High Risk Situations

High Risk Situations.

The final component to review in the first box of the acting out cycle is a high risk situation. Of all the therapy work in treating sexual compulsivity, this is the easiest component to identify, the easiest component to create prevention plans, and the least successful at reducing sexual compulsivity. Don’t get me wrong; it is very important, but between thoughts/thinking errors, feeling triggers, and high risk situations, clarifying and reducing high risk situations simply require structural interventions that can easily be circumvented if the other issues aren’t addressed.

First, let’s define a high-risk situation. It is the setting in which an acting out behavior occurs. Assume you take a snap shot of the behavior. In that snap shot, you have the setting that can easily be described. Based on the following snapshots, you can start to see how easy it is to identify a high risk situation.

I was home alone.

I was surfing the internet for work.

I was taking a walk in the park.

I was chatting with friends at the bar.

I drove by the __________ (fill in the blank, it could be bar, strip club, book store, park, etc).

I had a fight with my partner.

I was fired.

I was just got a raise/made a big sale.

I stopped at the gas station and they had magazines.

I saw the inserts in the newspaper.

I saw something on TV.

Snap shots simply describe the setting. As you picture your behavior, simply describe what is going on in the environment. The classic questions of Who, What, Where, When, and How are the tools for identifying high risk situations.

What where you doing right before?

What was going on?

Where were you?

Who was with you?

What time is it?

When did it happen?

How did it happen?

Second, developing a prevention plan is simply a matter of developing a structural intervention; a structural intervention is something that gets in the way or removes the high risk situation. So, for example, if you’re surfing the internet, you can identify an intervention such as an internet blocker, or an internet tracker, or have someone watching over you, or don’t have your house connected to the internet. These are all interventions to reduce the possibility of accessing pornography online. These types of interventions are simple to identify and are a matter of brainstorming ideas. In my opinion this is a necessary but not sufficient intervention in treating sexual compulsivity.

The difficulty lies in the fact that the interventions can be easily circumvented. Take the online pornography use. Even if you put all of those interventions in place, it is possible to use the cell phone to access pornography. You might have access to the internet at work. Thus, all the tools at your home become ineffective and require additional structural interventions. Or, with the amount of explicit material in our culture some people struggle with underwear or swim suit magazines as a high risk situation. Thus all of the internet interventions fail to address the reality of access to explicit media.

Feeling Triggers

This post continues the conversation expanding the acting out cycle, and in particular the top box. As you can see from the previous posts, I place a significant amount of emphasis on thoughts and the associated thinking errors that we use to understand our world. On an equal level, it is important to understand our behavior, including when you engage in sexually compulsive behaviors in response to the feelings. It is my opinion that every acting out encounter has an associated thinking error, feeling trigger and high risk situation (which will be reviewed in the next post). The following list of feelings is far from exhaustive; it is provided to help you begin identifying the feelings associated with an acting out event. The key is that each person is different; you need to identify the feelings associated with your unhealthy behavior. The feeling triggers vary from person to person. I listed some feelings and asked a few corresponding questions for you to consider. From the 12-step tradition, there is an acronym “HALT” that highlights four feelings (hungry, angry, lonely, tired) that are often associated with compulsive/addictive behaviors. It seems appropriate to start there.

Hungry: When was the last time you consumed food/nutrition/water?

Angry: How do you express anger? How intense is your anger? Who/what are you angry about? Are you angry and trying to hurt someone?

Lonely: Who do you connect with? How do you connect with someone in a way other than sex? When was the last time you experienced this sense of connection? Are you comfortable being by yourself? What are your thoughts when you are alone? Am I manipulating this person to spend time with me? To like me?

Tired: When was the last time you rested/slept? How adequate is the amount of sleep? How long has your day been? What kind of tiredness are you experiencing (i.e., physical tiredness, emotional)?

Depression: Depression exists on a continuum from extreme clinical depression (i.e., suicidal) to sadness associated with daily living. What is your level of depression when you are acting out? If you are on medications for depression, are these medications current? And taken at the prescribed level? If you’re not on meds, should you be evaluated for medications? What is relationship between your acting out behaviors and your attempt to feel better, connected, or appreciated?

