Drama Therapy

An Interview with Zev John Berkowitz

Drama Therapy is the intentional and systematic use of drama and theatre processes to achieve healthy psychological growth and change. John Berkowitz is a Licensed Clinical Social Worker. He explains that the general aims of a Drama Therapy session include exploring ideas, issues and problems using drama-derived activities; expressing and exploring feelings, developing spontaneity and imagination and creativity, improving self-image and self-confidence, developing social and relationship skills.

John Berkowitz describes Drama Therapy which involves several different forms of expression such as movement, voice work, body language and speech.

Drama Therapy by John Berkowitz offers a variety of working methods that are applicable to a wide variety of clients.  It can help the process of emotional growth through the development of trust, risk taking and the experience of different ways of being. The role of John Berkowitz is to provide a safe, supportive space to enable and encourage the client/s to express her/himself in whatever way they are able. Drama therapist’s work in a variety of settings including health, education, social and prison services, as well as in private practice. The playful and active approach makes it a very suitable intervention for adults and children with learning disabilities and autism.

The methods used in John Berkowitz‘s drama therapy include spontaneous and dramatic play, drama games, mime, role-play, scripts, masks, myths, stories, metaphor and symbolism. A dramatic talent is not necessary for participation. The emphasis is not on performance but on the experience of the group or individual. The role of the Drama therapist is to develop a program with appropriate aims, objectives and structures to meet the needs and abilities of the client/s.

John Berkowitz’s Drama therapy reaches far beyond a single discipline, drawing freely from concepts of psychology, theatre/drama, psychoanalytical theory, anthropology and theories of child development.  We can go far back as ancient Greece to discover its roots where ancient forms of healing rituals and theatre performances influenced what we classify as drama therapy today.


Drama therapy in modern society began in Europe in the 19th century.  The first recorded use of the word drama therapy was by Peter Slade, who in the 1930's referred to all forms of carefully applied Drama as drama therapy.  By the 1960's in Britain, a remedial Drama Centre was set up by Sue Jennings and Gordon Wiseman to work with children and adults with a wide range of needs.  The British Association of drama therapy was formed in 1976 and provided a professional base for those who had been using Drama in therapy and education since the early 1960’s.  Drama therapists trained abroad began working in Ireland in the mid 1980's and the first training in drama therapy began in 2002 in NUI Maynooth.


Q: Do I need to be able to act to participate in drama therapy?

John: No. drama therapy helps people to use their creativity to work on issues that are important to them.  It does this by using Dramatic and Theatrical processes which are explained to the client but you do NOT have to act to make use of drama therapy.

Q: Do I have to role play in front of other people?

John: No. You will not have to do anything you do not want to do.  While drama therapy can involve the process of taking on roles - this is only done if the client wants to do this. There are many other ways in which drama therapy can work with a client.  For example through story making, using scripts, movement, sound etc.


Q: Do I have to dress up?

John: No. Again. You do not have to do anything that you do not want to do.  In Drama Therapy, the methods used are chosen to suit the client and what he/she is comfortable with.   The use of costume and dressing up will only be used where appropriate and so long as the client is happy to do so.


Q: Is drama therapy always done in a group?

John: No. Drama Therapy can be done with individuals and in a group setting.


Q: Will I have to speak or perform?

John: Drama therapy is psychotherapy through the medium of drama.  Obviously, for the client to benefit communication is essential. However, one of the advantages of drama therapy is that it offers the client a range of communication opportunities - through movement, sound, facial expression, role, and creative imagination.  The client will not be asked to do anything they do not wish to do – including performing.


Alternative Therapies

When you think of psychotherapy, the first image that comes to mind might be one of a distressed patient lying on a couch, talking, while a desk-bound therapist takes notes. But while traditional talk therapy can help people struggling with depression, anxiety and the stresses of daily life, the latest research on the brain and the mind-body connection has sparked a proliferation of approaches that may reach deeper levels of emotional healing than talking alone.

“Talk therapy is actually a little removed," says Dr. Martin Rossman, clinical professor at UC San Francisco Medical School. "A story might relate some of our disturbing experiences, but it can distance us from real emotions and somatic [body] feelings."

Talking takes place in the cognitive, or "thinking," part of the brain, and our thoughts are often the problem, adds Wolf Mehling, a physician at UCSF's Osher Center for Integrative Medicine. To help combat negative or obsessive thinking, many new therapeutic approaches focus on letting go of thoughts and becoming anchored into bodily sensations.

Though alternative treatments will probably never replace traditional talk therapy, new psychotherapeutic approaches can be used in conjunction with talk therapy to help people achieve optimal mental health, says Don Hanlon Johnson, professor of somatic psychology at the California Institute of Integral Studies in San Francisco.

The bottom line, says Johnson, is that "we need all the help we can get. If you look at the entire population, what helps one person doesn't always help another. So we need many avenues to psychological, physical and spiritual well-being."

Alternative treatments run the gamut from techniques that are championed by mainstream mental health professionals to practices that are more in the "fringe" realm of meridian-tapping and energy work. Here is a glimpse into four of the more widely accepted nontraditional approaches, each with an element of mind-body awareness:


Mindfulness Practice


Rooted in Buddhist meditation techniques, mindfulness practice has become accepted among many Western mental health professionals as a powerful psychological tool. The practice is usually taught in a group, in which people learn to focus on their breath and body sensations in moment-to-moment awareness.


