Category Archives: THERAPY
Getting High and Sexual Intimacy
Alcohol and drugs are often used to relieve anxiety during sex. However, in addition to leading to dependency, they can also lead to psychic and physiological dysfunction. While getting high may ease the discomfort involved in “hooking up,” it can also become a prerequisite to sex and damage one’s ability to create authentic intimacy.
Even though having sex while high may create the impression of deep connection, this experience is largely illusory. Because this depth of experience is mistaken for reality, the need to be high becomes an integral part of sexual relatedness. In addition, those whose anxiety is relieved by drugs are even more likely to become addicted to being high when physically intimate.
The establishment of healthy sexual functioning is a virtual minefield. For adolescents, coupling sex with getting high can abort the normal learning process that occurs during experimentation. Getting high then becomes a prerequisite for sex early in life.
Many substances heighten sensation and create a sense of the profound. This heightened physical and psychic experience leads to an intensity that is, of course, purely chemical. While alcohol may cause a dulling effect and even lead to blackouts in which memory becomes blocked, other substances create a false sense of connection. When two people have taken substances that blunt anxiety around sex, we have a couple coming together in a hazy and unreal way. Some substances even create the sense of intimacy while actually blocking one’s ability to relate to another person. When the substance is removed, one’s partner may suddenly seem like a stranger or become, all at once, dull and boring. The end result is that sex without substances may seem uninspiring at best.
I worked with a gay man who was addicted to crystal meth. He claimed that the drug allowed him to feel uninhibited around and during sex. We worked on the addiction and my patient started going to 12-step Narcotics Anonymous meetings. Because of our work and the support of the program, he was able to stay clean and get his life together. Being able to relate sexually with others, however, was proving to be a more difficult endeavor. Because he had used meth for his whole adult life—he was now near 40—the prospect of having sex without being high was unimaginable. Because of his frustration, he avoided sex, never having learned how to relate sexually while sober. Eventually over time he began to engage sexually, while being clean, and entered into a long-term relationship. It had been a difficult road.
By no means is this phenomenon limited to crystal meth; I had an almost identical problem with someone who used marijuana.
Many people go to bars to look for a date or to hook up for sex. This, of course, leads often to drinking. While alcohol indeed reduces anxiety, it can impede relating in a realistic way. I’ve often been told tales of people hooking up in bars only to realize in the morning that they brought someone home whom they can barely relate to or to whom they’re not even attracted. And while the result of such experiences is typically embarrassment and regret, these are rarely enough incentive to stop the behavior.
Sex is most meaningful and intimacy most real when the mind is sharpest. When sexually stimulated by another human being, and not a chemical, authentic intimacy can flower and profound connection can be established. Instead of a chemically induced fantasy, the groundwork is laid down for genuine relatedness.
Sex and Medication
Medications provide enormous relief from acute or chronic pain, dysthymia and depression. When physical or psychic pain interrupts optimal functioning, opiates and anti-depressants can relieve suffering and help debilitated people lead normal lives. But even when taken as directed to address pain, side effects from these medications can cause serious sexual dysfunction. In addition, opiates are rife with the danger of addiction and abuse.
Many people taking these medications end up choosing between relief from pain and an active sex life. When those taking medication are in a relationship, both partners can contribute to the decline of physical intimacy.
Medications can cause lust to dissipate and sex drive to plummet. For men, failing to achieve or maintain an erection can cause frustration and leave the partner feeling rejected. Healthy communication can alleviate some of the discomfort, but because sexual issues within a couple are so difficult to talk about, communication easily breaks down, leaving each partner in the couple isolated and distressed. If this issue festers long enough, a couple’s sexual dysfunction becomes the norm such that even after discontinuing medication, sexual dysfunction can be very difficult to reverse. Both partners must be willing to risk discomfort talking about sexual issues and establish open dialogue to repair what has been lost.
