exhausting to organize and participate in, for most people our expectation is that our happiness will come about as a result of our marriage, that there is something inherently magical in the wedding itself that will act as a talisman in protecting couples as they begin their marital or committed relationships.

While this is the myth of the power of the wedding, the reality is far removed from the myth. To start with, given that the divorce rate has climbed over the last 30 years, I can confidently make the assumption that more and more of the young adults currently walking down the aisle or having commitment ceremonies, are the product of divorced parents. A parental relationship full of conflict, unrealistic and unmet expectations is often the template that couples use when starting with their own marriages. We are unprepared for what a marriage really means, and unskilled in how to cope with the reality of sharing our life with another person. Our own parents created the blueprint and the backdrop for our expectations, both good and bad, for what could come our way as a result of joining our life with that of a romantic other. So, there’s marriage and then there’s long-term healthy marital relationships. In order to have the latter, you need to fully understand what marriage is about, develop some skills so that you can engage honestly in your relationship and be willing to put some work into the relationship.

So, the wedding is over. And you may have the blahs. Here’s a list of things I recommend that you think about or do as a couple:

1. Exhaustion is very common following a ceremony of such magnitude. The frenzy leading up to the ceremony itself means emotional and physical challenges, including arguments with family members over who will and will not be attending; differences of opinion over what the philosophy and theme of the wedding will be; arguments over clothing; competitiveness between family members for speeches, etc.; late nights and sleepless nights. So, once the wedding is over, take it easy. Get lots of sleep. Eat healthy, nutritious food, exercise enough to keep your blood pumping, do de-stressing kinds of activities (yoga, meditation, listening to music, strolling in the woods or park, reading quietly). Stress and exhaustion leads to depleted immune systems, so take steps now to look after yourselves so that you can recover adequately from the wedding before you catch the first virus that comes along!

2. One of the things that people often say after the wedding is over and the front door has closed, is that there is a feeling of “let down.” The rose-colored limelight shines brightly on a couple while they’re taking their vows. But once the cameras have stopped snapping, once the videos have been taken, it’s back to reality. Be kind to yourself during this period. Find ways to honestly talk with your partner about how you’re feeling – they probably feel something similar. Take time out to do things that make you feel good about yourself and to find ways to make your new partner feel good about themselves too.

3. If you haven’t already sought pre-marital therapy, look into post-marital therapy. Suggest to your partner that the two of you see a therapist in order to learn some skills that will help you over rough spots, before the rough spots have developed. If you are readers, ask for recommendations for good books (I recommend anything by John Gottman, Ph.D and David Schnarch as great places to start. Gottman gives a great series of questionnaires that provide couples with endless amounts of useful information that they need to know about each other, and the pitfalls in relationships that Gottman discusses can happen in any relationship.) Read the books out loud to each other and discuss the ideas that they contain. Don’t be lazy about this. Relationships take work. In fact ALL relationships take work, it’s just that marriages take even more work than any other relationship.

4. Take the time to develop your routine together. For couples who have gone from living alone to living with their partner, there is a huge upheaval in their lives. It takes time to iron out differences of opinion, to figure out who is responsible for what household tasks, to develop a family life that is a unique blend of where both partners came from. Don't expect this to happen over night It takes years to build a couple.

5. If you haven’t already had the conversation, start to talk about what it means to be a couple. It's surprising how different people's definitions can be. For example, do you expect to spend every minute together or do you value friendships and separate interests and activities, alongside your intimate relationship? If you aren’t a joined-at-the-hip couple, just how much time do you envisage spending together. Every night? Every other night? All weekend? Check in by phone once, twice three times daily? How much contact is too much? What does this mean to you? Is the idea of faithfulness central to your idea of coupledom? How will you decide what is private and what is shared between the two of you? Do you have a sense of shared and individual goals for you and your partner? What are they? Do they differ? What is your plan for incorporating any differences into this relationship? Are you planning on having children? Who will be the primary caretaker? What are your feelings about divorce? Who divorced in your family and why? What are your partner’s thoughts on keeping a marriage vibrant? How will you handle big differences in opinion? In what ways are you able to receive and show love in this relationship? (For some couples, physical gestures such as making morning coffee, cooking meals, etc communicate love. Others prefer romantic and affectional physical actions, such as hugging, kisses, sending cards, surprise notes, etc.) Make sure that you each know what these are.

6. Talk about sex for hours and make sure to eradicate secrecy over sex. Talk with your partner fully and honestly, disclosing everything about your sexual history. Be prepared to be clear about what you’ve done, who you did it with, what you liked and what you didn’t/don’t like. Don’t ever fake enjoying sex. If your partner sucks in the bedroom, gently tell him or her. I’ve known clients who would rather lie about their partner’s ability to satisfy them sexually and then leave the relationship, than be willing to talk about what is unsatisfactory and fix the problems with some honest communication.

7. Start right from the beginning with a conversation about money and work, as this is one place where couples tend to come unglued. What is your family’s history with money? What messages were you given about money as you were growing up? Did your parents fight over money? What is your personal relationship like with money? Does it run through your fingers like sand? Do you horde away every penny you make? Is long-term financial stability important to you or do you have a “live for the moment” attitude about your finances? In what way will your attitudes mesh and/or conflict with those of your partner? Is your career important to you? What do you value most about your work life? Do you plan to always work? Weddings and commitment ceremonies can cost a great deal of money, and many couples begin their committed lives together in debt. Make sure to take time to talk about how you as a couple will tackle this issue.

We like to think that love is enough. It’s not. Most of the couples who come to see me for therapy are in crisis. They aren’t in my office because they don’t love each other, but because they can’t figure out their way around the relationship dynamic that has become so problematic for them. If you are pro-active in working on your relationship, you may not have to reach this point.