Prime

I have just finished watching the movie "Prime," starring Merryl Street and Uma Thurman. In case you haven't seen it the premise is that a 37 year old, recently divorced woman (Uma Thurman) falls in love with the 23 year old son of her long-time therapist, played by Meryl Street. The therapist realizes fairly early on that Uma's paramour is her very own son, and makes the decision not to tell her client that she has realized this.

Did anybody else feel entirely too discomfited by the dishonest way in which the therapist handled her ethical responsibilities towards her client? I felt as if I was crawling out of my skin sitting on the couch watching her. I guess this is one more awful representation of therapy professionals to add to my ever-growing list. I asked family members watching the movie with me what they thought of Meryl Streep's portrayal of a therapist, and whether they would have felt safe and comfortable with her as their therapist. Comments were that she was (a) giving too much advice and not giving the client any room to breathe (b) putting her own interests ahead of those of her client (c) confusing her own issues with those of the client (d) making her client uncertain, confused and bewildered by her antics, while denying that she was acting any different or feeling anything unusual and (e) being affected and annoying!

Once the therapist realizes that Uma Thurman is dating Meryl Streep’s son, it becomes increasingly apparent that the therapist is using the client’s sessions to find out information about her son.

Contrary to Streep’s representation of how therapy is conducted, therapy is NOT about a clucking maternal figure, “chatting” with a client and hand-holding their way through a session, while commiserating, in clichés, about how hard life is! A therapist should be able to challenge their clients to see their lives in new and different ways, not alternately soothe them into oblivion with well-placed platitudes about love, romance and religion and the occasional affectionate patting of cheeks.

I’m still shuddering.

Dual Relationships

I decided to write this blog after receiving a comment recently by somebody who became romantically involved with their therapist and was seeking advice for how to handle the outcome.

In my own experience as a client, it’s definitely a huge bonus if the therapist is friendly, warm and caring. But the ethical guidelines that govern therapeutic relationships, no matter what type of therapist you are, always maintain strict rules around what are known as dual relationships. Therapy relationships are one-sided for very good reason. As much as your therapist loves you and/or you come to love your therapist, they will never and, in my opinion, should never be your friend or romantic partner.

Clients take a huge risk in opening up to a therapist. Most people coming to therapy usually start from a place of extreme vulnerability and unease in their lives. Maybe they are in a shaky marriage. Perhaps they are beginning to look at their sexual orientation. They may recently have begun to work on their sexual abuse history. They may have just lost a significant relationship in their life. Or perhaps they have had a miscarriage or a child has just died. Whatever the presenting issue, people rarely come to therapy because they are so gosh-darned happy, that they need to sit down with a complete stranger and talk about it. The nature of this relationship automatically creates an imbalance of power and it is the therapist’s job and professional duty to uphold the boundaries between him/herself and the client. Any time your relationship with a therapist is anything but a therapist and a client, that is considered a dual relationships.

One important perspective that all therapists need to maintain is the ability to put their clients needs above their own. If I have a clear and vested interest in having some of my important emotional, physical and psychological needs met from my client in the context of a friendship and/or sexual relationship, how can I remain committed to putting them first? Any time a therapist is in a position where they cannot put their client’s needs above their own, they are on shaky ethical ground and it is their responsibility to make the decision about whether the therapeutic relationship is moving (or has moved) into dual relationship territory. Many dual relationships have innocent beginnings, (for example, you find yourself in the same book club as your therapist, or he/she is on the PTA, or n your local community watch group, etc.) but can quickly become exploitative and harmful to the client.

When data from national studies were measured, it was shown that 4.4% of therapists (7% of male therapists; 1.5% of female therapists) have had sexual relationships with their clients. The ethics codes of ALL mental health professions prohibits sexual relationships between clients and therapists, precisely because there is a recognition of the potential for psychological damage from these relationships developing. The most common emotional outcomes for clients who have become involved in a sexual relationship with their therapist are feelings of emptiness and loneliness, difficulty trusting in relationships, confusion over boundaries and the nature of helping relationships, an increased risk of suicidality, anger, feelings of guilt, hesitance and indecision in making life choices. On top of this people often find that their feelings fluctuate wildly, and report feeling out of control and an increased feeling of unpredictability in their lives. When research has been carried out on the outcomes for therapeutic relationships that became sexual in nature, in almost all cases the experience of the former client is predominantly negative. In addition, therapists who engage in sexual relationships with their clients rarely stop at just one client – they have often had multiple other sexual relationships and often choose the most vulnerable clients to initiate sexual contact with.

