Running head: AND SEXUALITY 1

Shame and Sexuality

A Literature Review

Presented to

The Faculty of the Adler Graduate School

______

In Partial Fulfillment of the Requirement for

The Degree of Master of Arts in

Adlerian Counseling and Psychotherapy

______

By

Meagan D. Betts

Chair: Rachelle Reinisch, DMFT

Reader: Erin Rafferty-Bugher, MA

______

2019

SHAME AND SEXUALITY 2

Shame and Sexuality

Copyright © 2019

Meagan D. Betts

All rights reserved SHAME AND SEXUALITY 3

Abstract

Shame is a self-conscious that can negatively mental and lead to multiple diagnoses such as , , eating disorders, self-injury, posttraumatic stress disorder

(PTSD), dissociative identity disorder (DID), , aggression, addiction, and suicide. The impact of shame on sexuality affects ’ lives through the influence of family, , , and . Every person has a unique story, and the purpose of this literature review is to determine the impact of that story on mental health. Additionally, the purpose of this project is to increase awareness of the impact of shame on sexuality, so mental health professionals are better equipped to understand their clients’ needs.

Psychology concepts such as inferiority , early recollections, horizontal and vertical striving, holism, and social are discussed. In addition, therapeutic interventions of two points on a line and increasing social interest and belonging can increase the awareness of shame and sexuality through an Adlerian lens. From an art therapy perspective, the expressive therapies continuum (ETC) is explained as the foundation in understanding how art therapy is beneficial when working with clients. Possible therapeutic interventions are proposed in theoretical scenarios with families, groups, and individual sessions when working with people who experience shame associated with sexuality.

Keywords: art therapy, Individual , shame, sexuality, LGBTQ+, expressive therapies continuum, holism, social interest, belonging SHAME AND SEXUALITY 4

Acknowledgments

I cannot express enough to my chair, Dr. Rachelle Reinisch, with her extensive knowledge, , encouragement, and guidance that supported me every step of the way through the completion of this Master’s Project. A special thank you goes out to my reader, Erin

Rafferty-Bugher, who supported and believed in me from the beginning to the end of my graduate school experience. I also want to acknowledge the faculty and staff of Adler Graduate

School who properly educated and prepared me to complete this project. Finally, I want to thank my community of fellow students, family, and friends who supported me through the learning and growing experience of balancing graduate school and life.

SHAME AND SEXUALITY 5

Table of Contents Shame ...... 8 Self-Conscious ...... 9 Shame Versus ...... 10 Shame and Mental Health ...... 11 Internalizing shame...... 12 Externalizing shame...... 14 The Impact of Shame on Sexuality ...... 15 Family ...... 16 Culture and Society ...... 19 Religion ...... 22 Individual Psychology ...... 25 Concepts ...... 25 Inferiority feelings...... 25 Early recollections...... 26 The horizontal and vertical plane...... 27 Holism...... 27 Gemeinschaftsgefühl...... 28 Shame, Sexuality, and Individual Psychology ...... 28 Therapeutic Interventions ...... 29 Two points on a line...... 29 Increasing social interest and belonging...... 30 Art Therapy ...... 30 Expressive Therapies Continuum ...... 31 Kinesthetic...... 32 Sensory...... 33 Perceptual...... 33 Affective...... 34 Cognitive...... 34 Symbolic...... 35 Therapeutic Considerations ...... 35 Family ...... 36 Group ...... 36 SHAME AND SEXUALITY 6

Discussion ...... 37 Implications for Practice ...... 37 Family...... 37 Psychoeducation ...... 38 Pour painting ...... 38 Board game creation ...... 39 Increase belonging and social interest ...... 40 Group...... 40 Clay figures ...... 41 Mask making ...... 41 Closure ...... 42 Increase belonging and social interest ...... 42 Individual...... 43 Early recollections ...... 43 Two points on a line ...... 44 Past, present, future ...... 44 Increase belonging and social interest ...... 45 Recommendations for Future Research ...... 45 Conclusion ...... 46 References ...... 47

SHAME AND SEXUALITY 7

Shame and Sexuality

The shame associated with sexuality is pervasive throughout all walks of life, regardless of age (Wiley, Miller, Quinn, Valentine, & Miller, 2017), gender (Lalonde, 2018), or culture

(Karver, Sorhaindo, Wilson, & Contreras, 2016). Increased awareness is needed in the mental health field to understand how shame intertwines with sexuality in clients’ lives. Shame has an impact on sexuality in various ways that are integrated throughout culture (Karver et al., 2016) , society (Lalonde, 2018), family (Bregman, Malik, Page, Makynen, & Lindahl, 2013; Petterson,

2103), and religion (Bolz-Weber, 2019; Freeman-Coppadge & Horne, 2019). It appears evidence supports the need for mental health professionals to understand the impact of shame on mental health.

Shame is an emotion that requires self-evaluation and begins with an outside source (e.g., family, culture, or religion) that communicates what is right and wrong (Muris & Meesters,

2014). According to Lewis (1971), it is important to know the difference between shame and guilt, because shame is more likely to have a negative effect on mental health. Shame can be so detrimental to mental health it can lead to multiple diagnoses (Kelly & Carter, 2103; Jones,

2014; Muris & Meesters, 2104).

Shame has an impact on an individual’s sexuality in differing ways, and every person has their personal perspective or story about how shame negatively affects their mental health. Research on how shame associated with sexuality originates within the family shows that parental rejection of sexuality can lead to depression, substance , risky sexual behavior, and suicide (Bregman et al., 2013). Shame about sexuality can originate from culture and society, which is revealed in Whitesel’s (2014) research with men who are overweight, and Karver et al.’s (2016) research with Indigenous women from Oaxaca. Religion is another origin for shame SHAME AND SEXUALITY 8 around sexuality as evidenced by Meladze and Brown’s (2015) research on the cognitive dissonance that comes with being gay and of Abrahamic , and Freeman-Coppadge and

Horne’s (2019) research about choosing for religious reasons, and consequently, the negative impact on one’s mental health as a result of this choice.

Through increased awareness gained through the research, mental health professionals can understand the impact of shame on sexuality and facilitate sessions with clients through proposed interventions that include Individual Psychology and art therapy. Multiple concepts of

Individual Psychology (Griffith & Powers, 2007) can be used to view shame with sexuality through an Adlerian lens (e.g., feelings of inferiority, early recollections, horizontal and vertical planes, holism, belonging, and social interest). The expressive therapies continuum (ETC) utilized by art therapists (Hinz, 2009) can be integrated with Adlerian concepts to create interventions specific to individuals, groups, and families struggling with shame around sexuality. The is that through increased understanding and awareness of how shame has an impact on sexuality, mental health professionals can help clients create change through art therapy and the Adlerian ideals to increase belonging and live on the useful side of life (Griffith

& Powers, 2007).

Shame

Shame is a cultural epidemic that mental health professionals need to address, and an increased awareness regarding the impact of shame on all areas of a person’s life is necessary to amend, heal, and become healthy and contributing members of society (Brown, 2012). People experience shame in different ways, both in where it comes from, and what is done to safeguard and regulate shame feelings. If mental health professionals understand the development of self- conscious emotions, it may increase their awareness and understanding of shame. SHAME AND SEXUALITY 9

Self-Conscious Emotions

Emotions are rarely experienced in their pure form (or one at a time). Rather, a mixture of several emotions is usually felt at one time along with one possible dominating emotion

(Tangney et al., 1996). When positive things happen, people can feel emotions such as , satisfaction, and . When negative things happen, people can feel emotions such as , , and . When instances occur where people react to their own behaviors or characteristics, self-conscious emotions are triggered (Muris & Meesters, 2014).

Self-conscious emotions involve a certain level of cognitive development that requires the ability to reflect and evaluate the self (Shen, 2018). To experience these self-conscious emotions, individuals must understand they have done something right or wrong. Reflection and evaluation of the self is filtered through an outside influence such as family, culture, or religion

(Muris & Meesters, 2014). This outside influence may have a concrete presence, but once internalized, physicality is not needed, which creates an internalized “other” (Schalkwijk, Stams,

Dekker, Peen, & Elison, 2016). When things happen that align with the views of the “other” and relate to the person’s character or behavior, the person will experience pride. When events take place that are inconsistent with the views of the “other,” or the person’s character or behavior, the person will experience shame and guilt (Muris & Meesters, 2014). Self-conscious emotions are necessary in socio-emotional development because they help to navigate, conform, and create a of belonging. According to De France, Lanteigne, Glozman, and Hollenstein (2017), there is importance in the experience of self-conscious emotions, but psychopathology is strongly linked to shame.

