Therapist Blog

TELEPSYCHOLOGY SERVICES

COVID-19 has made for uncertain times and left many people feeling anxious, overwhelmed, and sad. Commonly, people have sought therapy to deal with such feelings. But these are not common times. Although the need for mental health services may be more critical than ever, many may be reluctant to seek treatment at this time. Social distancing requirements are an obstacle to meeting face-to-face for psychotherapy sessions. Telehealth services are an option, but these practices are unfamiliar to many, and therefore some may be reluctant to use them. In this article, I will provide information about telehealth services which I hope will help some feel more comfortable using them.

Although the current pandemic has accelerated the practice of providing therapy at a distance via the telephone or a video link, often referred to as telepsychology or teletherapy, this method has been employed for decades. Individuals who were geographically isolated, medically ill, physically disabled, or who lacked transportation or access to childcare were among those who most benefited from this practice. However, it was not until the outbreak of COVID-19 and the stay-at-home order that accompanied it, that this practice became a standard for delivering mental health services. Private insurance companies, as well as Medicare and Medicaid, have supported this trend by issuing more flexible rulings on coverage (Greenbaum, Z., Monitor on Psychology, July – August, 2020).

Telepsychology services increase access to healthcare, but doubts about its effectiveness may exist. Because these practices have been used for quite some time, there is a body of research that demonstrates its effectiveness. Reviews have found that therapy, delivered by video and telephone, are effective in treating a variety of mental health issues, including depression, anxiety, adjustment disorders, (Varker, T., et al., Psychological Services, Vol. 16, No 4, 2019), substance abuse, eating disorders (Slone, N.C., et al., Psychological Services, Vol. 9, No. 3, 2012), and Post Traumatic Stress Disorder in veterans (Turgoose, D., el al., Journal of Telemedicine and Telecare, Vol. 24, No. 9, 2018). In addition to considering veterans, researchers also found that telepsychology practices are effective in other populations, including children and adolescents (Slone, N.C., et al., Psychological Services, Vol. 9, No. 3, 2012). Investigations (Brenes et al., 2010; Mozer et al., 2008, www.apaservices.org/legal/technology/telephone-psychotheraoy) have also revealed the effectiveness of telephone therapy in older adults. This finding is especially important given the increased vulnerability of older adults to COVID-19 and their decreased familiarity and access to videoconferencing.

Additionally, high patient satisfaction rates (Jenkins-Guarnieri, M.A. et al., Telemedicine and e-Health, Vol. 21, No 8, 2015), higher retention rates in telephone therapy over face-to-face therapy, and equivalent outcomes for both approaches. (Mohr, D. JAMA, Vol. 307, No. 21, 2012) have also been reported. A therapeutic connection between therapist and clients has also been established in remote treatment (Stiles-Shields, et al., Journal of Consulting and Clinical Psychology, Vol. 82, No. 2, 2014).

Yes, these are uncertain times that call for flexibility and the ability to adapt. Receiving psychotherapy via telephone or videoconferencing is one modification at everyone’s disposal. Although it may be unfamiliar, at first, it may be worth giving it a try. Not only has it been shown to be effective, it can offer much needed help in managing ordinary life stresses in these extraordinary times.

Mothers and Daughters: Renegotiating the Bond

The fabric of the mother-daughter relationship is intricately woven. Although most women value this bond, frequently, they have difficulty understanding and maintaining it. In this article, I will identify the tasks confronting daughters at mid-life as they relate to their mothers. I’ll also discuss the process of renegotiating the mother-daughter bond, as well as strategies that may improve the relationship during this life stage.

The mother-daughter relationship is important in shaping a woman’s identity as a female, wife, lover, mother, friend, and professional. The influence that mothers have over their daughters comes about because, as a daughter develops, she “takes in” her mother and then carries her voice internally. Even if a mother is no longer living, she still can exert a strong influence. As a woman matures, she must decide the extent to which she wants to adhere to the attitudes and beliefs that she absorbed from her mother versus develop and abide by new and different ones.

Identifying the values and messages received from a mother is an important first step in understanding the tie that a woman has with her mother. Here are some of the questions that a woman might ask to better understand her mother’s influence.