Studies have demonstrated that it can alleviate symptoms of depression and anxiety and that it may help prevent depression relapse. It's also been shown to reduce feelings of stress and loneliness, help manage chronic pain and increase success rates of addiction recovery.


"Focusing on the present moment eliminates ruminating thoughts based on past experiences or anxiety about the future," says Mehling. "You allow yourself to get space between the perception and your interpretation. It helps you to distinguish thoughts from reality." This process can also help with impulse control, Johnson says. "Many problems are rooted in the fact that we're dissociated and unaware of our bodily response to things. People aren't aware of harmful impulses until they get out of hand. So mindfulness practice is about teaching people to slow down and notice when impulses arise."


Guided Imagery


Guided imagery is a mind-body technique that teaches people to use their imaginations to achieve a relaxed, focused state. Under the guidance of a therapist or CD, listeners use their senses to evoke positive, safe, relaxing images.



The idea is that the body and mind will respond to images as if they are reality. If you imagine sucking on a lemon, chances are your mouth will water as if you are actually tasting a lemon. Much in the same way, people respond to comforting or relaxing images by experiencing feelings of increased well-being.

Research has shown that people who practice guided imagery have lower levels of the stress hormone cortisol and an overall decrease in depression, anxiety and fatigue. Guided imagery may also help motivate people to make positive life changes, such as losing weight or starting an exercise routine.


"The ability of imagery to connect with emotions -- the way an experience actually feels in the body -- is what makes it such a great therapeutic tool," says Rossman, who explains that images can be powerful catalysts for psychological change because they are formed in the more primal, emotional parts of the brain. He adds, "Imagery is the natural language of the unconscious mind -- and it's the unconscious mind that we need to deal with in deep psychotherapy."


Internet Addiction​

According to The Office for National Statistics (ONS), in 2010 a staggering 30.1 million adults in the UK (60 per cent) accessed the Internet almost every day. Continuing advances in technology now mean that more people than ever before are able use the Internet extensively for both work and social purposes, and research and communication which previously would have been time consuming now takes just a matter of minutes.


Popularity of the Internet

The use of social networking sites (Facebook, Myspace, Friends etc.) is becoming increasingly popular, with 43 per cent of Internet users posting messages to social networking sites, chat sites and blogs in 2010. This activity has proven to be most common among Internet users aged between 16 and 24, of whom 75 per cent posted messages and 50 per cent uploaded self-created content in 2010. Though social networking is an activity heavily associated with younger generations, in 2010 31 per cent of Internet users aged between 45 and 54 used the Internet to post messages.

Whilst it is a positive step that we can now talk, search, shop, play, find love and experience all of the other far reaching benefits of the Internet, as with everything in life, there can't be a positive without a negative. Internet Addiction Disorder (IAD) is the term used to describe excessive computer use which begins to interfere with daily life. As it stands, IAD is not officially recognized as a clinical disorder, though an increasing body of research and evidence is establishing internet addiction as a public health concern, with many leading health experts now advising it be officially recognized as a clinical disorder.

The condition exists in many subtypes, all of which are essentially characterized by excessive, overwhelming or inappropriate use of online activities, which if done in person would usually be considered negative. For example, compulsive gambling, shopping, pornography use or gaming.


Types of Addiction

Internet addiction disorder covers a variety of compulsive Internet activities including the following:


Though the Internet is often a great way of escaping reality, spending excessive amounts of time on the Internet engaging in cybersex, viewing pornography, spending time in adult chat rooms or carrying out relationships in online fantasy worlds can begin to have negative repercussions on an individuals real life relationships.

On the World Wide Web we are able to change our identity, remain anonymous and engage in fantasies all from the privacy of our own homes. Whilst this is fine in moderation, compulsively participating in any of these activities can lead to individuals neglecting their real life relationships, career and emotional well-being.



The Internet is a great way to meet and interact with new people and may even lead to the development of a romantic relationship. However, online relationships are often far more intense than those in reality and there is opportunity to live out our ultimate fantasies. A huge problem with online relationships is that many people online lie about their sex, age, appearance, relationship status and job, meaning that when online friends meet in real-life, unfortunately they may not live up to one another’s online persona resulting in significant emotional distress.



According to the Gambling Commission there are an estimated 236,000 to 378,000 problem gamblers in Britain. Whilst problem gambling has been an issue for a number of years now and there are many associations and support groups offering help and advice, the ease and availability of gambling online has made it more accessible than ever. In addition, recovering gambling addicts may also find it far more difficult not to relapse with the temptation of 24 hour online casinos which are open to anyone of any age. In addition, the financial problems brought on by online gambling can also result in stress, anxiety and depression.



Many individuals find enjoyment in playing online role playing games in their leisure time, and not everyone who does this is an addict. The vast majority of online gamers are able to strike a balance between gaming, work, friends and family, but unfortunately for some the compulsion to play online games becomes uncontrollable meaning that other areas of real life are neglected.



Online shopping or auction shopping can be just as financially detrimental as online gambling if a habit gets out of control. Shopping addicts have a tendency to purchase things they don't really need and can't really afford but they do so in order to experience the temporary high of placing a winning bid or owning something new.