Since discontinuing needed pain medication is not a beneficial option — pain itself inhibits sexual performance – couples must learn to override a lack of lustful feelings with sensitivity and empathy. If one partner is experiencing feelings of rejection because of the other partner’s lack of interest in sex, it’s helpful for both partners to establish an open dialogue. Such a dialogue permits the couple to distinguish between drug-induced rejection and rejection that might arise from other causes. Above all, it’s important to remember that pressure inhibits sexual feelings. By expressing hurt and rejection, caused by insecurity, one partner can exacerbate the problem by pressuring the other to continually reassure sexual interest and attraction.
Penetrating the wall of drug-induced frigidity takes diligence and work. Sensitive touch and physical openness without pressure to perform can help the medication-taking partner relax and enjoy non-genital physical intimacy for its own sake. Relaxation can open up sexual intimacy and break through a partner’s medication-induced disinterest in sex.
I worked with a couple who for many years had a healthy sex life. However, when the husband was put on Oxycontin, a time-released opiate, for chronic pain, their sex life broke down. The medication managed the pain so the husband could function normally but it left him with no interest in sex. Because Oxycontin was by far the most effective medication for his pain, he became resigned about his disinterest with sex and his wife felt shut out and undesirable. While the couple was able to address and work through most of the problems in their relationship, when it came to sex, the issue was fraught with discomfort. Instead of being able to talk through the problem, the wife would try and seduce her husband or ask for sex, only to be rejected. This left the wife feeling hurt and isolated. Both were aware of their loss of physical intimacy but were not able to help each other reestablish a physical connection. Finally, through suggestion and exploration, I helped the couple establish a reawakening of their physical intimacy. Beginning with non-sexual touch, without sexual pressure, and slowly adding sensuality, the couple learned new ways to be physically intimate. The slow progression took the sting out of hurt feelings and helped the couple communicate physically without needing to have lust drive the physical encounter. Both the husband and wife were able to relax around this issue and build a satisfying sex life. It was not the same sex life as before, when it was driven by lust, but one equally rich, deep and connected.
Our society teaches us that sex is driven by lust; if people are attracted to each other, sex is unproblematic and easy. If and when sexual problems arise, people rush to the conclusion that the relationship is dysfunctional and needs to be reassessed. Any sexual problem in a relationship needs to be addressed with compassion and empathy. When medication is deemed appropriate for physical or psychic pain, the solution should not be a choice between pain and sex. When a couple learns to incorporate changes within their sexual relationship, there comes about a new and satisfying sexual intimacy.
Love and Substance Use
Drugs and alcohol provide an illusion, an illusion that ranges from love to despair. Many substances evoke both positive and negative feelings, euphoria and anxiety, side by side, with the negative emotions typically following the positive. This affects the user’s emotions and perception of reality, and subsequently the stability and wellbeing of a couple.
The affect of drugs and alcohol on a couple will vary with the frequency, the social context, the kind of dependence and the kind of substance. A relationship is also affected by whether one or both partners partake. When feelings experienced while “high” are confused with “real” feelings, serious ruptures and rampant misunderstandings are likely to adversely affect healthy romantic interactions. While this phenomenon can occur in any kind of relationship, the intimacy of romantic relationships exacerbates this dysfunction.
Keep in mind there is a difference between use and abuse. When individuals choose to put a substance into their body, they aren’t necessarily affecting their relationships or their ability to function. However, addictive use and, at times, periodic recreational use, may cause a serious rupture within a couple. This may be followed by recrimination, dishonesty, misunderstanding, and a breakdown of empathy.
Many substances foster feelings of omnipotence that lead to narcissistic behavior. This clouds empathy and sensitivity and makes it easy to disregard others’ feelings and needs. When feelings of euphoria are prominent, one can seem to be highly empathic to others when, in fact, the feelings are originating from the user’s own narcissistic needs. Although being high may seem to heighten connection between people, it ultimately separates people in a haze of unreality. This can be most acute and damaging within a couple – particularly when such feelings and behavior exacerbate dysfunctional communication already problematic in the relationship.