What messages did I receive from my mother about being a woman, mother, wife, lover, professional?
What role did I play in my family?
What were my mother’s values and how did she convey them within the family?

The clearer a woman is about the messages that she receive, the more empowered she can feel and less like a prisoner of her childhood. She will be better able to distinguish factors that played out in her past, but which do not necessarily need to operate in her current life. Potentially, she can be more in charge of her life.

This work is important for all women. But for women who had a difficult or perhaps traumatic childhood relationship with their mother, the work is even more crucial, because their past may be having a significant adverse impact on current relationships. In such instances, often there is anger, and it may take work to get to the point of saying, “I deserved better.” A woman is entitled to feel whatever feelings she may have, However, she is not entitled to continue to blame her mother for her current unhappiness. A mother is responsible for how she treated her daughter as a child, but a daughter is responsible for what she does about it as an adult. Although it may be hard for a daughter to give up the assumption that she can change her mother, and that some day her mother will love her the way she wants to be loved, it is imperative. A daughter can’t change her mother, however, she still may ask the following questions:

How would I have liked my mother to mother me?
How do I wish she could change?

It is important for all women to recognize the feelings that they experienced growing up and not deny or forget them. These feelings are part of a woman’s identity, history, and strength. For some, this process may involve mourning the childhood that never was. Forgiveness may not be suitable and love is not required. Other women may recall their childhood with fond memories. Nevertheless, they may recognize that they wish to not behave in accord with the spoken or unspoken dictates of their mother.

Whatever a woman’s past relationship with her mother, it can be extremely helpful for a woman to get to know and understand her mother’s past and learn her life story. Learning the context in which her mother operated may provide insight into the messages that a mother imparted to her daughter. Asking questions also conveys a desire for a deeper connection. Additionally, it is a major step in equalizing the relationship. In Goodbye Mother, Hello Woman, Marilyn Boynton emphasizes how important it is for women in their 30s and 40s to equalize their relationship with their mother. She says that this process entails a woman coming to know her mother as a woman with all her limitations and vulnerabilities, rather than solely as a mother who is responsible for nurturing her daughter. As an equal, a woman is better able to define what she thinks and believes, and how she wants to behave, rather than feel compelled to adhere to her mother’s ways of being. In turn, a daughter is more likely to feel empowered and more self reliant on herself for nurturance, soothing, and self-care.

Myths About Sex

Myths about sexuality abound. But in this article, I would like to focus on the commonly held view that when couples stop having sex, it is usually because the woman has lost interest or desire. To the contrary, most often, in such circumstances, the man decides to stop sexual intimacy; and he makes this decision unilaterally and communicates it non-verbally. This notion reflects cultural biases for both sexes that are related to age, as well as gender.

For women of all ages, there is the false belief that they are not interested in sex. Mature women face the added stigma of being perceived as withered and past their sexual prime. In truth, women of all ages are sexual, and increasingly older women are recognizing their vibrancy in many areas of their lives and are appreciating what they can offer. Men also encounter cultural biases that perpetuate this myth. Specifically, men’s sexuality is perceived as a sole function of their biological make-up which creates the impression that they are always ready for sex. Not only does this idea put a tremendous amount of pressure on men, it also interferes with recognizing the complexity of their sexuality. As with women, men’s sexuality can be impacted by emotions, self-esteem, and body image. Not infrequently, men link their masculinity with their ability to perform sexually. Whereas a positive view of masculinity can enhance sexual desire, difficulties with erections, intercourse, and orgasm can impede desire as feelings of frustration and shame take over. In turn, men frequently curtail sexual relations. Although a man’s loss of confidence can occur at any age, it often occurs with age as testosterone declines, erections vary, and ejaculations are delayed. One out of three couples stop being sexual by sixty-five years old; and two out of three couples stop physical intimacy by seventy-five years of age.

Challenging faulty, but commonly held, beliefs about sex is difficult because these ideas are deeply engrained. However, doing so is important because it can not only minimize pressure on the individual and tension in the relationship, but it also can add to the richness and depth of the experience.