SHAME AND SEXUALITY 10

Shame Versus Guilt

The difference between shame and guilt has less to do with the situations that caused shame and guilt and more to do with motivation (Tangney et al., 1996). Helen Block Lewis defined the difference between shame and guilt in 1971, and her influential work is still referenced in current research (Muris & Meesters, 2014; Schalkwijk et al., 2016; Tangney et al.,

1996). Lewis (1971) wrote that shame is directly focused on the self, and guilt is focused on the behavior and the action. While there are negative feelings about the self associated with guilt, they are not the primary focus (Lewis, 1971). With shame, one might say “I blame my personality and myself,” and with guilt, one might say, “I blame my actions and behavior”

(Tangney et al., 1996).

Mintz, Etengoff, and Grysman (2017) studied the correlation between guilt, shame, and parenting styles. Mintz et al. (2017) found a connection between positive parenting and guilt versus negative parenting and shame. The associated negative parenting behaviors connected with shame included utilizing physical , demeaning or embarrassing the child, and .

This parental treatment can make a child feel worthless and insignificant, which leads to shame

(Mintz et al., 2017). Mintz et al. (2017) found that positive parenting was not correlated with shame-proneness. Shame is correlated with addiction, depression, violence, aggression, bullying, suicide, and eating disorders, and guilt is inversely correlated with these issues (Brown,

2012).

Guilt and shame can be painful; however, guilt is usually less painful than shame. For instance, when individuals experience guilt, they are more apt to attempt to repair the situation

(Tangney et al., 1996). According to Shen (2018), guilt is more advantageous than shame because of the drive to amend the issue, and guilt could be considered a relationship enhancer. SHAME AND SEXUALITY 11

Shen (2018) stated there is a lack of understanding about why guilt has not replaced shame in the world. When people feel shame, they are more apt to conceal and withdraw (Shen, 2018;

Tangney et al., 1996). Shamed people feel exposed and experience a sense of worthlessness, powerlessness, and a shrinking (Tangney et al., 1996). This emotional shrinking leads to community shrinking, which creates a smaller social circle as a result of (Shen, 2018).

Isolating from the experience of shame can be destructive and powerful (De France et al., 2017).

Guilt and shame (i.e., self-conscious emotions) overlap with some psychological symptoms, but they are differentiated by psychological trends, physiological effects, and severity (Shen, 2018).

Out of all the self-conscious emotions, shame interferes the most with healthy psychological functioning (Shen, 2018).

Shame and Mental Health

Shame is associated with depression, anxiety (Muris & Meesters, 2014; Muris, Meesters,

Bouwman, & Notermans, 2015), eating disorders, self-injury (Kelly & Carter, 2013; Shen,

2018), posttraumatic stress disorder (PTSD), dissociative identity disorder (DID; Dorahy et al.,

2017), narcissism, aggression (Jones, 2014; Schoenleber, Sippel, Jakupcak, & Tull, 2015), addiction (Luoma, Guinther, DesJardins, & Vilardaga, 2018), which could potentially lead to suicide (Skerrett, Kõlves, & De Leo, 2016). Shame has a direct impact on relationships and creates anxiety, , and dysfunction (Dorahy et al., 2017). People find different ways to regulate and cope with shame feelings as a way to safeguard oneself.

Elison, Lennon, and Pulos (2006) developed the Compass of Shame Scale (COSS), which is used to assess how people regulate shame. The COSS is divided into categories of internalization and externalization, and they are further divided into four categories: attack self style, withdrawal style, attack other style, and avoidance style. With the attack self style, shame SHAME AND SEXUALITY 12 is recognized, accepted, and then directed inwardly with anger and self-blame, which magnifies the feeling of shame. Individuals with the attack self style are prone to feeling the most shame when compared with all the shame regulating styles. When individuals possess the withdrawal style, shame is recognized and accepted, and people make attempts to hide and withdraw from the situation. Conversely, when individuals cope with shame through the attack other style, shame is unaccepted and unrecognized, and people blame others for the situation. When engaged in this attack other style, people experience a diminished feeling of shame through attacking others. When using the avoidance style, shame is unaccepted and unrecognized and people distance themselves from the shame feelings; this distancing is usually outside of consciousness through the use of humor, which neutralizes shame feelings. The COSS self-rated assessment allows the participants to score in multiple categories for each answer as the regulation styles can occur simultaneously and overlap (Elison et al., 2006).

Internalizing shame. The attacking the self and the withdrawal regulation styles fall under the category of shame internalization. That is, when shame responses become too prevalent in an individual, shame turns inward and anxiety and depression may occur (Muris &

Meesters, 2014). Muris et al. (2015) found a positive correlation between shame and anxiety.

Muris et al. (2015) received 126 questionnaires from parents with non-clinical children (i.e., children without a mental health diagnosis) between the ages of 8-13. Three different questionnaires were utilized to assess anxiety, self-conscious emotions, and behavior inhibition.

Muris et al. (2015) found an overlap of shame and guilt regarding anxiety symptoms, but shame was directly correlated with higher levels of proneness toward anxiety symptoms versus feelings associated with guilt. SHAME AND SEXUALITY 13

Pulcu et al. (2014) found differences in brain function with individuals who are more inclined toward shame and have a history of major depressive disorder (MDD). Through the use of magnetic resonance imaging (MRI), brain scans were completed on 21 adults with a remitted diagnosis of MDD, (i.e., there was a prior severe episode with diagnosis and treatment; however, the person did not experience symptoms or co-morbidity within the past twelve months). Fifteen of the 21 adults were not on any medications. A control group included 18 adults without a history, or family history, of MDD or other severe mental illnesses. During the MRI scans, participants were given statements that conflicted with social and moral standards and asked to rate the level of unpleasantness for each standard. After the scan was complete, participants were asked to rate each statement with more detail. The researchers found that all participants answered similarly, but the MRI scans presented a different view. There was no difference between remitted MDD clients’ medication status, nor was there substantial differences between participant scans in response to guilt. The participants with remitted MDD had MRI scans with higher activation levels in the amygdala and posterior insula when they considered the statements that invoked shame. (The amygdala and posterior insula are connected with emotional stimuli and sensory perception.) While Pulcu et al. (2014) correctly theorized activation in the amygdala, activation in the posterior insula was unexpected. The posterior insula is related to pain with temperature, touch, and affiliative touch. Affiliative touch is connected with early bonding with others, and shame anticipates rejection. Through this understanding of how the amygdala and posterior insula work, Pulca et al. (2014) validated a connection between shame and sensory perception.

The relationship between shame and addiction can be cyclical, and shame can lead to the abuse of substances, which results in more shame due to the substance use (Wiechelt, 2007). For SHAME AND SEXUALITY 14 example, Luoma et al. (2018) studied how shame affects alcohol consumption, and 70 participants who were actively drinking completed a daily survey within a specific timeframe.

On days where increased shame was experienced, there was a likely increase in solitary drinking, and this population drank alone more often and consumed more alcohol when drinking alone when compared to individuals with low shame levels (Luoma et al., 2018).

Kelly and Carter (2013) studied the connection between eating disorders and shame with

74 patients between the ages of 18-55. The participants were in an intensive hospital program for eating disorders (both inpatient and outpatient). Multiple assessments were administered and used to assess eating disorder symptoms, self-criticism, self-esteem, shame, and depression.

Kelly and Carter (2013) found that shame was a connector between eating disorder pathology and self-criticism. That is, those with higher levels of shame had an increased eating disorder pathology (Kelly & Carter, 2013).

In a study of 65 adults with chronic PTSD, 20 adults with DID, and 125 volunteers as the control group, Dorahy et al. (2017) found that participants with PTSD and DID experienced higher levels of shame versus a control group. Multiple evaluations were used to assess shame, trauma, relationship distress, and dissociation. Over 90% of the participants with DID, and almost 50% of the participants with PTSD, had high shame levels, and with the control group, less than one-third scored similar high shame levels. When the group members had a mental health diagnosis and their shame increased, pathological symptoms increased. Participants with higher shame levels had a heightened hesitation toward relationships and feared they would be rejected or exposed, which created more shame (Dorahy et al., 2017).