I am working with a gay male couple who have been together for 6 years. The partners have different cultural histories which causes some friction in the relationship. They both use drugs and alcohol recreationally, mostly when going out together to socialize. When they are home alone together, they claim to be content and argue little. They do, however, have issues of trust and when they go out and take club drugs, the trust issues explode and feelings of insecurity, paranoia, and heightened sexuality come to the forefront, exacerbating the milder mistrust that already exists. While this couple uses drugs relatively infrequently (they say 5 times a year), they will binge for days at a time, leaving them rife with drug-induced depression. This occasional drug use has caused havoc in the relationship and has led the couple to seek treatment. Most of my work has involved separating the issues caused by the substance use from those occurring in the couple’s everyday lives. It is not an easy task since the conflict provoked by the drug use bleeds so easily into the pre-existent mistrust.
Another couple I worked with had been together over two decades. They had a loving healthy relationship and had come into treatment, not because there were major problems, but rather to keep and maintain open lines of communication. They both enjoyed a nightly glass of wine before dinner. One of the partners started drinking a strong margarita instead of wine during their pre-dinner ritual. While a glass of wine didn’t affect either’s ability to relate, the margarita drinker became very high and lost his ability to communicate in any realistic way. Because of this, his partner felt shut out and asked that his partner refrain from drinking hard liquor at those times and go back to a glass of wine. Because both in the relationship were sensitive to each others’ needs, and listened to and respected each other, the margarita drinker, not wanting his inebriation to cause conflict in the relationship, went back to wine. If the couple hadn’t already had good communication skills, the drinking could have created a major rupture.
Substance use often creates volatility and unpredictability in couple relationships. Unless monitored with honesty, understanding, and open communication, drugs and alcohol can cause serious ruptures between partners. Left unaddressed, these ruptures can develop into a breakdown of the relationship. Unreality and erratic mood overtake any ability for healthy communication.
When is Silence Golden?
Silence can be very difficult to tolerate for both the analyst and the patient. In fact, because so many patients want an active and engaged therapist, I often fear that protracted silences may even drive the patient away and out of therapy. While ongoing silences can be rich in psychic material, I have found that silences are often misunderstood. And unless the patient has an understanding of how therapy works, silences are not particularly useful. It’s essential to initiate patients to the therapeutic process by first establishing a safe and empathetic environment that gradually allows them to tolerate longer silences.
Difficulties with silence are not the patient’s alone. I struggle with longer silences as my reflex is to intervene with a question or statement to alleviate my patients’ (and my own) anxiety. Because of my discomfort, my impulse is to replace the silence with action. An important part of the therapeutic process is figuring out whose feelings are whose and when to break the silence. It’s essential, of course, that I don’t break the silence out of my own anxiety, but only when the patient’s anxiety is becoming unbearable for him or her, not for me. Intervention at an inappropriate moment can interfere with the patient experiencing feelings that need to be experienced. At other times, a question or statement that breaks the silence helps the patient feel more secure in the room.
In classical analysis, silence is an essential tool. The classic theory is that the patient should lead the treatment; if the patient is silent, the therapist waits for him or her to engage. While this approach is clearly valid, many patients find it helpful if, at times, the analyst leads. But with the analyst leading, there is of course the danger that the treatment will follow the therapist’s agenda and not that of the patient.
It also makes a difference if the patient is lying down on the couch or is sitting in the chair, facing me. Invariably, those who lie on the couch find it easier to endure silence.
A couple of examples illustrate this dilemma:
I had a patient, a man I had seen for many years, who came in one session, lay down on the couch, and remain silent throughout the whole session. I struggled silently with whether to intervene, at what point, and whose anxiety was whose. I decided to let silence reign and not let the anxiety — which was no doubt at least partly mine — compel me to action. At the end of the session, my patient sat up. He then thanked me for allowing him the space to sit with him without verbalizing. He said that he really needed that time to just be. I was happy that I didn’t succumb to my own discomfort and ask a question or give an interpretation.