Breaking a Stalemate: Resolving Conflict in Couple Relationships

How a couple resolves important issues when each partner holds a strongly different perspective is a key component of a successful relationship. Without this skill, at best, couples find themselves going around in circles and feeling frustrated by the stalemate, rather than feeling like members of the same team who share common goals and each other’s best interest at heart. Over time, bitterness can build.

Quite often, the feeling of being opponents results from a mind-set that is focused on the end result. Did I get what I wanted? Did I convince my partner that my way is the right way? Did I win the argument? Underlying this approach is a belief that justice needs to be served. Unfortunately, to arrive at this perceived sense of justice, partners, all too often, engage in destructive behaviors, such as name calling, criticizing, and diminishing the other. It’s as if, the end justifies the means.

When a couple finds themselves relying on an adversarial approach to solving conflicts, they might want to consider a change in course that puts more emphasis on the process of negotiating a solution, rather than the end result. Specifically, attending to the process might involve each partner articulating their partner’s perspective, rather than repeating their own point of view once again. Doing so, requires listening to the other, something most people deeply desire. It is also important that each partner be willing to take the risk of expressing their vulnerability.

As the couple listens to each other and talks honestly, the core concern of each partner is likely to manifest. Reacting to a partner’s concerns with respect, kindness, and compassion is critical. It leaves a partner feeling valued, despite differing points of view. This approach offers the best chance of finding a compromise in which each partner’s needs are met. Although this work can be scary, it is the true work of a relationship and offers the opportunity to deepen and strengthen the bond.

The Power of Menopause

I recently attended a conference, sponsored by the American Association of Sexuality Educators, Counselors, and Therapists (AASECT). The conference, entitled, ‘Bridging the Divide: Shedding Light on the Taboos and Pleasures of Sexuality,’ offered a wide variety of workshops. One of the workshops that I attended was Debra Wickman’s and Saida Desilets’ presentation, ‘A New Look at Menopause: Myths, Truth, and Power of Mature Pleasure.’ I’d like to share some of the idea offered in this presentation, along with some of my own thoughts on this topic.

The lecture began with a list of myths, associated with menopause, including:

Mature women are not interested in sex
Sexy needs to look young
Sex stops at menopause
Sex is painful after menopause
Pleasure is only for the young
Mature women are proper and don’t like to have fun

For many women, these commonly held views contribute to a dread of menopause, create shame about sexuality, and negate vitality. How ironic that mature women, abundant with wisdom garnered from years of lived experiences, are cast as withered and diminished! Yes, certainly there are changes that take place as women age, and, as necessary, they should be evaluated by a medical provider to insure optimal health and well-being. These changes can impact psychic and emotional states, as well as sexual functioning. But the mind-body link is bi-directional. That is, in the same way that bodily changes can affect women emotionally and psychologically, women’s perceptions and attitudes about themselves, aging, and menopause, and the emotions that they evoke, can also impact bodily sensations and experiences.

In “The Wisdom of Menopause,” Christine Northrup, talks about menopause as an opportunity to “come home to oneself.” Facing bodily changes and major life shifts, such as the loss of a partner or an empty nest, women can feel empty and depleted. It is not uncommon for some women to become depressed, anxious, or turn to food, alcohol, or drugs to numb the pain. But alternatively, women can use their emotions to guide them through this transition and, in the process, discover their strength and power.

For women to come into their own requires self-acceptance and an acknowledgement of worth at any age. But accomplishing this goal as women age can be especially challenging because of the rampant ageism that they confront; and even more daunting because of well-established cultural taboos which dictate that sensual pleasure is not the domain of older women. Additionally, to the extent that women define their sexuality in accord with the traditional view that sex is a partner experience, the more likely they are to perceive their sexuality as compromised as they age, given that oftentimes, women do not have an available partner due to divorce or to their partner’s death or chronic illness.

According to Saida Desilets, in order for mature women to own their sexuality during menopause, they need to re-examine it; and that begins by asking, ‘What is the deeper meaning of sexuality?’ Most fundamentally, a revised orientation recognizes women’s inherent value and intuitive knowledge about their bodies, psyches, and sensations. Also essential is a definition of sex that considers it a reflection of who one is, not what one does. If women are engaging in partner sex that may translate into not viewing sex as a sport that focuses on performance and score keeping regarding frequency. Instead, women may need to turn their attention to reassessing the status of their relationship. Such consideration is important because, for many women, a close relationship is critical for feeling sexually drawn to a partner. Honest and open discussions between partners about sexual changes and what modifications may better accommodate those changes may be a good place to start. Others, may need to find ways to reconnect with their partner emotionally, particularly if they drifted apart to focus on raising children and advancing careers.