Externalizing shame. Attacking others and the physical or psychological avoidance regulation styles fall under the category of shame externalization (i.e., feelings of shame are SHAME AND SEXUALITY 15 deflected and directed outward). When individuals feel identity or social rank is threatened, anger, aggression, and blaming behaviors are used to prevent feelings of shame (Muris &

Meester, 2014). Schoenleber et al. (2015) found a correlation between shame and aggression in a study with 103 shame-prone men with a history of trauma. The participants completed a survey on shame and aggression and reported engaging in physical aggression (49.5%) and psychological aggression (88.3%) within the past year. A cyclical pattern occurred between shame and aggression, which further potentiated shame and increased aggression. Inversely,

Scholenleber et al. (2015) found that guilt-proneness was not correlated with aggression.

Jones (2014) wrote about shame, anger, and the persistent offender population and stated anger is used as a tool to bypass and deflect shame through the blaming of, and aggression toward, others. Jones (2014) stated individuals with an inflated self-worth or narcissism were more likely to blame or become aggressive with others; the combination of narcissism and aggression to bypass shame feelings increased the likelihood of recidivation. Thomaes, Stegge,

Olthof, Bushman, and Nezlek (2011) studied the correlation between narcissism, shame, and aggression with 175 students between the ages of 10-13. Thomaes et al. (2011) found that due to the strong need to protect the ego, narcissistic children are more apt to convert shame into anger, to lessen feelings of shame, and to defend their inflated self-worth. In addition, narcissistic children did not hold anger quietly inside, but the anger was readily expressed and observed by others.

The Impact of Shame on Sexuality

Sexuality can be described in different ways and encompasses a wide range of definitions that depend on the source and perspective. According to Funk and Wagnalls New World

Encyclopedia (“Sexuality,” 2018), SHAME AND SEXUALITY 16

Sexuality describes a person’s capacity for sexual and romantic feelings toward others. It

is an important aspect of human behavior. Humans engage in sexual behavior for

, out of , to conceive children, or for other reasons. Sexuality influences how

we behave and feel in a wide range of situations. It affects how we view our roles in life,

especially in the family, at school, in the workplace, and in our community. Our

sexuality helps define our attitudes about love and sexual relationships. Each person’s

sexuality is unique and may be influenced by family, culture, peers, religion, media, and

life experiences. (p. 1)

People experience shame around sexuality in many ways, and every person has their own story of how sexuality and shame intertwine and overlap in their lives. To understand how shame has an impact on sexuality, the following research is viewed through the lens of Schalkwijk et al.’s

(2016) “other” that creates shame: family, society, culture, and religion. The following studies delineate between gender and , utilizing different terms for separate populations. The current acronym for the community that does not identify as cisgender (i.e., identifying as the gender assigned at birth) or heteronormative is LGBTQIA+ (, gay, bisexual, , questioning/queer, asexual/ally, plus other orientations). For the purpose of this paper, LGBT will be utilized, unless researchers use a more appropriate term for their studies. Even though there is separation of populations in the following studies, shame around sexuality affects all people regardless of gender or sexual orientation.

Family

In terms of LGBT identity, parental rejection is associated with shame, which leads to depression, risky sexual behavior, substance abuse, and suicidal ideation (Bregman et al., 2013).

Skerrett et al. (2016) completed a psychological autopsy with 27 next of kin of an LGBT person SHAME AND SEXUALITY 17 who completed suicide. During a psychological autopsy, an interview takes place with someone who knew the deceased well. The purpose of the interview is to gather information about what led up to the suicide and how it had an impact on the life of the deceased (Skerrett et al.,

2016). A small living control group (i.e., three participants) of LGBT individuals were utilized in this study and completed the same questionnaire as their next of kin. Skerrett et al. (2016) found that an LGBT suicide victim was several times less likely to have an accepting mother or father. There was also a high-level of shame, a lack of self-, and dissatisfaction with appearance. In every psychological autopsy case, the deceased had a mental health diagnosis, or was diagnosable, and was more likely to have experienced physical and . As a result of this information, Bregman et al. (2013) suggested family guidance and proper support for positive identity development. In an effort to reduce suicide rates, Skerrett et al. (2016) suggested that LGBT individuals need school services, health services, and family counseling to offer proper support.

Pettersen (2013) studied the effects of shame created by childhood with 19 individuals through the Norwegian Center. The Norwegian Incest Center was founded in

1986 to create a safe space about a topic (i.e., childhood sexual abuse) that is shame-filled and creates a collective silence within the community. As of this writing, there are 20 centers throughout the country funded by the Norwegian state budget. During focus groups, shame appeared in seven different categories: emotions, family, body, food, self-image, sex, and therapy (Pettersen, 2013).

When speaking of emotions, shame was mentioned more than any other emotion and was used 203 times. In the family category, participants felt shame and responsibility for the abuse.

Participants did not feel ashamed of the abuser, yet they felt ashamed of their mothers SHAME AND SEXUALITY 18

(mentioned 123 times) who did not protect them. The body came up most frequently in the focus groups (225 times), with participants speaking about how their bodies felt shameful and filthy.

Thirteen participants brought up issues with food and shame, that is, eating too much or too little, to control their bodies after experiencing the loss of control due to the abuse. Self-image was mentioned 186 times, which Pettersen (2013) believed could be confirmation that shame is more related to how people view themselves versus the actions associated with abuse. Most participants spoke of shame around sex (mentioned 92 times) and had memories of sexual abuse stored in the body. Participants mentioned how they desired closeness with their partners, yet they felt disgusting and full of shame. At times, the feelings of and shame led to dissociation or feeling so sick they would vomit. Shame in therapy came up 68 times.

Participants associated shame with opening up and trusting a therapist. Pettersen (2013) recommended focusing on these seven categories when working with clients who experienced childhood sexual abuse to help them regain a sense of worth.

Grossman, Richer, Charmaraman, Ceder, and Erkut (2018) studied adolescent perspectives on communicating with family about sexuality and examined the difference between parental and extended family communication. Twenty-two adolescents were interviewed in 7th grade, and then, several years later in the 10th grade. Overall, most teenagers preferred to talk to an extended family member about sex and sexuality. Talking to a parent about sex felt more awkward, and there was fear of negative reactions, being judged, or , which could lead to shame (Grossman et al., 2018). O’Sullivan, Meyer-

Bahlburg, and Watkins (2001) addressed communication between mothers and daughters about sexuality. Mother-daughter discord may arise from family values and teachings that sexuality is defined by male sexuality and behavior and when mothers provide guidance about SHAME AND SEXUALITY 19 . O’Sullivan et al. (2001) found that many adolescent females who attempted to talk with their mothers about sexuality were met with either refusal to address the topic or an attempt to control the behavior through fear, moral teachings, and shame. To lessen rejection, judgement, and shame, researchers encouraged the involvement of extended family and other safe adults when communicating about sexuality during the developmental adolescent years

(Grossman et al., 2018; O’Sullivan et al., 2001).

Culture and Society

Wilson, Wiley, and Rosen (2012) examined curricula from 990 Texas school districts. The majority of these Texas schools used shame and fear-based strategies to teach abstinence. More than 94% of Texas schools teach an abstinence-only model, which means that abstaining from sexual activity is the only healthy and moral option for unmarried people.

There is a lack of medically accurate information on sexually transmitted diseases, infections, and contraceptives in the Texas sex ed curricula. Wilson et al. (2012) divided the curricula into three categories of teaching: “1) exaggerating negative consequences; 2) demonizing sexually active youth; and 3) cultivating shame and guilt to discourage sexual activity” (p. 3). In the examined Texas curricula, students were taught that being sexually active before is bad for society, can cause medical problems, legal issues, poverty, disease, low self-esteem, depression, and possibly lead to . Students who were not sexually active were described as morally superior, while sexually active teens had poor judgment and a lack of character (Wilson et al., 2012). Even though the curriculum is designed to keep adolescents sexually abstinent, statistics show that Texas adolescents rank high above national averages in sexual risk-taking behaviors and teenage (Wilson et al., 2012). These curricula SHAME AND SEXUALITY 20 promote fear and shame, along with an ineffective means of preventing risky sexual behavior and . As of 2012, Texas policymakers are committed to continuing the abstinence- only education (Wilson et al., 2012). Since Wilson et al.’s (2012) study, abstinence-only education is still taught in the majority of Texas schools (Wiley et al., 2017). A shift in statistics shows in an increase in the number of schools choosing not to teach sex education at all. Sex education is not required in Texas, with 25.1% of schools not offering any sex education, 16.6% teaching abstinence-plus education, and 58.3% teaching abstinence-only education (Wiley et al.,

2017).