If your therapist has initiated sexual contact with you, or has offered to terminate therapy so that you can become involved in a relationship outside of the therapeutic context, I suggest that you seriously consider contacting another therapist. If the therapist is licensed or affiliated with a nationally recognized mental health association, consider contacting the association to ask them what action they suggest you taking. Clients frequently get “crushes” and/or fall in love with their therapists. These are complicated feelings to navigate and it is imperative that the therapist remain professional, impartial and maintain strict physical boundaries in order for clients to safely explore these feelings. The power imbalance in a therapy relationship rarely goes away, after either friendship or a sexual relationship has been established, and the power is nearly always in the therapist’s favor.

Taking Care of Business

It’s Monday. I rarely see clients on Mondays. It’s a day for catching up with my reading,(professional journals and books and the new waiting room “Oprah” magazine, before it goes out to the waiting room!) returning calls to prospective clients, paying bills and doing paperwork. Every other Monday I have lunch with my friend Doriana, a Neuropsychologist and Italian born. But not today.

While I talk about Mondays as “my day off,” I’m still hard at work taking care of some of the important aspects of being a psychotherapist –the minutiae of running a business. For example, in my office sits a bright red suede loveseat. I fell in love with it two years ago, and since then its cheerful red has become somewhat soiled and dirtied by the fingers of anxious clients. While waiting for Carpet Busters to arrive and perform miracles on the couch, I return a call to a guy called Steve, from a health club in Watertown. He wants to know if I’d like to be the exclusive therapeutic referral source for clients from their fitness club membership. This “referral source” honor will cost me $800 per year, and for this I get to be the only psychotherapist who advertises in the foyer of the health club. I tell him that I’ll get back to him. My practice is already full, and don’t know if I can handle any more referrals. I call a colleague, Bettina Dee, a wonderful EMDR therapist in Watertown Square, and ask her if she’s interested in using the advertising slot. She is and says that she’s very appreciative of the opportunity. Bettina moved to the Boston area from California, where she had a thriving clinical practice. She’s just launching her practice here, where her clinical specialty is working with women who have had traumatic birth experiences.

As I type, I have a very friendly young man here from Carpet Busters in Waltham, MA, cleaning both the couch and my carpeting. When I pointed out the love seat and the specific areas I wanted him to concentrate on, he said, “I bet that’s tear-stained.” Good observation. And coffee-stained, pen-blotched and greasy where anxious people have grasped the arms of the couch and clung on for dear life. If only a fresh couch could be a fresh start for all the couples who sit on this couch, working so hard to make their relationships work.

As Guy, the carpet man, works on cleaning my rugs and couch, we chat backwards and forwards about what I do and about where I’m from, and about his business. It turns out that he’s been to Portsmouth in the south of England. Like 250 million other people I’ve met in the last 20 years while living in the US, he comments that he “loves” my accent. By the end of the visit, bringing cleanliness and order to my cozy little office, he’s pronouncing the word “dirty” with a delightful British accent as “dirty” with a “t” instead of a “d” – as in “dur-dee.” I point it out to him and he looks embarrassed, but seems pleased. When people tell me they love my accent, I frequently tell them that I like theirs. Most Americans are stunned. “I have an accent?” is a frequent response. I have one adolescent client who loves country and western music. On one occasion, she was playing me her favorite C&W song, I put on a southern accent and sang along with her. She shrieked and told me to stop. "It freaks me out that you sound like that!" she said. I've never done that again. Accents are very powerful things, don't you know.