Internet Addiction Symptoms

Each and every one of us will use the Internet in our own way for different purposes and for varying amounts of time. Some individuals who use the Internet for work purposes may choose not to dedicate much of their leisure time to web browsing. Others will use occasionally, for instance for a once weekly food shop, others will use weekly perhaps for reading their favourite online paper or blog, and others will use social networking sights daily for keeping in touch with friends and family.

Internet usage only becomes a problems when it begins to take up too much of your time, to the point where you start to neglect whats going on in real-life.

There are various symptoms of Internet addiction, and each individual is likely to experience a different set. However, below are some key indicators to be aware of:

  • Losing track of time - Many Internet addicts find that they lose themselves when they are online and as a result consistently spend longer online than initially intended.

  • Social isolation - Cracks in your real-life relationships may indicate that you are spending so much time focussing on Internet relationships and activities that you are neglecting the current real-life relationships you have with family and friends. Some individua ls may also find that they feel their online friends 'understand' them in a way that no one in real-life can.

  • Temporary high - As with any addiction, individuals keep returning for their next 'fix' because it gives them the feeling of euphoria and excitement. If you tend to rely heavily on the Internet for stress relief purposes as a pick-me-up or for sexual gratification then it could be a sign of a deeper underlying issue.

  • Feelings of guilt and defensiveness - If you are feeling guilty and constantly trying to justify the amount of time spent on the Internet, or if you are lying about or trying to hide what you do online then this could be an indicator of Internet addiction.

  • Physical symptoms - Aside from the emotional aspects, excessive computer addiction also causes some physical side effects and discomfort including strained vision, back ache, neck ache, headaches, sleep difficulties, carpal tunnel syndrome and weight gain or loss.



As mentioned throughout this fact-sheet, escapism is a factor which draws many people to the Internet. Anyone wanting to relieve the stresses, strains and issues which are present in their everyday life can use the Internet as an outlet for these negative feelings as it can provide temporary comfort, company, and entertainment.

Certain individuals may find themselves at a greater risk of becoming addicted to the Internet, for example those who engage in little social activity may try to build new relationships and relate to others by using chat rooms etc. Below are additional factors which may increase a persons risk of developing an Internet addiction:

  • Other Addictions - Individuals who are addicted to gambling and sex for instance (or recovering) may turn to the Internet to fulfil their needs.

  • Depression - Depression can lead to Individuals turning to the Internet to escape their negative feelings.

  • Anxiety - People suffering from anxiety may feel drawn to the Internet as it is a way of distracting themselves from any fears and worries they may have.

  • Social mobility - If a person suddenly finds themselves less active than they used to be (for instance recovering from a serious illness) and it is difficult to leave the house or meet up with family and friends then they may go online to seek additional social interaction.



There are many addiction services and avenues of treatments available to help individuals back on the road to good health, one of which is counseling. The ultimate goal of counseling is to help individuals either reduce or stop their addiction all together, depending on their specific needs and goals. Though each counsellor will have their own unique way of working, sessions may involve exploring different ways of dealing with certain urges and triggers and exploring the origins of the problem and the underlying reason for your addiction. A counselor may also use a technique known as cognitive-behavioural therapy, which is a way of changing an individuals thoughts and behaviours surrounding a certain act or issue. Counseling is a safe and confidential way of exploring your addiction and the affect it is having on your well-being and fulfilment. A counselor will work with you to help you make sense of your circumstances, to identify your choices for change and to offer support throughout the entire process.


What should I be looking for in a counselor or psychotherapist?

While there are currently no official rules and regulations in position to stipulate what level of training and experience a counselor dealing with Internet addiction needs, we do recommend that you check your therapist is experienced in this area. An accredited course, qualification or workshop undertaken as part of continuing professional development will also provide further assurance that your counsellor has developed the necessary skills. In regards to psychological treatment, as with other addictions, cognitive behavioural therapy (CBT) is considered a useful tool to break the habit of addiction.



The following is an interview with a teacher of a student suffering from ADHD

John Berkowitz: What is the first thing you notice about a student with ADHD?

Marian: Well I'd have to say the fact that they always seem to be very distant.  I struggle to maintain their attention and it's very difficult to keep them on task.

John Berkowitz: Do they tend to struggle in class and with grades?

Marian: The kids with medication seem to have been able to adjust well but it seems at times it is very easy for them to lose focus.  You can definitely distinguish between the medicated and non-medicated children.

John Berkowitz: How so?

Marian: They are actually able to sit in their seats without moving around.  They are able to maintain focus on me. When we do silent work, they can sit there and work calmly while the non-medicated students tend to look around the room, tap their fingers, or disrupt others.


John Berkowitz: What kind of teaching strategies do you use when dealing specifically with the students with ADHD?

Marian: Well first of all I have met with or tried to meet with all of the parents.  They have weekly progress reports sent home to monitor their work and grades in class.  I try to set aside time each day so if needed they can come to me with any important questions.  I try to keep them involved in the lesson plan so i can maintain their attention.  And when possible, i try not to let them stray towards the back of the classroom.  The hardest part is to keep their attention on me and the material though.  Once i have that, the learning just seems to fall right into place.



The following is an interview with a third year college student diagnosed with ADD.  

John Berkowitz: How long have you been diagnosed with ADD?

Joseph: I was first diagnosed with ADD when I was in sixth grade.

John Berkowitz: Who first noticed you had a problem?