Manic: Surprisingly, people will act out in response to feeling good. Similar to depression, mania can range from extreme manic where people stay up for days, and often require hospitalization to feeling good for an accomplishment and seeking a reward. What accomplishment did you just finish? What are two or three positive things that happened today? recently?

Anxiety: How worried, nervous or preoccupied are you? What is the focus of the worry? Does the behavior increase or decrease the worry/anxiety?

Shame: How might your sexual behavior be an attempt to cope with shame? How might your sexual behavior reinforce your shaming messages? What are the sources of shame?

Fear: How is fear associated with your behavior? Are there payoffs associated with risky behavior? To what degree are you being intimidated/forced into behaviors?

Guilt: How is guilt associated with your sexual behavior?

Horny/Aroused: What are healthy sexual outlets? How is this behavior healthy/unhealthy? Are these behaviors congruent with your values?

Again, these are simply a list to start with. I'm hoping that you'll be able to take this list to jumpstart the questions to ask regarding other feelings that may be present.

More on my therapeutic approach

The past few days have been a light work load. As I result, I’ve had time to read and reflect. I am currently reading a book by Irvin Yalom, The Gift of Therapy: a letter to a new generation of therapists which serves as the catalyst for this post. (In my studies, Irv Yalom is considered a “classic.” His work on group theory and therapy was a must read.)

The three values that shape my life and work are healing, courage and freedom. If you review the first page of the sexualhealthinsittute.org website, these three words are integrated into a mission statement. I try to use these values that shape all my relationships in my personal life as well. I thought it might be helpful to expand on these values as they relate to my work with clients.

Healing.

Nearly every client I work with struggles with a sense of brokenness, impairment in their ability to relate to others, struggle to get by in life, and otherwise simply connect with their own internal power. In some clients, the pain and brokenness is palpable: you see it in their face, the way they walk, talk, and the way they look at others in the world. My goal is to provide a space where they can experience as sense of relief from their pain and brokenness, if even for one hour. While the sources of the pain are varied, the amazing consistent struggle is that every client is struggling to experience a sense of healing. Healing might be mean relief, or awareness, or even insight as to why pain might be there. While I’d like to believe that the pain and brokenness will go away, in some cases the pain and brokenness might be permanent. Such might be the case of a loss, illness, or death; or as some theorists hold, experiencing pain and brokenness is simply a part of being human. When the pain cannot be erased, I’m committed to walking part of the journey together. Sometimes simply walking with another person is enough to ameliorate the feeling of separateness and isolation that accompanies the pain and brokenness. Sometimes the shared experience can transform the pain and brokenness into an awakening that is startling.

Courage.

Too often people minimize their own courageous behaviors. Our culture, through the movies and media, has reduced courage to acts of bravery on the battlefield. Unless you are facing a life or death situation, courage does not exist. This portrayal minimizes the infinite expressions of courage that I see in my work. For me, courage is the commitment to act in the face of fear. Courage is expressed by simply showing up in my office. Courage is expressed by disclosing to your partner the sexual compulsive behavior. Courage is expressed when a sex offender sits before his victim apologizing for his crime and asking for forgiveness. Courage is in the victim of a sex offender who confronts their abuser determined not to let the offender’s behavior destroy their life. Courage is in the individual who profoundly accepts an insight into reality; whether it is accepting the thought “I’m gay,” I’m positive,” or the addict who says “I have a problem.” Courage is when a client takes a moment where he or she is confronted and says “your right.” Courage is when a client accepts an awareness of how a particularly thinking error has shaped his/her life. In the many years I’ve been doing this work, I’m amazed at the number and types of courageous expression. And, in my own personal life, courage is when I confront a client out of a commitment to healing, even if I’m fearful the client will bolt and terminate therapy. As therapists, were taught that we’re supposed to help our clients feel better. I know I’ve created temporary pain for a client by uncovering and reflecting a painful reality. My commitment in my work is to be as open, honest, loving and courageous as possible to facilitate healing. And yes, that may mean sharing things with you that you don’t want to hear. Courage is when we struggle through the pain. That is when healing occurs.

Freedom.