Karver et al. (2016) examined how values shifted generationally around sexuality.

Participants included 19 Indigenous women from Oaxaca, Mexico, and they resided in 12 different communities that were divided into two age groups: 18-25 years and 34-55 years. Indigenous women in Oaxaca experience gender and ethnic discrimination, increased poverty, and limited access to resources (Karver et al., 2016). While values are beginning to shift generationally around Indigenous Oaxacan women’s sexuality, high levels of discrimination still exist. All participants experienced shame when they discussed sexuality, which created a lack of knowledge regarding and barriers to receiving contraceptives or control over their fertility. In this Oaxacan culture, and motherhood define a ’s worth. The older generation stated they were unable to refuse men’s sexual advances, while all ages reported an inferiority to men. If a woman engaged in sex before marriage, there was a high probability she would be ostracized from her family and community. A limitation of this study was the sensitivity of the topic, which could potentially create more reserved answers due to the shame surrounding sexuality. The researchers suggested an increase in education, services, and access to contraceptives to normalize the topic (Karver et al., 2016). SHAME AND SEXUALITY 21

“Women are essentialized and reified into a maternal body in a way that humiliates, shames, and oppresses them,” (Lalonde, 2018, p. 288). Women can experience shame around sexuality through defining their worth in terms of virginity and motherhood (Karver et al., 2016).

Sexuality and shame may intertwine with all areas of fertility, including menstruation, pregnancy, motherhood, and . Lalonde (2018) tackled the topic of denial and shame regarding women’s voluntary sterilization. In other words, women who choose to undergo a sterilization process (i.e., tubal ligation or Essure) face shame and denial of services. Denial of service is most often due to a pronatalism view, which promotes childbearing and leads to the expectation that womanhood is defined by motherhood. Women without children are viewed negatively, and these women repeatedly have to justify their choice to remain childless. The tendency is to view voluntary sterilization as a deviant and shameful choice (Lalonde, 2018).

Manago, Ward, Lemm, Reed, and Seabrook (2015) studied the connection between social media (Facebook), body shame, and ; 815 college undergraduates (467 women and

348 men) participated in the study. Participants completed a packet of questionnaires that assessed Facebook involvement, body consciousness, body shame, and sexual assertiveness.

Manago et al. (2015) theorized there would be gender differences in the results; however, minimal differences were identified. Manago et al. (2015) found that as Facebook usage increased, self-consciousness increased, which created fluctuations in self-worth and an increased to be seen as sexual. Susceptibility to body shame increased as this pattern increased, which led to a decrease in sexual assertiveness. Sexual assertiveness refers to the to speak up for sexual wants, needs, likes, and dislikes. According to Manago et al.

(2015) “Our data suggests that body shame is detrimental to sexual assertiveness regardless of one’s gender role expectations” (p. 10). SHAME AND SEXUALITY 22

According to Fehlbaum (2015), within the gay community, physical appearance is extremely important, and weight is a strong factor in sexual attraction. Whitesel (2014) posited that fat, gay men are marginalized twice. That is, a gay man’s sexual orientation is stigmatized in a heteronormative society, and he is discriminated against within the gay community due to his larger body size. Body shame about being overweight is promoted in the mainstream and gay communities, and heavier men feel unwelcome and unwanted in both communities.

Whitesel (2014) suggested safe spaces are needed for this population. Safe spaces can be used to redefine sexuality to fit all orientations and sizes, and this shift and healing of shame requires enormous and courage.

Religion

Bolz-Weber (2019) proposed a sexual reformation in Christianity to let go of shame surrounding sexuality in a belief system that historically promoted a culture of purity and heteronormativity. Bolz-Weber (2019) suggested that while being heterosexual and staying abstinent until marriage fits with a percentage of the population, a large percentage of Christians fall outside of this cultural norm, which fuels the belief that something is wrong with these people, and this belief creates shame.

Meladze and Brown (2015) studied shame with gay men of Abrahamic and examined how participants cope with the cognitive dissonance that comes from the belief that their sexuality is shameful, and most Abrahamic religious believers view as immoral. Meladze and Brown (2015) represented three main Abrahamic : Judaism,

Christianity, and Islam. Other belief systems were represented in a comparison group and included philosophical or new age religions or no religion. A majority of the non-religious men, or those who followed a philosophical or new age faith, believed their religion accepted their SHAME AND SEXUALITY 23 sexuality. The non-religious group included men who abandoned religion because they could not reconcile the internal conflict between their sexuality and religion. Most of the 133 participants were Asian and Caucasian men between 20-80 years old.

Meladze and Brown (2015) gathered their results through an online survey that measured religious orientation, internalized shame, and internalized homonegativity. Approximately half of the participants in an Abrahamic religion could not integrate their sexuality with religion because of the conflict between the two. Meladze and Brown (2015) divided the men between intrinsic or extrinsic religiosity defined by their religious orientation. Men with intrinsic religiosity believed that religion has an impact on all areas of a person’s life, and those with extrinsic religiosity were less committed to religion and relied on it more for community, comfort, and protection. Participants with intrinsic religiosity experienced higher levels of shame and internalized homonegativity. Meladze and Brown (2015) stated that mental health professionals cannot ignore the seriousness of internalized homonegativity experienced by gay men who struggle to integrate religion with sexuality. It appears it may be a counseling dilemma to successfully approach deeply ingrained beliefs to lessen internalized homonegativity and shame.

Quinn, Dickson-Gomez, and Kelly (2016) studied how homonegativity affected Christian gay men or bisexual black men. This study was specific to the black church. Quinn et al. (2016) described the important role the church plays in black communities and families, which is historically rooted in slavery and emancipation. In the black community, religion is often enmeshed with culture, family, and community and makes it difficult to separate church from the other areas of one’s life. The black church has been criticized as a source for homonegativity, which spreads to all areas of the black community. Quinn et al. (2016) completed 21 interviews SHAME AND SEXUALITY 24 with pastors of black churches, along with 30 interviews with church-going black men who identified as gay or bisexual, between the ages of 16 and 25. While the pastors universally believed homosexuality was a , they stated they would welcome all people regardless of sexual orientation. The gay and bisexual men felt differently after pastors condemn homosexuality, which created a struggle to integrate sexuality with religion. Most of the men still chose to be an active part of the church even though they felt judgement and shame about their sexuality. Because of the interconnected nature of culture, family, and community with the church, it creates a higher risk to separate from the black church (Quinn et al., 2016).

Freeman-Coppadge and Horne (2019) studied the impact of being LGBT and Christian and the decision to choose celibacy to create harmony between the incompatibility of sexuality and religion. Twelve men and women between the ages of 23 and 50 participated in Freeman-

Coppadge and Horne’s (2019) study. Seven participants identified as celibate, and the remaining five participants identified as former celibates. Eight participants reported an unsuccessful past attempt to change their . Through an informal interviewing process, Freeman-

Coppadge and Horne (2019) found that a celibate LGBT Christian was associated with shame and instability, which led to distressed functioning and development and affected all areas of their lives. Participants reported a worsening of mental health disorders such as depression, anxiety, and suicidality, along with desperation, pain, and hopelessness. Reports of increased sexual tension led to risky sexual behaviors, and many participants had multiple partners with no protection. Choosing celibacy also led to , which created secondary issues such as diminished social skills, the creation of codependent relationships, sexualizing friendships, and social withdrawal (Freeman-Coppadge & Horne, 2019). Freeman-Coppadge and Horne (2019) suggested mental health professionals must work on identity integration for those who continue SHAME AND SEXUALITY 25 to choose celibacy. In addition, mental health professionals need to find ways to alleviate loneliness as a way to decrease the dissonance between sexuality and religion (Freeman-

Coppadge & Horne, 2019).

Individual Psychology

Individual Psychology does not appear to directly address how shame has an impact on sexuality because shame is only briefly mentioned in the writings of Alfred Adler (Ansbacher &

Ansbacher, 1964). Multiple Adlerian concepts can combine to give a different perspective and a greater picture of the impact of shame on sexuality. The following research explores concepts, connections, and therapeutic interventions through the lens of Adlerian theory.