Joseph: Well I had been struggling in school.  I was having problems finishing my work and found it especially difficult to concentrate.  After numerous notes home my parents set up a meeting with a doctor.  After undergoing many observations and many behavioral tests through multiple visits I was diagnosed with ADD and immediately subscribed Ritalin.

John Berkowitz: How long have you been taking medication for it?

Joseph: I began taking Ritalin shortly after.  I took it regularly all through school until my senior year in high school.  Senior year I began taking it as needed.  For example, when I knew i was going to have a quiz or test or if I needed to study at home.

John Berkowitz: Now to your knowledge, what is Ritalin?

Joseph: Ritalin is a mild stimulant used to help me focus.  There is a short release and a long release type.  The short release lasts for 2-3 hours and the long release could last up to about 10 hours.

John Berkowitz: When would you take the short release and when would you take the long release?

Joseph: I would always take the long release when I was in grade school, middle school, and high school.  Now that I'm in college I take my Ritalin only when I have tests or quizzes or when I know I'm going to need to focus like if I have to read something long or do some lengthy studying.  And unless it is going to be a long study session I try to only take the short release.

John Berkowitz: What is the most significant difference you have noticed when taking Ritalin?

Joseph: When I am on Ritalin it is like night and day.  Normally I would have trouble reading something or trying to do homework.  When I take my Ritalin it almost seems like it gives me motivation and I seem to have an interest in my work.  I get it done much more quickly and don't have to go over it three or four times to take it in.

John Berkowitz: Did you ever receive any behavioral treatments or programs?

Joseph: When I was in elementary school I was placed in a once a day program with the "slower" kids.  We would meet in a room before lunch every day and go over our work and get help from our tutors.  I really didn't like it and fortunately that was my first and last time into that room.  I really just didn't want to be given that negative stigma if you know what i mean.  I mean, once I got on my medication, most of my teachers didn't even know I had ADD and that is the way I liked it.  I didn't want to be treated any differently.  Outside of my pill mixed with the rest of my vitamins every morning, I wasn't any different, ya know?

John Berkowitz: Where do you think you'd be without Ritalin or any other ADD medications?

Joseph: Probably struggling in a community college somewhere.  Definitely not at University, on track to graduate in four years. I am very thankful for Ritalin and all the research gone into the ADD field.  I owe a lot of my academic accomplishments to the available and useful medications I have received.

Sexual Addictions in Couples Counseling


There has been increased media coverage of celebrity relationships in recent months. Much of this questions whether sexual addiction exists or is an excuse for philandering.(1) Life Works, a UK-wide organization that specializes in sexual addiction, has reported a 25 per cent increase in footfall at its clinic over the past six years. They put this down to increased awareness. ‘Behaviors haven’t changed in thousands of years – there just wasn’t any help before,’ says Life Works founder and chief executive Don Sarratt. In my own work as a relationship and family counsellor, supervisor and trainer, I have noticed an increase in individuals and couples presenting with sexual addiction.


Despite recent sexual addiction research(2) showing that relationship counseling plays only a small role in the treatment of sexual addiction, I would argue that sexual addiction issues are not new to couple work. In my practice it is quite common for those being supervised to present issues related to sexual addiction in their couple work, requesting theoretical knowledge and practical training.


Sexual Addiction

Carnes (3) defines sexual addiction as a ‘pathological relationship with a mood-altering chemical/experience’. Goodman (4) suggests that sexual addiction is characterized by two key features: ‘recurrent failure to control the behavior’ and ‘continuation of the behavior despite significant harmful consequences’. Other signs include:

  • Persistent pursuit of self-destructive or high-risk behavior

  • Sexual obsession and fantasy as a primary coping mechanism

  • Increasing levels of sexual experience because the current level of activity is no longer sufficient

  • Inordinate amounts of time spent in obtaining sex, being sexual, or recovering from sexual experience.

  • These signs may be located within a four-phase, sexual addiction cycle, which intensifies with each repetition.(3)


Sexual Addiction Cycle

1. Preoccupation phase: the trance or mood where the addict’s mind is engrossed with thoughts of sex (often the most rewarding part of the cycle).

2. Ritualization: the addict’s own special routines that lead to the sexual behavior (this intensifies the preoccupation, adding to the arousal and excitement).

3. Compulsive sexual behavior: the sexual act, the end goal of the preoccupation and ritualization (addicts are unable to control or stop this behavior).

4. Despair: the addict’s hopelessness about his/her behavior and sense of powerlessness.


As well as this cycle there are often secrets and delusions that can lead to the following ethical dilemmas for both the addict and the counsellor.


Ethical Dilemmas

These mainly occur around issues of trust, disclosure and health risks. For the client, conflict of issues such as being discovered or becoming infected can arise with high risk/excitement around multiple affairs, seductive role sex (serial conquests), paying for sex, anonymous sex, voyeurism (including pornography) and exhibitionism.


The counsellor may have dilemmas about limits of confidentiality relating to illegal sexual behavior and professional boundaries in terms of the counsellor/client relationship. Leavitt (5) notes that secrets place the counsellor in a potentially powerful position, where one of the main dilemmas is in ‘playing God’. Thus there is a need for the counsellor to be clear about the ethical and legal limits of confidentiality. Leavitt argues that accountability with discretion is the ‘most helpful position for the couple counsellor, given the complexity of secrets, their gravity and consequences and that some secrets are better shared and some are better not’.