Our society often equates freedom with free will. We often take a narcissistic view that freedom allows me to do what I want; and more often than not, freedom is framed as “You can’t tell me what to do.” In essence, unless I get my way, or what I want, I’m not experiencing freedom. The current rhetoric in American Politics is based on this approach. Instead, in my work, I emphasize freedom as a profound acceptance of what is. With this acceptance there is the ability to generate new possibilities to act. Hence, truth is the prerequisite for freedom. (This perhaps helps the reader understand the emphasis on confronting thinking errors.) From the profound acceptance of truth/reality, the client is better able to make choices that reflect a positive goal in their life. Two examples come to mind. First, profoundly accepting that you are manipulating others around your chemical or sexual behavior allows you to stop manipulating others. If you aren’t accepting this reality, your denial prevents you from being free. A second example is a person who profoundly accepts their same-sex sexual attraction. Avoiding this reality creates shame, depression, avoidance, and a diminished sense of self. Acceptance allows the opportunity for the individual to make free choices about what to do next. Why the emphasis of a profound acceptance? Too many times, both in my personal life and in my professional work, I see situations where someone says they accept “what is” only for the thinking errors to change to type of avoidance. Hence, for me a profound acceptance is acceptance that creates a transformation. And honestly, this type of acceptance is incremental and a process rather than an off/off switch. Therapy is the process of radical acceptance of “what is” and therefore allowing freedom. When this experience occurs, the experience is transforming, both for the individual and for me as a witness to their courage and freedom.

The three values shape my work. It is the therapeutic relationship that I commit to living these values with integrity. Now, I’m human, and I know I make mistakes. I welcome opportunities for my own growth in this process as well. While it may be your therapy hour, I know I’m touched by your transformation.

Thinking Errors

This concept has a variety of different names depending on the theoretical orientation of the clinician. You might have heard terms such as “psychological” defenses,” “cognitive distortions,” or even “stinkin’ thinkin.’” All of these labels refer to a behavior pattern based on an unhealthy thinking process. As illustrated in the compulsive cycle, and in the power of thought discussion, our thoughts shape our reality; we act based on these thoughts. Too many times I’ve heard the comment that “I didn’t know what I was thinking,” “How come I couldn’t stop myself, because I knew I shouldn’t be doing this.” My response is to affirm that the acting out cycle is sophisticated; people will act on thoughts they may not fully realize that are present. The speed by which we experience various thoughts is simply too fast for us to fully understand all of the thoughts upon which we act. Some of these thoughts might be suppressed and/or repressed; other thoughts might be so automatic that we simply don’t recognize their power. The purpose of therapy is to help the client reveal the unhealthy thinking patterns in one’s life.

In the Broadway Musical, “Wicked” at one point the heroine enters the City of Oz. The citizens of Oz wore green colored glasses. After a while, the citizens “forgot” they were wearing these green glasses, and they simply concluded that everything was in fact “green.” This was why Oz appeared to be the Emerald city. In a similar way, our thinking pattern colors our view of life. These patterns are so pervasive, we simply don’t realize they are present. Sometimes the assumptions have a limited impact in our life; other times, these thinking patterns are so unhealthy they result in pain and negative consequences in our life or the lives of others around us. Often, these thinking errors are attempts to minimize pain, justify our behaviors, or otherwise help us avoid reality. As you increase your initial awareness of thinking errors, the variety and number of thinking errors will surprise you. You’ll be surprised at the prevalence of these thoughts, and how we use these thoughts to justify almost all behavior, including speeding, avoiding tasks/responsibilities and justification for harming others.

As mentioned in the previous topic “The Power of Thought,” I hold that our thoughts and feelings are intertwined, with the feelings arising from the thoughts. Thus, thinking errors contribute to our experience of feelings. Notice the example of the missing car in the previous post. You can experience a range of emotions simply by being aware of the thoughts. The feelings then, can facilitate increased thinking errors. Consider the following example:

I think my boss is out to get me. So, when we talk, I’m verbally defensive and avoidant. When my boss confronts me, I feel even worse and disconnected. I then feel angry because they are also hurting me. After the conflict, I feel alone. Then, the loneliness is used to justify sexual acting out.

This is but one example of the interplay from the thoughts/feelings.