A revised view of sexuality also calls for women to view sexuality as a partnership with oneself. Although this shift in perspective is more obvious for women without partners, it is essential for all women. It requires becoming increasingly comfortable with including different forms of pleasure into one’s repertoire. For some women, it may include meditation, caring for a beloved pet, daydreaming, or developing a deeper connection with nature that comes with taking walks, birdwatching, or gardening. While these activities may awaken vitality because of their calming effect, other activities, such as achieving a goal, exercising, deep breathing, eating good food, and shopping, may be equally enlivening because of their stimulating nature. Although none of these activities are sexual per se, they can heighten sensual awareness, and in turn, trigger what Desilets refers to as “micro-moments of pleasure.” From this perspective, engaging in these activities champions the idea that there is no expiration date on pleasure. Pleasure is ageless and as such, aging and menopause are part of an evolutionary process that entails blossoming, rather than shutting down.

Cancer and Sex: Intimacy, Romance, and Love After Diagnosis and Treatment

Guntpalli, S.R. & Karnich. (2017). Sex and Cancer: Intimacy, Romance, and Love After Diagnosis and Treatment. London: Rowman & Littlefield.

A cancer diagnosis and the process of treating it often have a profound impact on many aspects of a person’s life. In Cancer and Sex, Saketh Guntupalli and Maryann Karinch, focus on breast and gynecologic cancers and how they affect women’s sexual functioning and, in turn, color and cloud their intimate relationships. In disclosing that Dr. Guntupalli is Maryann Karinch’s gynecologic oncologist, the authors convey their personal investment in writing this book and their hope that they can help women living with these cancers.

The second half of this book provides many practical solutions, based on input from patients, as well as specialists. However, this book is more than a practical guide. To help readers arrive at optimal solutions, the authors explain why cancers and their treatments affect sexual functioning. They include exploration of the physical changes induced by these diseases and their treatments, the mechanics of sex, and the role of stress.

The information in this book is comprehensive and useful. But perhaps, even more critical is the hope that Guntupalli and Karinch offer women. They offer reassurance to women that they are not alone in encountering disruptions in their intimate life after a cancer diagnosis and treatment. And by suggesting a broader definition of sexual intimacy that is not limited to intercourse, the authors encourage their readers to be creative, open to a variety of pleasures, and to the possibility that they may arrive at a level of intimacy with their partner that exceeds the closeness they experiences prior to their cancer diagnosis.

Can’t Get You Off of My Mind

Oh, it’s been such a long, long time
Looks like I’d get you off my mind
Oh, but I can’t
Just the thought of you
Turns my whole world misty blue

So begins the song, ‘Misty Blue,’ written by Bob Montgomery, and recorded by several artists, beginning in 1966. The words so aptly capture the struggle that many encounter in trying to move on after a relationship ends. This difficulty can be especially perplexing when an ex-partner was not a good fit or behaved in problematic ways. To complicate matters, people are often critical of themselves for thinking about an ex-partner and worried they will not be able to arrive at a more joyful place in their life.

Making peace with the end of a relationship can begin by acknowledging that preoccupations with a former partner cause mental and emotional anguish and do not warrant self-criticism. It can also help to consider the reason behind the trouble letting go of a relationship. More specifically, ask whether it is the loss of the individual or whether it is what the ex-partner represents that is at the root of the struggle to let go. Considering these questions creates a broader focus that can lead to feeling empowered, rather than out of control. Although one cannot change your ex-partner’s behavior, how either of you behaved in the relationship, or the fact that the relationship ended, a person can change their understanding of them self.

