The New Orleans Institute
at
River Oaks Hospital
New Orleans, LA
Stress is defined as
pressure on the system
status quo. Trauma is a
stress so great and
unexpected that it
cannot be defended
against, coped with or
managed.
(Boss [2006]. Loss, Trauma and Resilience: Therapeutic Work With Ambiguous Loss.)
Source:
Internal
External
Type:
Normative
Developmental
Predictable
Clear
Volitional
Catastrophic
Situational
Unexpected
Ambiguous
Nonvolitional
Duration:
Acute
Chronic
Density:
Isolated
Cumulative
(Boss [2006]. Loss, Trauma and Resilience: Therapeutic Work With Ambiguous Loss.)
Situations of Physical
Absence and
Psychological Presence.
Situations of Physical
Presence and
Psychological Absence.
Both occurring
concurrently.
(Boss [2006]. Loss, Trauma and Resilience: Therapeutic Work With Ambiguous Loss.)
Ability to be aware of, control and monitor
emotional reactions, impulses, and behaviors.
Ability to repair emotional distress, usually
through taking control and renegotiating the
environment.
[Katehakis (2010). Erotic Intelligence]
1. Unhealthy passive coping skills = escape,
avoidance, chronic sexual fantasies, isolation and
withdrawal from others. This unhealthy nonrelational set of skills is referred to as autoregulation.
2. Unhealthy active coping skills = gamut from
substance abuse to engaging in process addiction
(i.e. sexual addiction). The relationship is with the
substance or the experience (i.e. excessive
masturbation, pornography, strip clubs, sexual
massage parlors, frequenting sex clubs, hiring
prostitutes, cruising restrooms, voyeurism,
exhibitionism, etc.)
[Katehakis (2010). Erotic Intelligence]
3. Healthy passive coping skills = solitary
activities such as journaling, reading,
meditating and contemplation.
This healthy set of auto-regulatory skills is a
form of self regulation which can be done
alone or include other people (physical
activities = skiing, swimming, hiking;
creative expression = composing music,
writing, art).
[Katehakis (2010). Erotic Intelligence]
4. Active coping skills = engaging or acting upon the
environment, such as seeking support or solace
from others and getting help to generate possible
solutions.
 Active coping (a form of self regulation) seeks
control of the situation using productive
methods to build resilience. (12 step meetings,
asking for hug, reaching out, forming
friendships).
 Interactive regulation is getting comfort and
support from relationships or other people.
[Katehakis (2010). Erotic Intelligence]
Pathological gambling
Pathological skin picking
Kleptomania
Compulsive buying
Trichotillomania
Compulsive Internet use
Pyromania
Compulsive sexual behavior
Intermittent explosive
disorder
Self injurious behavior
Binge eating
Hoarding
[Grant (2008). Impulse Control Disorders.]
Lies you tell yourself, lies you tell others.
There are lies that are justifiable (surprise party).
There are lies that are toxic.
Lies can cover shame and guilt associated
with hurting self/others.
Some believe that the truth will make
matters worse.
Obsession about lies can cause loss of
productivity by day and insomnia by night.
Lies build walls between self and others,
which erode self confidence and faith.
[Corley & Schneider (2002). Disclosing Secrets]
Core qualities of many impulse control
disorders:
1. Repetitive or compulsive engagement in a
behavior despite adverse consequences.
2. Diminished control over the problematic
behavior.
3. An appetitive urge or craving state prior
to engagement in the problematic
behavior.
4. A hedonic quality during the performance
of the problematic behavior.
[Grant (2008). Impulse Control Disorders.]
1. Affect regulation functions > include the ability to
avoid becoming overwhelmed by strong affective
states with the use of self soothing, self enlivening,
and arousal-balancing skills.
2. Self care functions > involve an individual’s ability to
provide protection and nurturance to him/herself.
The ability to recognize high risk or dangerous
situations and to respond appropriately is a self
protective skill. The ability to recognize and
articulate needs and to set priorities to meet them
are part of self nurture.
[Goodman (1999). Sexual Addiction: An Integrated Approach]
Validation
Confront Victim Thinking
12 step Participation and Trauma Treatment
Self Affirmations and Self Acceptance
Cognitive-Behavioral Mantra: Contain, Reframe, Refocus
Triggers: Anticipation, Normalization, Preparation
Teleological Interventions
Unmasking the Inner Voice
Reinforce the Observer Self
Four Dimensional Commentary, Repetition, Summary
Dynamic Interpretation
Clinical Heliocentrism
[Borisken (2004) PTSD and Addiction]
1.CHALLENGE old thoughts
2.COPE with strong feelings
3.CHANGE your environment
4.CREATE a balanced life
[Sbraga & O’Donohue (2005) The Sex Addiction Workbook]
Wanting
satisfaction
right away and
not wanting to
wait for more
distant
rewards.