Consider an alternative thought instead. My boss is simply doing her job. She was put upon by the corporate management to hold people accountable. So, instead of her being “out to get me,” she is simply frustrated and short with me.

In this second example, my feelings and subsequent behaviors will be completely different. The key, however, is to be aware of the thinking error that first occurs: “My boss is out to get me.” As you go through the examples below, a sense of persecution is one type of thinking error. We use this thinking error to justify many of our behaviors.

Now, I’ve listed a summary of thinking errors. In NO WAY ARE THESE EXHAUSTIVE. The mind is an amazingly creative source of never ending thinking errors. These examples are simply provided to represent the primary types of thinking errors and to help you become aware of the various patterns in your life.

Justification: making excuses for our behaviors.

I deserve...

It happened to me and no one cared.

I was angry.

It’s what I would want

Repression: forgetting things that are uncomfortable.

I didn’t know

Seemingly unexplainable naivete,

memory lapse

lack of awareness of one's own situation and condition

Displacement/Blaming: telling ourselves that someone else or something else is responsible for our actions.

If she/he had not done what she/he did

She/he started it.

She had a reputation.

He didn’t tell me to stop.

She’s a tease so it was as much her fault.

My partner wasn’t interested in sex

Victimization: Using a one’s own history as a justification for behavior.

I’m the victim in this case. There is nothing I could do.

“I had no other choice.

It happened to me when I was his age.

I never get what I want.

No one was there for me.

Minimization: playing down the nature of the discretion or the harm.

It’s only this one time.

No harm, no foul.

I was just trying to make her feel better.

Things just got out of hand.

I’ll only do it one last time.

It’s just pictures, no one was hurt.

Denial: Refusal to accept external reality because it is too threatening;

I didn’t know it was against the law.

I won’t get caught.

I didn’t think my partner would care.

Catastrophizing/Exaggerating: exaggerating the reasons for or the consequences of our actions.

If I hadn’t done it something awful would have happened.

Over-Generalization: use of terms such as “everybody”, “never”, “always”, “no one” to increase the argument for our behavior.

Everybody else seems to do it.

I am never wrong.

I know others did it so I figured it would be okay.

You always blame me.

Misinterpretation: deliberately taking the comments or actions of another out of the context

I just did what you told me to do

Escaping/ Fantasy: Tendency to retreat into fantasy in order to resolve inner and outer conflicts

I hoped it would make me feel better

I didn’t want this to happen.

Projection. Shifting one's unacceptable thoughts, feelings and impulses onto someone else so as to blame or attack them.

prejudice,

severe jealousy,

hypervigilance to external danger,

Intellectualization: Unacceptable denial or avoidance of emotions by focusing on the intellectual aspects. In my treatment approach, this is a recognized danger.

Reaction Formation:

I’m out of work, but I need to buy this because it is so cheap. Look at all the money I save.

This defense can work effectively in the short term, but will eventually fails.

Power of Thought

I place a lot of emphasis in my treatment approach in helping the client understand their thinking patterns. As you can see from the model, the application of this emphasis is the concept “thinking errors.” I will return to this in a future blog. To do so, I need to first discuss the power of thought. I use three books as resources for the background on how powerful our thoughts are. If you want to read more, please read Slowing Down to the Speed of Life by Carlson and Bailey, Flow: The Psychology of Optimal Experience by Mihaly Csikszentmihalyi (yeah, that’s his name, he’s Czech), and Blink: The Power of Thinking Without Thinking by Malcom Gladwell.

For the sake of the conversation, I need to reduce and simplify the implication of their theories. To fully understand the material, I recommend additional discussion and review of the material. In essence, all awareness and knowledge are based on perceptions and through the analysis of these perceptions we arrive at a thought that guides are feelings, choices and behaviors. This is a bit different from how many people think. Often, we hold that feelings come first. Yet, consider the following scenarios.

