Category Archives: COUPLES

Sex and Medication

by Zelik Mintz | Leave a comment

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

by Zelik Mintz | 1 Comment

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?

by Zelik Mintz | Leave a comment

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.





My Analytic Dilemma

by Zelik Mintz | 1 Comment

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

by Zelik Mintz | Leave a comment

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.



Teaching Couples to Empathize

by Zelik Mintz | 1 Comment

Empathy forms the cornerstone for a successful therapeutic relationship.  While we may find empathy difficult to establish or even define, it is vital for building trust and engendering communication.

When working with couples, empathy is complicated because the therapist must, in addition to conveying empathy to each individual, teach each member in the couple to empathize with each other.  Within this triad, the danger of rupture is real, and the work, perilous.

In couples’ therapy I begin by framing the issues as they’ve been presented.  I make it clear that such problems will be considered on a 50/50 basis.  That this is imperative is obvious – I’m not going to take sides or make one person the sole cause of a problem. When a member of the couple feels that responsibility for a particular action (or non-action) resides with the other, I remain rigorous in holding to the premise that responsibility is shared equally.  I never treat an issue as though it were one person’s fault even when pressured by a member of the couple to do so.  I have found that this egalitarian approach is eventually accepted by the couple and contributes greatly to the balance of the work.

Virtually all problems with couples result from misunderstanding and a lack of communication.  Once I’ve taught the couple to behave in an empathic way, issues long cemented shut through repetition are revealed such that the couple can view the problem from a different perspective.

Sex and money are the most problematic and intractable issues in most relationships because those issues are really about much more than just sex and money.  Couples generally have assumptions that issues like sex and money will be complimentary and problems suggest dysfunction in the relationship.  But in fact conflicts in relationships are natural when two people merge their lives, each of the couple bringing into the relationship the entirety of his or her histories.

I often work with couples who have a substantial sexual problem, mostly when sex has ceased to be an expression of intimacy.  This is probably the most difficult area to facilitate change and growth.  

I worked once with a couple who had a total breakdown of physical intimacy, each blaming the other for   the dysfunction.  The man in the relationship had closed down and was not capable of physically or emotionally initiating or following through with physical intimacy.  His early sexual trauma was reactivated when he shared it with his girlfriend.  The woman blamed her boyfriend for not being attracted to her anymore (their early sexual relationship was very good) and angrily accused him of distorting his history.  This created a serious rupture of trust that caused the man to shut down.  I helped each of the couple talk about their pain – she of being rejected, he of not being trusted and cared for.  This reframing helped them feel empathy for the other.  The couple did not stay together but they were able to part with understanding and compassion.

Such understanding, compassion, and honesty are necessary for establishing empathy and replace defensiveness with loving communication.  The role of the therapist is to model empathic behavior and help each in the couple accept and appreciate their differences as well as similarities, furthering an emotional maturity in which a healthy relationship thrives.

Sensuality, Sex, & Relationships

by Zelik Mintz | Leave a comment

Couples are often at a loss when inevitably infatuation runs its course and the topography of sexual desire shifts. As a relationship matures, the initial lust abates and familiarity and predictability become the norm. Couples who seek counseling to reaffirm their sexual relationship often expect their sex lives to be as they were at the beginning. While that early phase cannot be revived, sex can function in a mature relationship to deepen a couple’s connection in profound and exciting ways. Embracing this shift often requires considerable work and experimentation.

Many factors contribute to loss of lust in a relationship. As couples become more familiar, they take each other for granted. Mystery and fantasy give way to compromise and predictability. Sex becomes routine and just another chore along with work, children, and bills. As sex becomes something to check off a list, it loses priority, becomes less frequent and can slip completely out of a relationship. I have worked with many couples who enter treatment because perfunctory or nonexistent sex is causing a major rupture in their relationship.

Many couples seek treatment in an effort to have the early magic reaffirmed; if it is not, they fear their relationship is dysfunctional and may even break-up. In such cases I first get the couple to bring sensuality into their relationship without any pressure to perform. Most couples think of intercourse as necessary for sexual intimacy, but through experimentation without the expectation of intercourse and orgasm, couples can learn to experiment with each other in new sensual ways. I help couples establish sensuality in their relationship that isn’t necessarily tied to sex. This helps couples develop a renewed awareness of each other’s bodies, redeveloping what had been lost by neglect.

Often, without the pressure to perform, touch becomes more sensitive. The boundaries between sensuality and sex become blurred and couples learn to put less importance on the hard line distinctions between the sex act and what feels erotic. I suggest that couples be playful when exploring sensuality to help move the focus away from the pressure to perform. I then suggest a gradual physical exploration, slowly moving the couple towards a more genital experimentation. This process helps the couple find, develop, and renew their physical intimacy without pressure and expectation.

With work and commitment couples can develop a new, exciting, open and fluid sex life that is an expression of their emotional intimacy. This new mature physical intimacy is deeper because it is an expression of the bond between the partners rather than an expression of lust toward the unknown.

When Lust Changes

by Zelik Mintz | Leave a comment

We often suffer from a misunderstanding of how our romantic relationships mature. Many of us fail to realize that, in a relationship, our feelings of lust naturally change and usually decrease.  This runs as a counter current to a society obsessed with sexual images and infatuation.   Madison Avenue and Hollywood, with their stories of romantic bliss, contribute to this misuderstanding by manipulating how couples view sex within relationships.

Sexual desire plays a major role in a budding relationship.  Infatuation is in full bloom and is driven by fantasy, need, and mystery.  For months or years lust remains strong.  It draws two people together such that they continue to learn about one another.  Often, however, reality butts up against fantasy and replaces feelings of excitement with those of disappointment.

When a relationship goes through a phase of diminished lust, many assume that something is wrong when, in fact, the relationship has entered a new more mature stage.  This maturity can deepen both love and sexual excitement but it will look very different than infatuation.  If both partners expect their lust to be as it was in the beginning, they may grow apart instead of deepening their physical and emotional bond.

I have worked with many couples whose bond has ruptured because of sexual dysfunction.  Because change in lust is interpreted as dysfunction, couple want to either get that lust back, look outside the relationship for satisfaction, or terminate the relationship.  If enough time passes without sex, thoughts of reviving it again seem insurmountable.  As a non-sexual relationship becomes the norm, sexual thoughts about the other partner can often feel incestuous.  By working on sensitization, empathy, experimentation, and risk, sex can often be rekindled, and what was once infatuation will be replaced by a deeper and more profound physical bond.

Our society, through media and advertising, teaches us to expect physical intimacy to be universally magical, spontaneous, and exciting.  Instead, intimacy is as complicated as life.  The couple needs to work on their sexual intimacy and establish a different but deeper physical satisfaction.