As my workload with sexual addiction increased I developed a way of working for practitioners, where individuals or couples present with sexual addiction within the couple context. This was done in the context of the integrative model of approach, method and technique.(6) (7)

Approach: The Relational-Integrative Model

The theories within the relational-integrative model (6) are made up of three theoretical approaches: CBT, psychodynamic, systemic and attachment narrative therapy. These are based on the ability to:

  • Offer diversity and flexibility in meeting clients’ needs

  • Address sexually addictive behaviors, the underlying addictive processes and intergenerational family patterns and attachments

  • Formulate the original couple fit/misfit and renegotiate the couple relationship

  • Explore relational factors with and between the couple and relational reflexivity with and between counsellor and clients

  • Work with transference and countertransference.

In this way the theories can be integrated into an assessment and a six-stage therapeutic framework (developed from Relate’s five-stage model for working with adult survivors of sexual abuse within the couple context).



As it is important to locate assessment within a collaborative framework, client/s and counselor jointly assess whether presenting issues are sexual addictions and explore options around the appropriateness of individual and/or couple work, separation work or referring on. Working ethically there is a need for the counselor to accommodate clients in the way that best meets their needs and still work within his/her own competencies. Suitability for couple work depends on the addiction and co-addictive pre-recovery phases of the couple. Individual work may be needed prior to couple work and the eventual focus on the recovery of the relationship.

Method and technique: the six-stage therapeutic framework

In keeping with an integrated approach, the framework was developed using a circular and recursive process that allows the counsellor to operate from several stages simultaneously. This also allows the client to decide where in the process s/he wishes to begin.


1. Sexual addiction signs and cycle and the co-addictive pre-recovery stage (8): Often the partner who presents with the sexual addiction attends counseling individually. The signs of addiction can be explored and the sexual addiction cycle drawn, with the client tracking the sexually acting out behaviors. The client’s co-addictive pre-recovery stage can also be explored. Signs/stages include:

  • Ignorance and denial: the client knows something is wrong but cannot identify what this is

  • Shock: discovery of the sex addiction, accidentally or by deliberate investigation – this stage often evokes strong, painful feelings

  • Problem-solving attempts including collating information, bargaining, controlling access to phones, ultimatums, competitive sexual activity, covering up sexual activities. Recovery begins with acknowledgement that the client/s are in crisis and need help.


2. Underlying factors and motivation for change: These relate to the intergenerational relational patterns and attachment styles of families of origin. Working with the couple’s family venogram to uncover overt and covert messages about sexuality/intimacy, sexual values and gender issues is often illuminating. This can help explore couple fit and sexual connectedness. Other factors include themes of secrecy and ‘sinfulness’, early sexualization, childhood trauma, abuse, neglect and sexual identity.


This work allows strong and painful feelings to emerge and time needs to be given to acknowledge, validate and address these. Only at this point can motivation for change be explored. This includes looking at the ambivalence and struggle between really ‘wanting to do it’ and really ‘wanting to stop’. Motivational interviewing using circular and reflexive questions (9) and paying attention to the ‘stage of determination’ is crucial. Developing hypotheses about relational patterns, lifestyles and rituals that can be changed is also important as these changes can lead to the restoration of trust and safety within the relationship.


3. Moving from ‘escape’ to ‘reality’: During counseling, sexually acting-out behaviors can become ‘live’ and need to be acknowledged and managed through transference and countertransference. As well as holding ethical boundaries it is important that the counsellor validates the client for being courageous enough to show the behaviors and invite a conversation about it. This duality helps bridge the gap for the client between ‘escape’ and ‘reality’. What happens relationally can then be connected to historical and current patterns, attachment styles and the couple fit.


4. Slips, lapses, relapses: A normal part of the recovery process which can be good learning in terms of identifying ‘danger zones’ and ‘safe zones’. Identifying healthy behaviors and what triggers movement into intermediate areas, lapses and relapses is important.


5. Re-storying intimacy: Having worked at a relational level the counsellor can invite story development through future-orientated questions and possibilities of emotional connectedness. Moving from a position of ‘I am the way I am’ to ‘I am the way I am influenced to be’, can help develop new stories of intimate communication and address fears of emotional closeness. White (10) notes that new stories can co-create and co-confirm new identities.


6. Developing healthy sexual relationships: Couple sexual counseling can be offered within the boundaries of the ‘human sexual response cycle’.(11) Where there is sexual dysfunction, a referral to sex therapy may be appropriate. The couple may need to develop new understanding of sexuality and how to communicate sexually; why they behaved and acted the way they did; and what the feelings were about. They may then learn to tolerate vulnerability in themselves and each other.


Case Study

Jim, a professional man in his 40s, attended individually for assessment. He presented with behaviors of seductive role sex, fantasy sex, and affairs (signs of sexual addiction). All Jim’s sexual activity was unprotected. Sarah, his wife, knew of the unprotected sexual activity, but not the affairs (secrets/ethical dilemmas). Jim worried about his distant relationship with his children, particularly with his son (underlying factors/motivation to change).


Exploring the couple’s relationship, Jim said there had been little sex because Sarah had had low sexual desire. Lately, however, Sarah had become as sexually active as Jim and his role in their relationship became one of recruiting ‘fuck buddies’ for them both (couple fit, signs, cycle of sexual addiction). The couple’s relationship appeared to be emotionally empty and Jim longed for emotional connectedness (motivation for change).