[Sbraga & O’Donohue (2005) The Sex Addiction Workbook]
Sexual self control difficulties are problematic
behaviors that result from four factors:
1.Distorted thoughts
2.Intense emotions
3.Specific situations
4.Physical sexual drive
Avoidance Strategies – avoid the situation altogether;
keep the situation from occurring; the best-case
preventive strategy in the case of an impending high
risk situation.
Control Strategies – for use after already in a high risk
situation; reminding yourself of consequences, use
decision matrix card; generate alternative coping
options.
Escape Strategies – leave the situation;
generate realistic options to remove
you from the high risk situation.
[Sbraga & O’Donohue (2005). The Sex Addiction Workbook]
Impatience: feeling things aren’t happening fast enough.
Argumentativeness: always needing to be right.
Depression: experiencing despair, hopelessness,
overwhelmed.
Self Pity: refusing to accept “what is.”
Arrogance: believing you have it all fixed or solved.
Complacency: forgetting recovery, not repeating affirmations.
Exhaustion: overly tired or poor health.
Dishonesty: telling unnecessary little lies.
Unrealistic Expectations: setting goals that are too high.
Forgetting Gratitude: preoccupied with problems,
forgetting gains.
Difficulty Managing Emotions: over or under-reacting.
Difficulty Managing Stress: not recognizing or reducing
stressors, lack of replenishment.
[Sbraga & O’Donohue (2005). The Sex Addiction Workbook]
Short Term
Losing
Control
Not
Losing
Control
Long Term
Benefits
Costs
Benefits
Tension
relief
Risk
STD
Don’t have
to change
Less
worry
Feel
frustrated
Self
respect
Costs
Multiple
losses
[Sbraga & O’Donohue (2005). The Sex Addiction Workbook]
Boring
Relapse Prevention Worksheet
Comprehensive relapse prevention
plan
Lapse sheets
Relapse fantasy
Relapse rehearsal
Neutral scene
SWITCH
Cycle
SWITCH
6 consequences for the behavior with refrain after
each consequence
SWITCH
Escape scene
Healthy statement
AUTOMATIC
RELAPSE
TRIGGERS THOUGHTS EMOTIONS BEHAVIOR REINFORCERS ACR’S
CHALLENGES
NEGATIVE CONSEQUENCES
1.Self knowledge
2.Comfort and
connection
3.Responsibility and
Discernment
4.Empathy with
emotion
[Katehakis (2010). Erotic Intelligence]
A – Emotional: bodily based feeling
B – Cognitive: socially thoughtful idea
[Katehakis (2010). Erotic Intelligence]
0 – Response shows no empathy.
1 – Response indicates some understanding of the
sense of shock, tone of voice plays an important role.
2 – Response shows a recognition of potential
feelings of abandonment and of anger, and links
them with the experience.
3 – Response adds to level 2 and reflects with deeper
empathy (empathy at the edge of awareness),
sensing feelings that are most frightening or most
painful to experience.
[Lendrum & Syme (2004). Gift of Tears]
1.Physical
2.Material
3.Psychological
4.Significant others
Place of event
Coincidental losses
Successive losses
Nature of event
Social networks
[Lendrum & Syme (2004). Gift of Tears]
Attachment history
Loss history
Age and stage of
griever
Intimacy level
Emotional complexity
Social networks
[Lendrum & Syme (2004). Gift of Tears]
Accept reality of loss
Experience the pain of
grief
Adapt to a world with
loss
Emotionally relocate
the loss and move on
with life
[Lendrum & Syme (2004). Gift of Tears]
1. Idealization as a protection against anger or guilt.
2. Vilification as a protection against pain and
underlying love.
3. Anger as a protection against intimacy and
underlying despair.
4. Depression as a protection against intense feelings.
5. Suicidal thoughts as a fantasy of release from pain
and despair.
Counselor Task: Recognize the protection and its function without colluding
in the denial of the avoided feeling.
(Lendrum & Syme [2004]. Gift of Tears)
Anger and guilt are generally experienced as
the most powerful feelings.
Most likely feelings to fear and repress.