Concepts

Rudolph Dreikurs believed that all humans have the same common goal in life: to find belonging (Griffith & Powers, 2007). The Adlerian concept of lifestyle is defined as the way a person moves through life (i.e., personality). Through feelings of inferiority, early recollections, striving for superiority by means of horizontal and vertical planes, holism, increasing social interest, or any other Adlerian concept that points to an individual’s lifestyle, at the core lies the same goal: to reach for belonging. Whether belonging is accomplished on the useful side of life, or the useless side of life through mistaken beliefs and goals, all individuals want to belong

(Griffith & Powers, 2007). The following Adlerian concepts provide a framework for understanding how an Adlerian therapist (i.e., one who practices through the lens of Individual

Psychology) may address shame and sexuality.

Inferiority feelings. “To be human means to feel inferior” (Alfred Adler, as cited in

Ansbacher & Ansbacher, 1964, p. 115). Adler believed all humans experience inferiority feelings, and those feelings create movement toward striving to reach superiority or completion SHAME AND SEXUALITY 26 of the self (Lamberson & Wester, 2018). These inferiority feelings are not abnormal or bad and create all improvements in humanity. Adler (as cited in Ansbacher & Ansbacher, 1964) wrote,

No human being can a feeling of inferiority for long; he will be thrown into a

tension which necessitates some kind of action. But suppose an individual is

discouraged; suppose he cannot conceive that if he makes realistic efforts, he will

improve the situation. He will still be unable to bear his feeling of inferiority; he will still

struggle to rid of them; but he will try methods which bring him no farther ahead. (p.

257)

When inferiority feelings invade all parts of a person, Adler described this as an inferiority complex (as cited in Ansbacher & Ansbacher, 1964). Shame is closely related to inferiority feelings that are pervasive in believing that the self is less than (Lamberson & Wester, 2018).

Early recollections. Early recollections are memories of specific incidents that happen in childhood (Griffith & Powers, 2007). In Individual Psychology, it is believed that the early childhood recollections correlate with current held beliefs. Adler believed, “There are no

‘chance memories’: out of the incalculable number of impressions which meet an individual, he chooses to remember only those which he feels, however darkly, to have a bearing on his situation” (as cited in Ansbacher & Ansbacher, 1964, p. 351). As current beliefs, feelings, and issues shift, so do early recollections. The primary emotion or understanding around the recollection may shift and change, as well as other memories that may surface as individuals face different beliefs (Griffith & Powers, 2007). A mental health professional can help a client analyze an early recollection by bringing awareness to the primary emotions associated with the memory and find a connection to the current issue or belief (Griffith & Powers, 2007). SHAME AND SEXUALITY 27

The horizontal and vertical plane. In 1954, Lydia Sicher introduced the concept of movement along the horizontal and vertical planes at the Annual Meeting of the American

Society of Adlerian Psychology (as cited in Griffith & Powers, 2007). The concept of movement was used as a visualization of Adler’s ideas between striving for superiority in the self versus striving for superiority aligned with social interest (Griffith & Powers, 2007). Abramson (2015) elaborated on Sicher’s planes of movement and illustrated the vertical plane as a ladder that stretched from deep in the ground up to the heavens. Each ladder rung has room for only one, whether that is one person, one community, family, race, gender, or religion. There is no sense of belonging on the vertical plane because everyone is either superior or inferior to each other. That is, everyone is rated higher or lower than others, and relationships are in constant (Abramson, 2015).

On the horizontal plane, Abramson (2015) stated, everyone is equal with space for all to walk together; however, a need continues to exist to strive to become better with others – not over others. Rather than competition, there is a cooperation between all to overcome life issues. Those who live on the vertical plane usually have low social interest, and those who live on the horizontal plane have well-developed social interest; however, no one lives completely on the vertical or horizontal plane, but all live somewhere in between both planes (Abramson,

2015).

Holism. “Holism posits the idea that the whole is greater than the sum of its parts and that, unified, the parts constitute a new and unique whole” (Griffith & Powers, 2007, p.

55). Millar (2013) wrote that people must be viewed through the eyes of holism; every part of a person is connected biologically, psychologically, dynamically, and socially. Rudolph Dreikurs compared holism to a mosaic; holism is the ability to look at the individual personality pieces or SHAME AND SEXUALITY 28 take a step back and see the whole person (Guttenberg & Sebian-Lander, 2019). It is nearly impossible to understand a whole mosaic (person) if the focus is on just one piece of the mosaic

(person). Holism is the whole mosaic and the individual pieces observed in a simultaneous manner (Guttenberg & Sebian-Lander, 2019).

Gemeinschaftsgefühl. Adler used the German term gemeinschaftsgefühl to describe a sense of community feeling, and there is no accurate English translation for the word. According to Griffith and Powers (2007), community feeling

encompasses the individual’s awareness of belonging in the human community and

the cosmos of which it is part, and an understanding of his or her responsibility for the

way the life of the community is being shaped by his or her actions. (p. 11)

Adler agreed to use the English term social interest to describe gemeinschaftsgefühl. Adler quoted an unnamed English author to describe social interest as greater than a feeling and more of a life : “To see with the eyes of another, to hear with the ears of another, to feel with the heart of another” (as cited in Ansbacher & Ansbacher, 1964, p. 135). Social interest creates the groundwork for mental health (Millar, 2013) and must be taught and cultivated with the idea that greater social interest decreases inferiority feelings (Griffith & Powers, 2007). When individuals experience a feeling of inferiority that communicates a lack of belonging, the feeling hinders the development of social interest, which can lead to (Abramson, 2015).

Shame, Sexuality, and Individual Psychology

The impact of shame on sexuality can be seen through the above Adlerian concepts within the following illustration. When an individual feels shame about sexuality, it can affect intimacy in the bedroom. For example, inferiority feelings may have an impact on the ability to perform intimate acts and decrease the satisfaction of both partners (Abramson, 1994). The SHAME AND SEXUALITY 29 person moves to the vertical plane instead of the horizontal plane. This vertical striving feels competitive instead of cooperative and decreases social interest due to the focus on the self instead of the situation (Abramson, 1994). Holism disappears with a hyper-focus on both the problem and the shame instead of seeing the whole picture, concentrating on pleasure, and fulfilling the Adlerian life task of intimacy (Abramson, 1994).

Therapeutic Interventions

Mental health professionals can use Individual Psychology techniques to help clients who experience shame around their sexuality. First, an Adlerian technique titled two points on a line is explored as a possible solution to help clients understand and make meaning of the discord associated with the impact of shame on sexuality. Second, researchers found (Abramson, 2015;

Karver et al., 2016; Skerrett et al., 2016; Whitesel, 2014) that increasing social interest and belonging can provide a safe place to decrease shame and normalize sexuality.

Two points on a line. Dreikurs stated “One needs two points to draw a line, and once a line is drawn, one knows an infinite number of points” (as cited in Griffith & Powers, 2007, p.

102). Dreikurs developed a therapeutic method called two points on a line, which creates a fast understanding of a client’s lifestyle and personality (Guttenberg & Sebian-Lander, 2019). This technique can help the therapeutic process, promote deep insights, and improve the therapeutic relationship between therapist and client, which creates a better opportunity for change

(Guttenberg & Sebian-Lander, 2019). If holism is viewed as a mosaic, then, two points on a line would be similar to taking two pieces of seemingly incongruent mosaic tiles and attempting to find a pattern between the two tiles in an effort to see the entire work of art (Guttenberg &

Sebian-Lander, 2019). SHAME AND SEXUALITY 30

During two points and a line, the therapist gathers incongruent ideas from the client and suggests hypotheses, including the incorrect hypothesis, which encourages the client to elaborate

(Guttenberg & Sebian-Lander, 2019). The therapist listens between the lines, notices words and phrases, and begins to see a pattern emerge. This process can enhance the therapeutic relationship as the therapist shows interest, a willingness to understand, and allows the clients to become the experts of their lives. When complete, clients will have a better understanding of their lifestyle, and they are able to complete Adlerian lifestyle statements such as “I am...Others are...The world is...I am only significant when…” (Guttenberg & Sebian-Lander, 2019, p. 147).