Tracking Jim’s sexual behaviors (sexual addiction cycle), his preoccupation began with the buzz of sexual fantasy and around his need to be found attractive and desirable (underlying factors). This phase triggered a mood altering experience that felt like intoxication that led to Jim ‘overdosing’ and becoming hostage to his own preoccupation. The thrill of ritualization intensified to exhilaration when he persuaded others to break their own boundaries and values about sexual activity. Jim then described his and Sarah’s relationship as being ‘sexually on fire’. This became a shared focus of energy and excitement and appeared to cement the relationship (underlying factors/couple fit).


Sarah attended counseling individually. I wondered whether she was competing with Jim sexually (stage three/co-addictive pre-recovery) or displaying signs of her own sexual addiction. She thought her activities got Jim’s attention and, as long as no one got hurt, they could both continue their sexual behavior. However, sex could only be achieved through fantasy (adopting a particular sexual identity) and Sarah believed that if this was given up, their sexual relationship would end and Jim might leave (underlying factors/couple fit). She was frightened to stop (motivation for change) and did not wish to continue counseling.  At the same time, Jim constantly worried about being abandoned and throughout his childhood had felt alone. His father had questioned Jim’s parentage and when Jim was 11, his mother had an affair, bringing him along with her. When this became known, Jim became a tug-of-war between his older sisters and mother. Jim’s view of women split into ‘good’ and ‘bad’: women were either idealized as the ‘Madonna’ or demonized as the ‘whore’ (underlying factors).


During counseling, Jim’s sexual fantasy became ‘live’. He used sexually acting-out behaviors and tested whether he could split me into the idealized or the demonized woman. Together we explored what was happening relationally and linked our discussion to his past and present experiences (transference and countertransference). In this way, instead of sexually acting out his vulnerability, he was able to ‘be in it’ and explore his underlying emotions of insecurity and anxiety (moving from escape to reality). He gradually began to change his behaviors, no longer needing the intoxication of the addiction cycle. Nonetheless, there were moments during counseling when Jim was either tempted or lapsed into old behaviors (lapse/relapse). Exploring the triggers and underlying behaviors together with what was happening relationally within and between the couple, enabled Jim to get back on track (motivation for change). He began to co-create a new relationship with Sarah, confiding in her about his feelings and connecting with her in a more emotional and intimate way. Sarah was able to tolerate this and not hide from it (re-storying intimacy).


I invited conversations of new stories of a healthy sexual relationship and sexual identity, stories that integrate the authentic self rather than acting out (developing healthy sexual relationships). When counseling ended Sarah chose to continue with her sexual activities and Jim chose to still recruit her fuck-buddies. Jim has given up his fuck-buddies and hopes that Sarah will also. As Jim says, ‘It is a work in progress.’



This case study shows that sexual addiction can be viewed, and worked with, in the couple context. It is complex work and there is a need to embrace both the relational-integrated approach and the six-stage therapeutic framework. The six-stage framework is both flexible and adaptable enough to meet clients’ needs in either an individual or couple context. I believe that sexual addiction is very different from an excuse for philandering and if more counsellors are to work effectively in this field, then more insight and training is essential.



1.Hattersley G. News Review. The Sunday Times; 4 April 2010.

2. Bird MH. Sexual addiction and marriage and family therapy: facilitating individual and relationship healing through couple therapy. Journal of Marital and Family Therapy; July 2006.

3. Carnes PJ. Facing the shadow: starting sexual and relational recovery. Wickenburg AZ: Gentle Path Press; 2001.

4. Goodman A. Sexual addiction: an integrated approach. Madison: International University Press; 1998.

5. Leavitt J. Common dilemmas in couple therapy. London: Routledge; 2010.

6. Faris A, van Ooijen E. Integrating approaches. Therapy Today. 2009; 20(5):24-27.

7. Burnham J. Approach – method – technique: making distinctions and creating connections. Human Systems. 1992; 3(1):3-26.

8. Coombs RH. Handbook of addictive disorders. New Jersey: John Wiley; 2004.

9. Tomm K. Interventive interviewing: Intending to ask clinical, circular, strategic or reflexive questions. Family Process. 1998; 27(3):1-15.

10. White M, Epston D. Narrative means to therapeutic ends. Norton USA; 1990.

11. Masters WH, Johnson VE. Human sexual response. California: Ishi Press International; 2010.

EFT Couples Therapy

Emotionally Focused Therapy for Couples or EFT couples therapy is a structured, short-term (8 to 20 sessions) approach to couples counseling that focuses on negative communication patterns, adult relationships, and attachment.  Dr. Sue Johnson and Les Greenberg developed EFT in the 1980s, on the grounds of a 50-year long research. 


The effectiveness of Emotionally Focused Therapy has been empirically proved. That is, research shows that 90 percent of couples undertaking Emotionally Focused Couple Therapy show significant improvements while 70-75 percent of couples move out of of distress.

During EFT couples therapy, the therapist and clients explore patterns in the relationship and plan strategies to develop trust and create a more secure bond between partners.


Promoting Healthy Dependency


Healthy dependency in a relationship is the flexible middle ground between the fused overdependence and rigid independence; it is the ability to rely on your partner while maintaining a strong sense of self. In addition, healthy dependency means feeling good about showing vulnerability and asking for help when you need it.