Most likely for our society
to be prone to deny.
Collusive secrecy develops
between the frightened
individual and the denying
community.
(Lendrum & Syme [2004]. Gift of Tears)
Where did the belief originate?
How does the belief impact/affect life
now?
What situations provoke this belief?
What are negative consequences to the
belief?
What are the positive consequence of
continuing this belief? (What am I
getting? What am I avoiding?)
(Dr. Jordan & Margaret Paul, From Conflict to Caring, 1989)
Intrinsic in the human psyche
Compensates for loss
Collection of remembered ties
Active and affective bond that helps people live with loss and
trauma in the present
Private perception of home and family for coping
May coincide or conflict with official records
Who is viewed as being in the family is of therapeutic importance
Staying connected in the mind’s eye
Relational reality is comprised of more than which can be
objectively quantified or physically measured
(Boss [2006]. Loss, Trauma and Resilience: Therapeutic Work With Ambiguous Loss.)
Domains to promote
resilience in family
functioning:
1. Belief systems.
2. Organizational
patterns.
3. Communication
process.
(Boss [2006]. Loss, Trauma and Resilience: Therapeutic Work With Ambiguous Loss.)
Rewriting Negative Scripts
Choosing Path of Stress Hardy or Stressed Out
Empathy
Effective Communication
Acceptance of Self/Others
Connections and Compassion
Dealing Effectively with Mistakes
Building Islands of Competence
Developing Self Discipline & Self Control
Maintaining a Resilient Lifestyle
(Brooks & Goldstein [2004]. The Power of Resilience).
Primary emotions = direct response to a present situation;
adaptive, informative, visceral reactions to interpersonal
reality.
Secondary emotions = secondary reactive responses to the
primary emotion that enables the person to cope with the
primary response; feelings about the feelings.
Instrumental emotions = emotional expression used to
influence others.
Maladaptive primary emotions = response to an
interpersonal reality from the past; adaptive in the past but
not attuned to current realities, which creates confusion.
[Johnson (2005)., Gurman (2010).]
1. Core Mindfulness Skills
“What” skills = learn to
observe describe and
participate, ability to apply
verbal labels, experience
the moment and participating
with attention.
“How” skills = focus on one
thing and being effective.
2. Distress Tolerance Skills
Learn to bear pain skillfully, tolerate and accept distress,
accept one’s current situation, self-soothing and
improving the moment.
(Linehan, 1993)
3. Emotional Regulation Skills
Learning to regulate affect in context of self-validation
a) describe the antecedent event
b) interpretations of the event
c) experiences and sensations
d) express emotions
e) the after-effect
4. Inter-Personal Effectiveness Skills
Skills in producing automatic responses and novel responses.
5. Self-Management Skills
Learn new behavior, and inhibit undesirable behavior.
(Linehan, 1993)
Recognizing your emotions
Overcoming barriers to healthy emotions
Reducing physical vulnerability
Reducing cognitive vulnerability
Increasing positive emotions
Being mindful of emotions without
judgment
Emotion exposure
Doing the opposite of emotional urges
Problem solving
(McKay, Wood & Brantley (2007) The Dialectical Behavior Therapy Skills Workbook)
1. Understand the origin of shame and its function.
2. Differentiate between shame and guilt.
3. Identify the defenses utilized to deny painful
feelings created by the shame.
4. Utilize specific shame reduction
strategies at critical points in the
treatment process.
5. Change negative core beliefs that
reinforce shame.
[Adams & Robinson in Carnes & Adams (ed) 2002. Clinical Management of Sex Addiction]
Diminishing Fear
Reducing Shame
Transforming Anger
Healing Grief
Reclaiming Damaged Dreams
[McDaniel (2008). Ready to Heal]
Birth
Love
Touch
Empathy
Trust
Ability to relax, be
soothed
Body image
Gender
identity
Self esteem
Power
handled well
Sense of owning self
Permission to explore
Social
skill development
masturbation/
fantasy
Loving/sexual relationship
with other.
[Zoldbrod (2005). Sex Smart]
Developmental > Sex is a lifelong growth process with each life
stage offering joys and challenges.
Biological > Includes your body and the physiological dimensions
of sex plus lifestyle dimensions.
Psychological > Involves your thoughts, behaviors and feelings.
Relationship > Consists of (1) couple identity, (2) cooperation and
level of mutual conflict resolution, and (3) intimacy (especially
mutual empathy).
Psychosexual Skills > Includes cognitive, emotional and
behavioral lovemaking skills.