Increasing social interest and belonging. When working therapeutically with clients,

Abramson (2015) suggested slowly guiding the client toward experiences that create a feeling of contribution and belonging (i.e., social interest). Encouraging community with clients can lead to a sense of belonging. Whitesel (2014) wrote about the double marginalization of fat, gay men, and how the non-profit group, Girth and Mirth, created a sense of belonging. Girth and Mirth created an encouraging family-like atmosphere that normalized size and sexuality for large gay men. With Indigenous women of Oaxaca, Karver et al. (2016) proposed creating educational and support programs to empower women to step away from limiting gender roles and to normalize sexuality. These programs could increase social interest and belonging. In the study completed by Skerrett et al. (2016) on LGBT suicides, they encouraged support through family counseling and school services to improve a sense of belonging and decrease suicide rates.

Art Therapy

Art therapy has been described as an interdisciplinary field where practitioners apply concepts from visual art and psychotherapy (Bucciarelli, 2016). Bucciarelli (2016) proposed a shift and suggested that art therapy should be described as transdisciplinary. Interdisciplinary SHAME AND SEXUALITY 31 implies existence between different ideas, while transdisciplinary implies moving beyond and changing to create something different. Art therapy does not simply combine art and therapy; it creates something different used to encourage biopsychosocial transformation (Bucciarelli,

2016).

Expressive Therapies Continuum

In 1978, the expressive therapies continuum (ETC) was proposed by Kagin and

Lusebrink as a way for art therapists to describe their profession through a common language (as cited in Lusebrink, Martinsone, & Dzilna-Šilova, 2013). Through the years, the ETC has been further explored and elaborated upon with an increase in the understanding of brain functioning

(Lusebrink et al., 2013). With the knowledge of the ETC and Pulca et al.’s (2014) research connecting shame with activation in the amygdala and posterior insula parts of the brain, the

ETC can be used strategically to create movement and change around shame associated with sexuality. The ETC consists of three levels of expression, and each level has two components on either side of a scale. The lowest level on the ETC is the kinesthetic/sensory level, which entails simple motor expression and involvement of the (Lusebrink et al., 2013). The second level is the perceptual/affective level, where lines, shapes, and color exist. The third level is the cognitive/symbolic level, which includes words, formation of concepts, problem solving, integration, and meaning (Lusebrink et al., 2013). A fourth level exists, which is creativity, and this level is separate from the other three levels and can occur at any level or represent integration with all ETC levels (Lusebrink et al., 2013).

The left hemisphere of the brain is associated with the kinesthetic, perceptual, and cognitive components of the ETC, and the left brain organizes information in a more linear matter (Hinz, 2009). The right hemisphere of the brain is associated with the sensory, affective, SHAME AND SEXUALITY 32 and symbolic components of the ETC, where emotional, conceptual, and spiritual connections are processed (Hinz, 2009). When one component increases on one level, the other component decreases on the same level; however, creativity can be found in both hemispheres of the brain

(Hinz, 2009). As the components are associated with brain hemispheres, each ETC level builds in complexity and utilizes a different part of the brain (Lusebrink et al., 2013).

The kinesthetic/sensory level is associated primarily with brain movement in the back of the brain, toward the brain stem, and is the first to develop in infancy, and at times, holds preverbal memories (Hinz, 2009). The perceptual/affective ETC level is primarily associated with the midbrain, which develops in childhood as lines, shapes, and colors are explored (Hinz,

2009). The cognitive/symbolic ETC level is primarily associated with the front of the brain and continues to develop at different levels as individuals learn and master the complexities of thoughts and self-reflection (Hinz, 2009).

A healthy functioning individual can successfully process information on all levels of the

ETC (Hinz, 2009). Creating brain movement within the levels of the ETC helps people process information on other levels, (e.g., when someone might be restricted and stuck in processing emotions and thought patterns; Hinz, 2009). By observing the client’s preferred activities and art medium with ETC knowledge, an art therapist can see where a client may be blocked and create movement toward healing and change. Through knowledge and training of the ETC, an art therapist can create a multitude of interventions and experientials that fit the client’s needs (Hinz,

2009).

Kinesthetic. The kinesthetic component of the ETC includes a focus on motor movement

(e.g., a toddler banging on a piece of paper with a marker; Hinz, 2009). Through the lens of the

ETC, as the focus shifts more toward kinesthetic movement, sensory awareness decreases SHAME AND SEXUALITY 33

(Lusebrink et al., 2013). In the toddler illustration above, the kinesthetic component includes an emphasis on action, movement, rhythm, and energy releasing, which makes the art medium a passive aid for action (Hinz, 2009). The kinesthetic component could include rolling, pounding, or scratching clay, hammering nails into wood, tearing paper, weaving, scribbling, or splattering paint (Hinz, 2009). The kinesthetic component can be used therapeutically to help a client raise awareness of bodily rhythms and cues to stimulate or release pent up emotions that are difficult to identify or express (Hinz, 2009).

Sensory. The sensory component of the ETC includes a focus on bodily sensation, (e.g., a young child finger painting; Hinz, 2009). The child’s focus is on the way the paint feels against the skin. Opposing the kinesthetic component, as sensory awareness increases, the kinesthetic component decreases (Lusebrink et al., 2013). The sensory component utilized in art therapy primarily employs the sense of touch, but it can also focus on smell or other senses. The sensory component could include stroking wet clay, a collage created with potpourri, shaving cream painting, and sensory exploration of items with eyes closed (Hinz, 2009). This component within a therapeutic setting can help a client ease focus away from cognitive thinking and move to a sensory experience. According to Hinz (2009), traumatic experiences are also stored within the senses, and an individual may remember the way an incident physically felt and smelled, so mental health professionals must be mindful when utilizing this component with clients (Hinz,

2009).

Perceptual. The perceptual component of the ETC includes a focus on lines and boundaries and differentiating forms and shapes (Lusebrink et al., 2013). As the focus on the perceptual component increases, focus on the affective component decreases. Pure focus on the perceptual component would be filled with shapes, lines, and minimal use of color to define SHAME AND SEXUALITY 34 forms (Lusebrink et al., 2013). The perceptual component might include contour drawings, doodling, and observational drawing (Hinz, 2009). Because of the lines and boundaries created here, the perceptual component can be used in a therapeutic setting to create boundaries to overwhelming emotions (e.g., anxiety) and safely hold the space for thoughts and experiences

(Hinz, 2009).

Affective. The affective component of the ETC includes a focus on color, tone, and value

(Lusebrink et al., 2013). As the affective component increases, the perceptual component decreases. High focus on the affective component would contain random or clashing colors with little to no form or boundaries. While therapeutic work with the perceptual component involves containment of emotions, the affective component creates space for the amplification of emotions (Hinz, 2009). The affective component may include painting to music, creating a body map of feelings, creating a collage of faces to distinguish emotions, paint pouring, and drawing or painting abstract emotions (Hinz, 2009). Utilizing this component within a therapeutic setting can increase awareness and a reclaiming of emotions, and the affective component of

ETC can be utilized when emotions are unspeakable or indescribable with words (Hinz, 2009).

Cognitive. The cognitive component of the ETC includes the utilization of problem solving, categorization, concept integration, and the inclusion of words (Lusebrink et al.,

2013). As the cognitive component increases, the symbolic component decreases. Examples of the cognitive component include game board creation (H. Smart, personal communication, June

2019) listening and following directions for an art project that requires more than two steps, drawing a timeline, and making a pros-cons or past-present collage (Hinz, 2009). This cognitive component can be used therapeutically to improve problem-solving skills. Additionally, the cognitive component can be used to increase understanding of cause and effect beyond direct, SHAME AND SEXUALITY 35 concrete experiences as clients relate learned experiences to other areas of their lives, which helps to reframe core beliefs and abstract thoughts (Hinz, 2009).

Symbolic. The symbolic component of the ETC includes global processing to give deeper, personal meaning to the integration of concepts, forms, and colors (Lusebrink et al.,

2013). As the symbolic component increases, the cognitive component decreases. Examples of the symbolic component are mask making, creating a personal coat of arms, self-portrait collage, creating symbols out of clay, and analyzing dreams and early recollections (Hinz, 2009).

Therapeutically, symbols in this component can be regressive or progressive. Regressive symbols most often “represent unconscious, archaic , needs, and urges” (Hinz, 2009, p.

148). Regressive symbols can show the origin of beliefs and help a client work through childhood issues. Progressive symbols can represent “future strivings and may reveal new goals and personal options” (Hinz, 2009, p. 148). Working with progressive symbols can create change and movement with forward momentum (Hinz, 2009).