A patient I’ve been seeing for a number of years comes into each session with nothing to talk about. He depends on me to ask questions and even after years of treatment, is very resistant to bringing in material for us to explore. He is someone who cannot access his feelings and for whom unconscious resistance has thwarted his treatment. After a long period, I decided to allow him his resistance and accept his need for me to elicit details of his week. Since he cannot access his feelings, exploring occasional silences has been fruitless. He needs me to check in with him to ground him and prevent him from fleeing as a result of his unconscious resistance. As I tailor each treatment to the needs of the patient and the dynamics of the dyad, I accept my more active role with this patient because the circumstances clearly warrant it.
Protracted silences present a dilemma for the analyst. I often explore these silences and the non-verbal feelings they induce. Such exploration allows me to discover vital information about the patient. On the other hand, when silence is intolerable for the patient, I learned to respect this and offer action that helps the patient feel safe and secure.
A Political Dilemma
What happens when a patient expresses a feeling or opinion that induces strong counter-transferential feelings in an analyst with passionate political opinions and views? The classical viewpoint, of course, is to keep such thoughts to one’s self. But what happens when the patient exhibits attitudes that are clearly prejudicial and at times even abhorrent to the analyst?
Following the old adage that the personal is indeed political, I am proud of my activism — albeit with age it’s more verbal than active — but at the same time I am committed to creating a safe and empathic environment for my patients.
As an analyst, my role is not to educate about politics or to explore prejudice even if what I hear is hostile bigotry. Yet, when I am confronted with thinking that I find offensive or culturally dangerous (albeit only verbal), my emotional response is the same as it would be outside the office. Do I remain silent? Will my own need for exploration represent my agenda rather than that of my patient? And how do I prevent such thinking from influencing my view of that patient?
Fortunately I am not confronted with this dilemma often. When it has happened, I have remained silent and let myself be with my counter-transferential feelings. But this does leave me wondering as to what might be a helpful and ethical intervention.
A patient of mine had consistently expressed his dislike of lesbians. When he was particularly angry, he referred to them as “cunts.” Since I’m very sensitive to sexism, the use of that word left me bristling. Because I continually remind patients that I want to hear all their feelings, I never responded. But I did struggle silently with whether to explore his animosity (my own agenda) or continually listen as he expressed his anger. Although we often worked on his anger issues, when he used that word I ultimately held and respected his feelings with silence. I often wondered if there would come a point when I might lead my patient to explore his prejudicial views. That time never came.
Many years ago I had a patient who was conservative politically and had no patience, sympathy, or understanding of minorities’ position in society. At one point he referred to Hitler as a great man. I asked him what he meant by that and he referred to Hitler’s power. I did not go any further with the comment, thinking that to do so may feel to him like an attack. Nothing else was said by this patient during the time I saw him that would allude again to the Hitler comment. That comment still haunts me all these years later. I often wonder if and how I might have responded differently to hearing something so abhorrent.
While these are extreme examples, there have been many subtler examples that contribute to this same dilemma. I wonder how much of my commitment to bettering society might extend to my one-on-one relationships with patients. Although I always err on the side of caution, I continually wrestle with how my silence as a therapist ultimately conflicts with my passionate political commitment to affect change.
My Analytic Dilemma
Few issues stir up more emotion than those revolving around HIV/AIDS. While the face of the disease has changed radically in the U.S., sero-conversion to HIV+ is not as rare as it should be. While my own views are no doubt colored by 3 decades of working with people with HIV/AIDS, I can be particularly blunt when confronted with a patient who is practicing unsafe sex.
Even though I always express thoughts with care and concern, my directness runs countercurrent to much of what I’ve been taught — that the expression of opinion should be kept out of the treatment. However, when dealing with HIV and AIDS, my concern for my patients’ physical wellbeing trumps my training.