Healthy dependency can have many positive effects on a relationship, including:

Increased satisfaction

Better communication

Improved parenting skills

Better mental and physical health


Healthy dependency helps create a more secure emotional bond between partners, teaching couples to show vulnerability with each other, express deep underlying emotions, and openly ask their partner to meet their needs. 


Who Can Benefit from EFT Couples Therapy?


EFT helps couples learn to show empathy and experience each other’s feelings, which in turn strengthens the attachment bond between them. Emotionally Focused Couples Therapy has been proven helpful in improving distressed relationships and helping clients deal with fear, anger, infidelity, and loss of trust in their bond. Additionally, EFT can help reduce symptoms of anxiety, depression or post-traumatic stress disorder.


What to Expect from EFT Couples Therapy?


An EFT therapist normally observes the dynamics between the partners in both therapy settings and the dynamics in their home lives, linking these dynamics and directing the couple’s interactions on more honest feelings. To do this, your EFT therapist will encourage you to explore your vulnerability and help you recognize the most profound and often blocked emotions. Furthermore, you and your partner will learn to stay attuned to each other’s feelings and to express these feelings in a way that will help you connect or rekindle your closeness. Finally, EFT will help you learn more productive ways to respond to emotional situations and conflicts in a relationship. EFT focuses on the present and helps you make changes in your relationship in the here and now.


Three Stages of EFT


Emotionally Focused Therapy consists of three steps:


De-escalating the couple’s negative cycle of interactions and help them understand that their problems lie in emotional distance and insecurities.

Restructuring Interactions: the therapist helps clients discuss their worries and fears in the relationship, encouraging them to turn to each other, be vulnerable, and become more open and responsive to each other.

Consolidation is the third stage of ETF: the therapist helps clients understand how they developed negative patterns and helps them identify how to change those patterns.


EFT focuses on the emotions and patterns in the relationship, encouraging both partners to become accessible, responsive, and emotionally engaged. Adults are capable of “secure attachment” and healthy dependency, meaning that they value bonding in close relationships but also keep up a strong sense of self. 


A secure attachment means that a person does not become overly distressed and insecure at being separated for a period of time. Securely attached adults know how to ask for their needs to be met and have no problem seeking support when they need it.




Couples Therapy & Marriage Counseling: One and The Same

Love, trust, compassion, and communication build the foundation of a romantic relationship. However, often, you may find yourself in a stressful situation with your significant other. This stressful situation may resolve on its own. Of course, there are ups and downs in every relationship, but when that relationship starts declining and the fights don’t seem to stop, you should consider looking elsewhere for a solution such as using couples therapy or marriage counseling.

Couples therapy and marriage counseling are two different but similar entities that are often confused as one. They play significant roles in helping a couple cope with the problems they’re facing. These problems could be related to any issue, including compatibility, habits and general communication gaps. 

Unfortunately, couples therapy and marriage counseling have a lot of stigmas associated with them, despite their high success rates. If you find yourself in a situation where you think you and your significant other need to visit a therapist or a counselor, then you should definitely talk to your significant other about your options. For that, you need to have sufficient knowledge about the topic yourself too. So, let’s look at what exactly couples therapy and marriage counseling are, and in which cases they’re useful! 

What exactly is couples’ therapy?

To understand couples’ therapy, we first need to understand the meaning of the word therapy. Therapy refers to the long-term management of a situation and it involves treating a situation from its roots. It may involve a few activities or tasks that are designed on self-improvement. 

Couples therapy also includes exercises that work on deep-rooted personal problems or habits that can result in disagreements or fights between a couple. Therefore, this form of therapy aims at resolving problems that have occurred during the past so that those problems don’t occur again in the future.

Therapists that specialize in couple therapy have spent years learning the behavioral sciences of a relationship and the ways it affects those individuals involved. The target of a therapist who specializes in couple’s therapy includes improving the communication gap between the individuals involved and instilling in them skills that will enable them to cope better with their problems in the future. Unlike marriage counseling, couples therapy is a long-term solution and being a long-term solution, it may take multiple sessions for the positive effects of couples therapy to manifest in the relationship. 

Many studies have explored the effectiveness of couples therapy on helping a couple cope and deal with their problems. One of the most major hurdles faced in this field is that by the time couples come to receive a couples therapist, one of them has already decided to leave the other. 

However, when done using the correct method and approach, couples therapy can prove to be very beneficial. It is very different from individual therapy, which is much less complicated because it targets only one person at a time. 

A couples therapists truly learns and understands the dynamics of a relationship. In addition, they may diagnose any underlying mental health issues that any of the partners may have. Then, the couples therapist may refer the couple to a psychologist as well, who can treat the underlying mental health issue. Therefore, couples therapy aims at not only in fixing the current issue at hand, but digs deeper into its roots, finding its cause, and then eliminating it so that the issue doesn’t persist and the couple can do better in the future.

A Couples therapist may ask the couple to do activities or little tasks. These could be as simple as not saying a certain word to the other individual for a fixed period or not sleeping together for a bit. For couples therapy to work, the couple must also be compliant and meet the therapist at each of the appointments; as missed appointments can delay the therapy and set it back. 


The Effects of Addiction on Couples in Therapy

Addiction is a complex and often chronic disease. Whether it involves substance abuse or a behavioral addiction, it affects the functioning of a person’s brain, impacts physical, mental, and emotional health and causes serious damage to relationships, families, school, work, and the quality of life in general.  