Therapeutic Considerations

Therapeutic sessions can vary depending on a multitude of factors and consider both the client and therapist (Wadeson, 1995). The mental health professional’s theoretical orientation

(e.g., Individual Psychology) and the mode of sessions (e.g., art therapy) can influence how sessions unfold. Wadeson (1995) stated it is important for the therapist to establish rapport and create a therapeutic relationship with the client. The therapist must also assess the needs of the client(s) and create goals and a plan for treatment (Wadeson, 1995). Through assessment and goal creation, the therapist can determine if it is in the client’s best interest to move forward with individual, family, or group sessions. Frequently, a client is encouraged to pursue family (Corey,

2017) or group sessions (Moon, 2016) along with individual sessions. SHAME AND SEXUALITY 36

Family

Bregman et al. (2013) and Skerrett et al. (2016) proposed family counseling services for adolescents struggling with LGBT identity and rejection. Similarly, Corey (2017) wrote,

If we hope to work therapeutically with an individual, it is critical to consider him or her

within the family system. An individual’s problematic behavior grows out of the

interactional unit of the family as well as the larger community and societal system. (p.

422)

When mental health professionals view the client through a systemic lens, family therapy can be advantageous to a diverse population of clients (Corey, 2017). Through family sessions, a therapist can observe the family interactions and how those interactions affect and influence all family members (Corey, 2017). Family therapy is usually brief and solution-focused because the focus of the family sessions is primarily on present issues (Corey, 2017).

Group

Moon (2016) addressed the therapeutic value of group art therapy and created a list of benefits unique to art therapy within a group setting. Moon’s (2016) list included items such as (a) creating a safe space to express difficult emotions, (b) building interpersonal relationships,

(c) creating hope and shared experiences, (d) reducing isolation, and (e) creating a sense of belonging and community. Therapy groups are predominantly created with a particular population in mind (e.g., women who feel shame around their sexuality and LGBT individuals who feel rejected by family, religion, or society). is important in group formation and leads to group cohesion, which makes the group more meaningful to every member (Wadeson,

1995). As a group becomes more cohesive, more possibilities for growth and change appear, and growth and change lead to deeper therapeutic work among group members (Wadeson, SHAME AND SEXUALITY 37

1995). Moon (2016) believed there is healing power in a group setting and stated, “The experience of authentically being seen, heard, and responded to in compassionate ways is powerful medicine” (p. 181).

Discussion

De France et al. (2017), Muris and Meesters (2014), and Shen (2018) stated shame has a negative impact on health. According to Karver et al. (2016), Meladze and Brown (2015), and

Skerrett et al. (2016), shame has an impact on an individual’s sexuality. Researchers explored the impact of shame on sexuality (Karver et al., 2016; Lalonde, 2018; Manago et al., 2015;

Meladze & Brown, 2015; Quinn et al., 2016; Skerrett et al., 2016), and through these stories, mental health professionals gain an understanding of the impact of shame on sexuality and how shame can affect everyone regardless of gender, age, size, religion, sexual orientation, or culture.

Implications for Practice

When art therapists work with clients who may be struggling with the impact of shame on their sexuality, art therapists can explore this issue within family, group, and individual client sessions. Therapy sessions can be grounded in the research associated with Individual

Psychology or art therapy. The following recommended therapeutic interventions may be altered and adjusted to align with the client’s needs.

Family. Parental rejection of an adolescent’s sexuality can lead to shame, and shame can lead to depression, risky sexual behavior, substance abuse, and suicidal ideation (Bregman et al.,

2013; Grossman et al., 2018; Skerrett et al., 2016). As a result, when adolescents experience fear of rejection about their sexuality, it would be beneficial to work with adolescents in family SHAME AND SEXUALITY 38 sessions. The following interventions are used to encourage healthy family functioning, prevent rejection, or create change after rejection and a perceived lack of belonging.

Psychoeducation. When an adolescent is fearful of rejection or is currently experiencing rejection from family due to their sexuality, psychoeducation about the impact of shame could increase the potential for change and acceptance. A mental health professional can explain the difference between shame and guilt (Lewis, 1971), how shame negatively affects mental health

(De France et al., 2017; Muris & Meesters, 2014; Shen, 2018), how positive versus negative parenting correlates with shame and guilt (Mintz et al., 2017), and how parental rejection is highly correlated with feelings of shame (Bregman et al., 2013), which leads to multiple diagnoses and a greater potential for suicide (Skerrett et al., 2016). Psychoeducation can increase awareness and understanding within families and help them move toward change, acceptance, and healthy functioning.

Pour painting. Pour painting is a common technique that some artists use. For therapeutic purposes, the proposed pour painting intervention includes the affective component of the ETC. That is, colors across the canvas with few or no boundaries. This experiential involves thinning paint to make it flow more easily across the canvas with equal amounts of paint and a clear paint additive such as Floetroll or school glue. Colors and additives are mixed in separate cups, and then each mixture is poured on top of the other into a larger cup. This larger cup is then poured onto a canvas, and the canvas is rotated, which allows the paint to flow to the edges and drip off. There is an element of letting go of the outcome through the pouring process, along with a peaceful meditative quality when watching the colors flow across the canvas, which gives the clients an artful piece. SHAME AND SEXUALITY 39

Pour painting can be used with clients to dispel ideas about a lack of creativity or art skills. In addition, pour painting could be used to help clients let go of perfectionistic tendencies and create movement in the right midbrain through the affective component of the ETC (Hinz,

2009) when the client is present with the flowing color. Pour painting can also be used with the family to create something together. Every family member chooses a color that represents them, which creates a work of art that represents the whole family belonging together on one canvas.

Board game creation. Creating a board game (H. Smart, personal communication, June

2019) can include all the components of the ETC (Hinz, 2009). When used with a family, the adolescent can create a board game during an individual session to possibly present to the family, or the whole family can create the board game. This board game would have a starting point and an ending goal on the board. A possible scenario when the family creates the game together may include a game where everyone pretends to be an adolescent coming to terms with identifying as

LGBT. The ending goal on the board could be a rainbow Pride flag, which represents feeling fully accepted and content in their identity as LGBT. Problems and obstacles are made up along the way (e.g., classmates making fun of the family member or fear of exploring a drastic change in appearance). Solutions and tool cards are created to help solve the problems and obstacles (H.

Smart, personal communication, June 2019). For example, solution and tool cards could include an open door to talk to mom or dad about the issue or keeping a journal to write ideas and feelings.

The therapeutic elements of the ETC are utilized throughout the entire process of board game creation. The family can utilize the kinesthetic component by cutting out cards or going for a nature walk to find objects to represent token pieces used to move along the board. The family can utilize the sensory component through their senses while on a nature walk, or they SHAME AND SEXUALITY 40 could smooth clay figurines with their hands if they choose to create token pieces out of clay. The family can initiate the affective component by coloring or painting in the background of the board and cards, and they can initiate the perceptual component by drawing boundaries and a path from start to finish. The symbolic component is utilized to give deeper meaning to the tokens, cards, or spaces, which are unique to the whole family or to each family member.

The cognitive component is possibly used the most throughout the process of the board game creation as the family problem-solves how to create a game with multiple steps from abstract ideas to a workable, concrete finished product. This creation can also be a bonding experience for the family as they gain awareness and toward the adolescent, create solutions, and increase belonging for the whole family.

Increase belonging and social interest. Another way to increase belonging and social interest is to create family game nights. Family game nights can be a way to joyfully bring the family together for bonding experiences. If the family enjoys bonding over board games, they could extend their board game nights to include community and family friends as a way to bring people together and create social interest. This extended invitation could also include other adolescents who do not feel fully accepted because of their sexuality and create a safe space to foster a sense of community.

Group. Women can experience shame around sexuality that involves self-worth, virginity, and motherhood. This can be seen in Karver et al.’s (2016) study on Indigenous women from Oaxaca and Lalonde’s (2018) article on women who are shamed for seeking voluntary sterilization. Creating a women’s art therapy group used to address this population would be helpful in redefining what it means to be a woman and to reclaim their bodies and SHAME AND SEXUALITY 41 identities. The following interventions are possible interventions in this proposed women’s therapeutic group.