An HIV+ patient was frequenting sex clubs and not always practicing safe sex. He justified this by assuming everyone else who didn’t practice safe sex was HIV+ or didn’t care. When I probed a little deeper, it became clear that he mostly feared stigma and rejection. My patient claimed that it was the equal responsibility of the other person to inquire about or divulge HIV status. He stated that his partners bear the ultimate responsibility for their own actions. After continuing to press the subject, I let go of my reservations and made clear the importance of self-disclosure for keeping both my patient safe from further infection and any of his partners safe. Clearly this was my own agenda, not my patient’s, and trumped any of my analytic training.
Another patient, who for many years had been desperately seeking a romantic relationship, was finally falling in love with a man with similar feelings. My patient also periodically went though strong hypocondrical fears around minor health issues. Two months into the relationship, my patient and his new boyfriend went to get tested for HIV. Delighted when the tests both came back negative, my patient made it clear upon inquiry that they were now going to have unprotected sex. After exploring the issue in session, I asked my patient if I could give my thoughts on the subject. He readily agreed. I expressed my concern that after two months of dating he barely knew his new boyfriend and was making a potentially devastating decision of trust extremely early in the relationship. He listened attentively and showed appreciation, but at the same time pointed out that my point of view was colored by my own experiences with AIDS during the ‘80s and 90s. Despite my feeling strongly that my history was not relevant to my concern, I refrained from pressing the issue.
Some therapists might view such patient behavior in an even more dismal light, and equate it with inflicting inward or outward violence. While this is a common attitude, the issues involved are much more nuanced and complicated and while I’m certain that my interventions were appropriate, I must remain vigilante in avoiding the simple expression of opinion instead of vital and necessary intervention.
An Analyst’s Advice
Most of my patients come to me seeking advice. Since I was taught that advice inhibited the analytic process and was not helpful to the patient, it has only been after two decades of work as an analyst that I have found this strict orthodoxy did not always reflect what is best for the patients in my care.
According to Webster’s, advice is “an opinion or recommendation offered as a guide to action, conduct, etc.” To advise is defined as “to give counsel to; offer an opinion or suggestion as worth following.” While it’s unlikely that I would ever proffer an opinion to a patient, I might, on the other hand, find myself giving counsel or recommendation. Clearly there is a distinction between giving counsel or recommendation and advancing an opinion.
While some might say I’m unorthodox, at times I find that giving advice is the exactly appropriate course of action. Working in the trenches has taught me the need for flexibility when applying the precepts of psychotherapy to the needs of a patient.
Several years ago, I treated a man who had difficulty maintaining an erection when having sex with his girlfriend. While Viagra was helpful with sustaining an erection, the medication inhibited an orgasm. This problem had been ongoing since the beginning of their relationship. At one point I asked him if and how his partner’s orgasms might play a role in their sexual dysfunction. Nonplussed, he said he had no idea and had never thought to ask. My thinking was that if the focus of their sexual difficulties was only on him, satisfying her may open up their sex life in new ways. I recommended that he approach the topic with her and do his best to break the sexual stalemate. By advising him, I allowed him to talk about the difficulties he had expressing sexual thoughts.
Another patient who was in a long-term relationship became infatuated with a co-worker and was having an affair. She felt very guilty about the affair and put an end to it while she contemplated what to do next. But because she saw her co-worker every day at work, she found herself being pulled into continuing spending time with her. This was confusing and only exacerbated her guilt. I thought it would be helpful to establish boundaries with her co-worker. I helped her set ground rules governing how much time she spent with the other woman. By working with her and advising her around boundries, I helped her clarify her needs and feelings.
As therapists, we must remain open to what may be best for those patients in our care. While there are many theories and modalities on how to best treat patients, it’s essential to remain flexible. I find that being open and eclectic, even at times giving advice, serves the people I treat and best yields improvements to their mental health.