1) You parked your car on the street. As you return from the store, you find that your car is gone. The awareness is that your car is missing. The feelings are derived from that conclusions based on various thoughts. Depending on additional thoughts, your feelings might be different, so consider the following.

a. You’ve been reading the news paper about how many cars have been stolen in the neighborhood. The thought that percolates to your awareness is that “My car is stolen” and you’ll probably have feelings associated with that thought, such as feeling violated and/or angry.

b. As an alternative, you notice a “No parking sign” during high traffic/rush hours. And you happened to park your car just before that time began, and returned to find you car gone. The thought might be “My car has been towed.” Notice, however, your feelings are different based on the thought. You might feel angry, or embarrassed, or shame because I should have known better.

c. Consider a third possibility such that you come out of the store talking on your cell phone. As you get to where you parked the car, you realize it is gone. As you think “My car is gone” with the complementing thoughts, you notice that 6 cars up is your car. Because you were distracted, you went to the wrong car. The corresponding feelings might be embarrassment, relief, and/or humor as you realize how much you overacted.

2) These three examples help explain how thoughts shape your feelings and subsequent behaviors. Gladwell highlights how much of our thought is actually automatic and can occur in the “Blink” of an eye (hence the title of his book). Sometimes our thoughts and reactions are so automatic that we simply don’t realize how many different thoughts we had in a particular moment. Not true, you say? Think about how many complicated tasks, thoughts, and attention to stimuli occurs while you are driving a car. Yet, you never truly “think” about driving a car. You simply “drive.”

The application in treating sexual compulsivity is to help clients realize how ritualized the acting out process is for many people. Too many times I hear from a client “I don’t know how this happened.” My response “I believe you, and the process of therapy is to help slow down the thoughts.” In the next blog I will highlight the concept of thinking errors. The concept is a direct application of the power of thought to the acting out cycle.

Professional Changes beginning Jan 08

Dear Friends and Colleagues,

January 2008 has arrived with a flurry of activity. I’m writing to catch you all “up-to-speed” regarding changes in my professional life.

I moved my private practice from a solo-practice in Uptown in Minneapolis to a group practice near Loring Park in Minneapolis. The new practice is a combination of the Sexual Health Institute and Human Interfaces. My goal is to use the synergy from the relationship with the two groups to grow the Sexual Health Institute. As of this date, we have two psychiatrists and four psychologists committed to providing quality mental health, psychiatric and sexual health services. This change reflects a significant change since I started my private practice over 10 years ago. And, as I expand my practice, I’ve decided to place an added emphasis on education and sexuality. To reach this goal, I’ve added two components to my work.

The first area is a new blog I started to help individuals who struggle with Sexual Compulsivity. The blog is located at: http://sexualhealthinstitute.blogspot.com. Please feel free to share this link with others. My goal is to steadily build a collect of resources that might be helpful to others. So far there are about 10 posts covering a range of issues that I would consider are an “intro” to sexual compulsivity.

The second area expressing my commitment to education is through public speaking. Too many people simply don’t know anything about sexual compulsivity and sexual health issues. In 2007, for example, I had my “22 seconds of fame” when I was interviewed by Tom Lyden of Channel 9 News regarding the matter of Sen. Craig and sexual compulsivity. In addition, I presented at a mental health agency providing professional enrichment and a few churches providing adult education.

In addition to moving my practice, I added additional staff. Please welcome Dr. Shannon Garritty, Psy D., LP. She is starting her practice at 1-2 days a week. As her case load grows, she will be adding hours. Her specialties include spirituality, wellness, anxiety, depression, sexuality, coping with life changes and couples therapy. Dr. Garrity is also a provider for Blue Cross and Blue Shield.

As a result of the changes and growth in my private practice, I decided to leave Alpha Services effective February 1. It’s hard to believe that three years passed so quickly. It is a difficult choice because I greatly admire the staff and community of Alpha. I also acknowledge many of the clients who created significant positive changes in their life. For current clients and probation officers, I’m working on transferring these clients to the new therapist.

Finally, I will continue teaching one course each quarter in the Walden School of Psychology program. I am also supervising graduate students in their thesis projects.

Please check out the updated website reflecting new contact information, a map to the new office, links to the blog, and information about Shannon and myself. The website is: www.sexualhealthinstitute.org.

My new work contact info:

Weston M Edwards, PhD, LP
1409 Willow St, Suite 109
Minneapolis, MN 55403
tel: 612.872.1500
fax: 612.872.2205
mobile: 612.987.4482
web: sexualhealthinstitute.org
email: Weston@westonmedwards.com