Clay figures. The prompt “What does it mean to be a woman?” can be used in a clay experiential that engages the symbolic component of the ETC (Hinz, 2009) as clients create deep personal meaning with this piece. If a kiln is not available for clay firing, air-dry clay or Model

Magic can be used. If Model Magic is used, colors can be mixed together to create new colors.

Kneading colors together uses the kinesthetic component of the ETC, and watching the colors mix uses the affective component of the ETC (Hinz, 2009). When people begin exploring clay, they alternate between the kinesthetic and sensory components as they focus on pushing, pulling, and smoothing the clay.

Clients can make symbols or figures out of clay to represent meaning associated with being a woman. When clients complete this figure, and everyone has had a chance to share, they have the choice to change the piece to their preferred meaning either by altering, making additions, or destroying the figure. This experiential can increase awareness around shame and sexuality and help create bonding and a safe space to share as group members relate to different perspectives about what it means to be a woman. The experiential intervention has the potential to create movement and a shift in beliefs about what a woman can be.

Mask making. In this proposed multi-week experiential, the group will make masks out of plaster strips, either molded onto a mask form, or molded onto their faces (Hinz,

2009). Choosing to mold the plaster strips onto faces can be a vulnerable experience, so it is recommended that the group has cohesion and members feel comfortable and safe with one another. Another consideration is to have vinyl gloves if clients do not like the feel of the wet plaster strips. The plaster strips are dipped in water and then smoothed across a mold or face, SHAME AND SEXUALITY 42 which uses the sensory component of the ETC (Hinz, 2009). Once dry, the mask can be removed for decorating.

Clients will decorate both the inside and outside of their masks using the symbolic component of the ETC (Hinz, 2009). The outside of the mask is decorated to illustrate how the client represents the self to the world. The inside of the mask is decorated to reveal what clients believe they need to hide from others. Decorations can include almost any media (e.g., magazine collage, paint, markers, oil pastels, or found objects). This experiential has therapeutic value through the process of creation and sharing with the rest of the group.

Closure. The group closure activity can include an experiential used to encourage and promote the continuation of self-care. During the closure activity, group members make spa items, which utilizes the sensory component of the ETC (Hinz, 2009). For example, members can make hand or lip salve, bath salts, or sugar scrubs.

Hand or lip salves can be made with similar ingredients of shea butter, coconut oil, and beeswax. Ingredients are melted in a crockpot and clients can add the melted mixture to a jar or tin and add their own scents and colors to personalize the experience. Clients can mix bath salts with Epsom salt, essential oils, and coloring in a Ziploc bag and pour into a jar. Sugar scrubs are created by mixing equal parts sugar and coconut oil along with color and scents. All product containers can be decorated to the clients’ preferences. Through this experience, the clients create something personal as a gift to themselves, and the items can be used after the group ends.

Increase belonging and social interest. When people share common experiences, it can create a deep sense of belonging. To further increase belonging and encourage social interest, the group could decide on a community activity or art project. One possible idea is participating SHAME AND SEXUALITY 43 in a women’s march and creating the posters together before the event. Another idea is to partner with a community or art center where group members can create an art show to raise awareness and understanding around women’s issues of shame and sexuality.

Individual. Many individuals struggle with internal conflict and experience shame when their religion does not approve of their sexuality (Bolz-Weber, 2019; Freeman-Coppadge &

Horne, 2019; Meladze & Brown, 2015; Quinn et al., 2016). When people decide to leave their religion, they may continue to carry shame associated with their sexuality. Individual art therapy sessions can be used to release shame, redefine self-identity, and reclaim a healthy view of sexuality. The following interventions include a focus on working individually with clients who want to let go of old shame and beliefs regarding conflicts between .

Early recollections. Early recollections can be adjusted to become an art therapy directive (Dreikurs, 1986). Within the context of shame about sexuality as a result of old religious beliefs, an art therapy experiential prompt could be, “Draw a memory of the first time you felt you did not fit in.” The client can choose what drawing media they desire to express the early recollection. Once completed, the client can share the memory with the art therapist as the art therapist takes notes about how the memory is described and asks about the involved primary emotions. The client is then asked to draw another picture and rewrite the story according to what they wish would have happened in the recollection using a preferred drawing medium.

Once complete and explained, feelings are explored with the new story as the client and therapist notice differences with media and colors used between stories.

The process of analyzing early recollections uses the symbolic component of the ETC

(Hinz, 2009) because the client is looking for connection and deeper meaning between the past and present. Depending on how the client approaches this experiential, different components of SHAME AND SEXUALITY 44 the ETC are utilized. Large, repetitive strokes represent the kinesthetic component, while blending chalk pastels with fingers represents the sensory component. Large color fields with minimal boundaries leans more to the affective component, while many lines, structures, and outlines leans toward the perceptual component. Shifting the story to a new outcome increases the potential shift within the client as the client processes the old memory in a new way and connects it to current beliefs and thought patterns.

Two points on a line.The Adlerian intervention of two points on a line (Griffith &

Powers, 2007) can be altered to an art therapy directive. The client can draw two points on a large sheet of paper and label each point as seemingly conflicting traits, behaviors, or beliefs that were previously stated. In this setting, possible points could be “Religion is all loving” and

“Religion hates me.” From there, the client creates a line between the points, drawing, coloring, or painting what is on the line and what surrounds it. When complete, the client and art therapist can find the pattern and connection between the conflicting statements and gain a better understanding of the client’s lifestyle. Two points on a line with an art experiential can create brain movement that utilizes the ETC and accesses new understanding and perspectives that might not be reached through a verbal intervention.

Past, present, future. The cognitive component of the ETC (Hinz, 2009) is most used in the proposed past, present, future art therapy directive, which includes the categorizing and separating of feelings and ideas associated with the past, present, and future. This proposed art therapy directive can be completed on one large sheet of paper or on three separate sheets. The client is asked to draw how they felt about their sexuality in the past, how they currently feel about their sexuality, and how they hope to feel about their sexuality in the future. A variety of mediums should be accessible for this directive to give the possibility of differentiating time, SHAME AND SEXUALITY 45

(e.g., collage materials, paints, markers, pencils, oil pastels, and chalk pastels). This directive can help create firmer boundaries between the past and present along with the potential to create hope and movement for healing and change.

Increase belonging and social interest. Encouraging the client to find a welcoming community can help to increase belonging and social interest. One suggestion for this could be through a religion or denomination that is fully accepting and welcoming of the LGBT community. Another suggestion is to find something similar to the nonprofit Girth and Mirth,

(Whitesel, 2014) that could create a family atmosphere and facilitate supportive events within the community. Encouraging the client to find a place of new belonging can promote healing from previous held beliefs of shame and rejection.

Recommendations for Future Research

In the literature reviewed for this project, it was difficult to find research on many topics that correlated with the impact of shame on sexuality. Researchers could pose the question,

“How is sex education addressed in the home?” Some schools no longer include sex education in their curricula. For example, a large percentage of Texas schools no longer offer sex education (Wiley et al., 2017), and children and adolescents receive sex education from other sources. Another possible research question could be “How does easy access to information and affect developing sexuality and the shame that surrounds it?”

Most researchers that connected religion, shame, and sexuality focused on the LGBT community (Freeman-Coppadge & Horne, 2019; Meladze & Brown, 2015; Quinn et al.,

2016). Abstinence teachings within religious communities can promote shame and affect all ages and genders (Bolz-Weber, 2019). A possible research question is “How does growing up with abstinence teachings affect individuals after marriage?” Religion affects shame around SHAME AND SEXUALITY 46 sexuality within the LGBT community; however, further research is recommended with other communities because this is an issue that affects a wide range of individuals.

Conclusion

Mental health professionals can promote healing and change with clients who experience shame associated with sexuality by utilizing art therapy and Individual Psychology interventions. With an increased understanding of the brain and utilization of the ETC, art therapy can be used to create change and movement in a client’s life (Hinz, 2009). Through the lens of Individual Psychology, increased social interest and belonging can promote the healing process in a client’s life. As a cultural epidemic, the negative effects of shame can have an impact on all areas of a person’s life (Brown, 2012). While sexuality can be a taboo topic

(Grossman et al., 2018; Karver et al., 2016), it is necessary to address sexuality within an

Adlerian holistic therapeutic approach (Guttenberg & Sebian-Lander, 2019) and view sexuality as a component of the whole person. There is hope that through increased awareness and understanding, therapists will be well-equipped to handle shame associated with sexuality. SHAME AND SEXUALITY 47

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