Addiction is a condition in which an individual engages in substance abuse or in a behavior that has gratifying effects, which causes the person to repeatedly pursue it despite the damaging effects. 

According to the Addiction Center,  HYPERLINK "" more than 20 million Americans age 12 and older have an addiction. At the same time, 100 people die every day from drug overdoses and this rate has tripled over the past 20 years.

The Effects of Addiction on Families and Couples

The scientific evidence proves that both addictive substances and behaviors powerfully stimulate the brain pathways of reward and reinforcement, many of which involve dopamine, the neurotransmitter that transmits information between neurons and helps regulate attention, learning, and emotional responses. Also, dopamine allows us to see the rewards and complete actions to accomplish them. 

In addition to different mental and physical health conditions, addiction has harmful effects on relationships.

A study conducted by the Substance Abuse and Mental Health Services (SAMHSA) suggests that   more than 10 percent of children in the U.S. live with a parent who has alcohol issues.

Living with addiction can make domestic life stressful, chaotic, and even dangerous. Some of the most common effects of addiction on families and couples include:

Loss of trust 

A family member/partner with addiction often struggles to keep up the promises and responsibilities. This usually causes a spouse to feel constantly frustrated while children can struggle with affection because of the parent’s unpredictable behavior. In addition, they may develop issues trusting other people as well, which can negatively affect both their childhood and adult relationships. 

Accumulated stress and violence

Addiction usually leads to excessive stress, as a sober partner may feel as though they are carrying all responsibilities by themselves. Furthermore, arguments easily escalate into violence. Studies have shown that 25 to 50 percent of men who commit domestic violence also struggle with substance abuse. 

Unpredictable and chaotic family life 

When a spouse and/or a parent is struggling with addiction, family life can become unpredictable, without any order or routine, which can have long-term consequences. In order to develop and thrive, children need routine and structure, and the absence of these can cause different problems.   

Financial issues

As most of the money becomes distributed towards the addictive substances or behaviors, the family may struggle to pay for basic needs such as food, utilities, clothing, rent or mortgage. In addition, the person struggling with addiction may lose their job which puts an additional financial burden on the family.


Substance Addiction and Relationships

Alcohol and substance addiction can severely damage spousal and family relationships. In addition to trust issues, financial problems, aggression, and violence in a relationship, substance abuse often leads to dysfunctional patterns in family functioning such as enabling and codependency. 

In an attempt to help the addict, a sober partner may turn into an enabler, making excuses, accepting blame, and taking on responsibility for the addict’s feelings and behaviors. Furthermore, they may develop a codependent relationship with the addict, overly focusing on the addict’s needs and feelings, maintaining commitment despite a lack of reciprocity or compromise of ones own needs to keep the addict satisfied, at the same time acting to fulfill their own needs for attachment and intimacy.

Therapy for Couples Struggling with Addiction

Addiction treatment often focuses on the individual struggling with addiction, while less support to couples is offered. However, there are numerous couples and family-oriented treatment options available today. Couples therapies such as addiction-focused couples therapy, family therapy, and general couples therapy have been proven to be helpful in assisting the couples address addiction issues.

Addiction-focused couples therapy usually involves outpatient treatment for persons with drug and alcohol abuse disorders and their partners. The therapist works with both partners to create and maintain a relationship that supports abstinence. 

Family therapies usually help spouses and other family members who want to help a person with the addiction, by teaching them to develop useful strategies for managing the relationship with that person.

General couples therapies may include the following:

  • Cognitive Behavioral Couples Therapy (CBCT)

  • Emotionally-Focused Couples Therapy (EFT)

  • Integrated Behavioral Couples Therapy (IBCT)

  • Group Therapy


The success of the therapy depends on a couple’s mutual commitment to treatment and a willingness to make changes. 

Behavioral Addiction and Relationships

Alike substance addiction, behavioral addiction activates the brain’s reward centers, releasing dopamine and other neurotransmitters that trigger feelings of enjoyment and euphoria. Behaviors addiction may include behaviors such as:

  • Gambling

  • Eating

  • Sex

  • Shopping or playing video games


The addictive behavior patterns can be intensively rewarding, creating a compulsion to engage in them. Nevertheless, these gratifying behaviors can become maladaptive and damage a person’s health, work performance, and interpersonal relationships. A person struggling with behavioral addiction may be doing or saying hurtful things or harming loved ones because of addiction. The often are compromise themselves or family members to indulge in addiction or engaging in addiction at the expense of other activities and duties.

To overcome these problems, the addict and their partners/family usually need professional support. 

Behavioral Addiction Treatment Options

Though very damaging, behavioral addictions are also highly treatable. For example, there is a program called the Twelve-step Recovery Method created by Sex and Love Addicts Anonymous that offers support to people who are suffering from sex and love addiction. Sex and Love Addicts Anonymous or SLAA is a program adapted from Alcoholic Anonymous to help sex and love addicts recover from their compulsions. 

Also, Cognitive therapy for Behavioral Addiction that focuses on changing a person’s thoughts is one of the most effective addiction treatments. 

Furthermore, there are different outpatient and inpatient treatment options for addictions available that can help behavioral addicts stop engaging in problematic behaviors and achieving long-term recovery. In addition, as both partners are affected by addiction, these treatments can help with addiction as well as the relationship/family problems that go along with it.


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