A self-reflective posture might begin with identifying what aspect of an ex-partner’s behavior is captivating. For example, someone could be drawn to another for their sense of adventure and willingness to take risks. In this case, being with that person could allow indulgence of the risk aversive part of oneself. Furthermore, their absence could engender the feeling of being depleted or compromised. In short, the inability to rid an ex-partner from one’s thought might serve to fill a void or be a manifestation of some disowned part of one’s personality. If this is the case, perhaps, a person could consider reclaiming this underdeveloped part of them self and cultivate a greater sense of adventure.

The end of a relationship might also represent the loss of good times, as well as future dreams and expectations. Sometimes, these losses are actually more significant than the loss of the actual ex-partner. Either way, it is important to grieve these losses and to not allow excessive thoughts of a former partner substitute for feeling the sadness and pain.

Pursuing a path of self-discovery not only has the potential to diminish the anguish of feeling overtaken by thoughts of an ex-partner, it also provides an opportunity to develop a richer, more well-rounded self-view and greater access to emotions. A stronger, wiser sense of oneself will not only feel empowering, it also would be a great way to begin a new relationship, if one choses to do so.

Is Your Spouse Your Soulmate?

Is your spouse your best friend or soulmate?
Is such a connection essential for a good marriage?

Before considering these questions, it is important to recognize that they tap into relatively new notions about the marital relationship. In Marriage, A History (2006), Stephanie Coontz points out that although people married for love in past generations, the need for financial, social, and personal security played a more significant role in the choice of a partner than it does today. As such, partnerships are less likely to be cemented solely on the basis of love. As gender based roles and expectations began to shift in the 1960s and 1970s toward greater equality, many placed a higher value on finding a partner who is a soulmate. This greater emphasis warrants further attention, not only for those looking for new love, but also for those who embarked upon relationships before ideas about companionship in marriage underwent transformation.

In Modern Romance (2015), Aziz Ansari, a writer, comedian, and actor, together with Eric Klinenberg, a sociologist, contend that the importance placed on finding a soulmate in this day and age creates an added pressure. However, in citing the lower incidence of divorce associated with marrying a soulmate, they suggest that the struggle is worth the effort. Although perhaps true, according to John Helliwell, whose research was cited in a recent article in the New York Times (October 15, 2017), such a connection may be beneficial, but not necessary. Specifically, married individuals reported a higher degree of life satisfaction than their non-married counterparts, even when their lives were well populated with friendships outside of their marriage. But, when married individuals identified their spouse as their closest friend, the level of satisfaction that they reported doubled. In short, Helliwell’s findings indicate that spouse who is also a best friend provides an added perk, but not an essential one.

Amir Levine, a psychiatrist and neuroscientist, takes into account sexual attraction when discussing attachment within partnerships in his book Attached (2010). It is this component that allows spouses to experience physical closeness in ways that are taboo in family relationships. Although sexual attraction tends to be strong in the beginning phase of relationships, it is likely to drop off as partners become increasingly familiar and committed over time. Instead, what becomes more prominent in a feeling of security which, according to Levine, is the component that allows an individual to describe a spouse as a friend. This sense of security is rooted in the knowledge that a partner can be trusted, and is available, reliable, and responsive. This knowledge about a partner creates a feeling of safety that serves as the foundation to better engage with the world, manage the ups and downs of everyday life, dream of possibilities, and bring them into being.

Moving from feeling titillated by a partner to feeling secure and safe with them, does not mean that a good sexual connection needs to fall by the wayside. In fact, too much emphasis on being ‘best friends’ may not be ideal. Not only can it be a sign of avoiding conflict (Caruso,2014), a healthy dose of aggression, along with feelings of longing, can actually fuel sexual desire (Caruso, 2014; Clulow & Boerma, 2009; Kernberg, 1995). This dynamic can play out as couples try to work out their conflicts and end up gaining a better understanding of their partner and, in turn, feeling emotionally and physically closer. Increasingly, the link between attachment and sexuality in long term relationships is being explored (Caruso, 2011; Clulow, 2009; Diamond, Blatt, and Lichtenberg, 2007); and there is support for the idea that individuals who are psychologically healthier in relating to others are better able to incorporate both a friendship bond and a sexual connection into their partnership (Caruso, 2014; Eagle, 2007). Oftentimes, there is a reciprocal effect when couples integrate these two components in to their relationship, namely, emotional closeness fuels sexual intimacy and physical closeness renews attachment.