[Metz & McCarthy (2011) Enduring Desire]
hysical
ecreational
esthetic
ntellectual
piritual
motional
exual
1. Develop positive, realistic
sexual expectations.
2. Sensual and sexual options.
3. Communicate sexual desires.
Elements in Your Couple Sexual Style:
 Intimacy
 Eroticism
[McCarthy & McCarthy (2009). Discovering Your Couple Sexual Style]
Beliefs or Standards > What each believes sex and relationships
should be.
Assumptions > What each believes sex and relationships
actually are.
Perceptions > What each notices about sexual behaviors
(selective attention).
Attributions > Causal and responsibility explanations for sexual
experiences (interpretations).
Expectations > Predictions of what will occur during sex
(anticipation, “self fulfilling prophecy”).
[Metz & McCarthy (2011) Enduring Desire]
Change Strategies
Small steps for trust building
Focus on individual behaviors that can increase
self-other relationship satisfaction
Recognize and reinforce partner behaviors that
promote relationship satisfaction
Introduce communication and problem solving
skills
DBT skills
[Compton & Follette in Gurman & Jacobson (2002)
Clinical Handbook of Couple Therapy]
Acceptance Strategies
Empathic joining around the problem
Turning the problem into an “it”
Tolerance building
Self care
[Compton & Follette in Gurman & Jacobson (2002)
Clinical Handbook of Couple Therapy]
Affection (hands on, clothes on interactions)
Sensuality (clothes on, semi-clothed, or nude nongenital pleasuring)
Playfulness (intermixes non-genital and genital
touch)
Erotic non-intercourse (erotic scenarios & techniques)
Intercourse (natural extension of the intimacy /
pleasuring / eroticism process)
[McCarthy & McCarthy (2009). Discovering Your Couple Sexual Style]
Empathy = glue of a good relationship, provides
solid foundation to resolve conflicts.
Paraphrasing > a tool for empathy
Three steps:
1. one partner offers an “I” message
2. the other partner paraphrases (“What I
think I hear”)
3. the partner who offered the original “I”
message appraises empathy (Yes or Not
Yet as to whether empathy is achieved.)
[Metz & McCarthy (2011) Enduring Desire]
Tangible Empathy (Skin Hunger)
1.Affectionate touch > day to day gestures of
closeness such as kissing, hugging, hand
holding to reinforce feelings of intimacy and
connection.
2.Comfort/compassionate touch > consoling
and soothing embrace, reassuring,
supportive and calm touch, non-sexual
touch, often outside of the bedroom.
[Metz & McCarthy (2011) Enduring Desire]
Relaxation: the launch pad for arousal and erotic flow.
Relaxation = calm pleasures.
The psychological importance of relaxation is that it
enhances responsiveness to touch.
Goal of relaxation = body comfort, simple openness to
touch, and enhanced sexual pleasure.
Three dimensions of relaxation that are important
1. physical relaxation
2. psychological comfort
3. feeling open, desired and accepted as a couple.
[Metz & McCarthy (2011) Enduring Desire]
Relaxation: the launch pad for arousal and erotic flow
(continued).
Sets the stage for sexual pleasure/response.
Physiological and psychological relaxation can
ameliorate performance pressure and anxiety.
Visualize relaxation.
Progressive muscle relaxation.
Pelvic muscle relaxation.
Mindful relaxation (use of cognition and imagery).
[Metz & McCarthy (2011) Enduring Desire]
Value sex as a good and positive element in your life.
Commit to sex being satisfying at every age.
Ground your sexual satisfaction on realistic, age-appropriate relationship and
sexual expectations.
Commit to creating your own couple sexual style.
Celebrate each others sexual body; engage in positive physical health
practices.
Respect, value and integrate individual and gender differences.
Value sensual touch for pleasure as well as sexual function.
Accept that sexual and relationship quality varies.
Ensure regular sex and integrate your real life into sex and sex into your real
life.
Personalize sex as playful, spiritual and special.
[Metz & McCarthy (2011) Enduring Desire]
Sex is important at any age.
Maintain a regular sexual connection.
Ground on accurate knowledge.
Define sexuality as mutual pleasure rather than intercourse.
Appreciate the importance of promoting desire as a core
component in healthy sexuality.
Psychosexual skills to build sexual anticipation and
receptivity.
Adopt the mantra of quality couple sexuality: desire,
pleasure, eroticism and satisfaction.
[Metz & McCarthy (2011) Enduring Desire]