Rather than asking a question about being best friends with a spouse, perhaps a better question would be asking whether you and your partner are able to balance your needs for safety and security with your longings for sexual intimacy. Once you’ve given this question some thought, you might want to consider getting your partner’s perspective.

Adult Daughters and Their Mothers

Sigmund Freud posed the question “What do women want?” Although I make no claim that I can answer that question for all women, I have some ideas, based on my work with them. Women want to feel fully alive and creative. They want to have loving connections, but at the same time, to function as independent, whole, unique individuals. Women want to feel comfortable with their longings and vulnerabilities, as well as with their knowledge and power. They want the courage and confidence to be themselves and enjoy others as equals, without being driven by an overwhelming need to please or rebel against them. And women want to be recognized for all of these complexities. Becoming this woman is a life long journey and there are many routes to achieve this goal.

One path involves re-negotiating the mother-daughter relationship. In this article I would like to share some thoughts about this process. For many women, their relationship with their mother is encumbered by feelings that are restrictive or by interactions that bind in unproductive, unhealthy ways. These dynamics can interfere with a woman developing her full potential. Oftentimes, for women to reclaim lost or dormant parts of themselves, they need to explore their past relationship with their mother. This may mean calling forth painful, as well as pleasant memories, of their mother, and examining negative and positive messages that they received from her. As women go through this review, they can understand more fully who they are and how they came to be in terms of their relationship with their mother. Many women come to realize that they are currently relating to their mother in the same ways that they related to her when they were girls; and that this pattern feels inhibiting, rather than growth producing.

As Boynton and Deli (1995) point out in Goodbye Mother Hello Woman, a key factor in whether a woman can change how she relates to her mother is her ability to shift her perception of her mother. Specifically, adult daughters need to view their mothers as “equal,” rather than as “mother.” Typically, women are not ready to equalize the power in their relationship with their mothers until they are in their 30s and 40s. This rethinking means releasing mother from the job of parenting and recognizing that she is a person with all the limitations that go along with being a person and that she will never be a perfect mother. Equalizing the relationship also involves the task of daughters learning to mother themselves, rather than relying on their mothers. Such self care involves a woman being loving, loyal, kind, compassionate, forgiving, and generous to herself.

Although the 30s and 40s are a time for reassessing one’s life, this process is life long and can be done whether or not one’s mother is still living. It is a soul searching process that offers women an opportunity to know themselves more deeply and to live more fully.

Health Benefits of Sex

It may seem fairly obvious that a healthy, satisfying sexual relationship can result in a stronger and more fulfilling connection with a partner. Less obvious are the potential health benefits that sexual intimacy affords. I will identify some of them which several articles that I reviewed have cited.

1. Boosts the immune system

A study from Wilkes University in Pennsylvania revealed a boost in the immune system of individuals having sex one to two times a week, compared to those not having sex. A 30% increase in immunoglobulin (IgA) proteins, an infection fighting antibody, accounted for this health advantage.

2. Relieves stress
3. Enhances mood
4. Promotes sleep

The feeling of well-being that comes from a satisfying sexual relationship not only has a psychological basis, it is also rooted in physiology. Endorphins and oxytocin are released during sex. These hormones activate the brain’s pleasure centers which, according to Laura Berman, Ph.D., create feelings of intimacy and relaxation which can ward off anxiety and depression. Additionally, the surge of oxytocin that follows sex may result in falling asleep more quickly.

5. Maintains heart’s strength
Dr. Mamet Oz, a specialist in cardiology, says that not only does sex provide a good work-out, it can also protect the heart. He cites a study in the Journal of Sex and Marital Therapy, which found that people who had sex an average of twelve times per month had greater heart rate variability. This increase in variability may result in a lower risk of developing heart disease.

6. Relieves pain
According to Barry Komisaruk, a professor at Rutgers University, “orgasms can block pain.” After an orgasm oxytocin is secreted, and in turn, endorphins, a substance that resembles morphine, are released into the system. Research has reported that this release resulted in relief in leg and back pain, menstrual cramps, headaches, and arthritic pain.