After Guy leaves, I sit and admire my slightly damp, but nonetheless clean couch and the rug whose colors are now more apparent than before, smothered as they were previously beneath the salt staining and trampled in mud from the after-effects of a New England winter. I return a couple of new client calls and emails. The first appointment for a new client or clients is nearly always the hardest one to make. Other people’s busy lives and a busy clinical practice make for scheduling challenges, and it’s interesting how different people handle the challenge. Sometimes prospective clients become frustrated and angry at playing phone tag as we try to find a mutually convenient time for the initial session. Sometimes they act apologetically and guilty for being so “difficult” to meet with, as if they are doing it on purpose. Yes, folks…even the first few telephone calls are therapeutically valid as far as I’m concerned!

Dori, the Executive Director of the non-profit agency next door, is in today. I give her Guy’s number in case she should need her office carpets cleaned, and she comes into my office to look at his handiwork. Dori is a great writer, and I ask her if she would be willing to edit my web pages text for grammatical errors and run-on sentences. Affirmative. I’ve been working on the text for so long that I’m making things over-complicated in my attempts to be succinct. The web designer is all set to launch the site as soon as he has the text and I need to also get a photograph taken. Photographs. Always a challenge. I’ve lost some weight recently and seem to be continuing to lose. Do I post a photograph at my current weight, or post a photo that’s a few years older figuring that I’ll look like that before too long anyway? I’ll mull this one over. Meanwhile, I’ll let you know as soon as the site is launched.

Why Sex Therapy?

When I tell folks that I'm a sex therapist, there are four questions that I'm usually asked almost immediately. (1) Why do people seek sex therapy? (2) Who goes to sex therapy? (3) What kinds of problems do people want help with? (4) What exactly is sex therapy?

Why do people seek sex therapy?
Over the course of a person's lifetime stress, trauma, illness, the side effects of medications, depression and lack of self-esteem can often negatively impact a person’s sexual functioning and desire. It is not uncommon for couples and individuals to experience sex-related challenges at some point in their lives. Everybody deserves to experience satisfying, exciting, loving and fulfilling sexual relationships and sexual contact and sex therapy can often help.

Who goes to sex therapy?

This list is not exhaustive, but some of the people who attend sex therapy are:

* Heterosexual men and women, singles or couples
* Gay, lesbian bisexual, transgendered and intersex individuals and couples
* Busy and exhausted parents who can't seem to find time for intimacy
* People in their 50's, 60's, 70's, 80's and beyond who have questions about their sexual functioning
* Sexual abuse survivors who want to have fulfilling sexual lives, but feel haunted by their past
* People re-entering the dating world after divorce or death of a long-time partner
* People in their early twenties who are embarking on their first serious sexual relationship
* Married men who cross-dress and whose wives either (a) don't know that they are married to cross-dressers or (b) have found out that their partners are cross-dressers and are scared, and/or confused and/or angry and/or upset.
* People who are sexually compulsive and feel that their compulsions are out of control.
* Individuals in a heterosexual relationship or marriage who are beginning to question their sexual orientation.


What kinds of problems do people want help with?

Some of the issues that sex therapy can help with are as follows:
* Difficulties either getting and/or keeping an erection
* Difficulties maintaining control of ejaculation or trouble with “timing”
* Inability to orgasm either alone or with a partner
* Finding the ability to relax and enjoy sexual activity a challenge
* Lack or loss of sexual desire
* Feelings of embarrassment or shame about your body and sexual functioning
* Painful intercourse (known as Dyspareunia)
* Involuntary spasming of the vagina (known as Vaginismus)
* History of sexual abuse, rape or threatened sexual trauma
* Intimacy and relationship problems that are affecting your sexual relationship
* When feeling bad about your body is negatively affecting your sexual life
* When you've been faking orgasms because you're too embarrassed or ashamed to talk about your difficulty climaxing
* When you find yourself passing on having sex with your partner because it's difficult to get and/or maintain erections
* You're so worried about "performing" that you avoid sexual intimacy
* Since having a baby, you're less interested in sex
* You want sex frequently and your partner isn't interested
* You don't want to have sex and you feel like your partner is constantly bugging you about it
* You feel like you spend too much time thinking or fantasizing about sex
* Having sex is painful and you feel hopeless about ever freely enjoying it
* You have questions about your sexuality and don't know who to ask
* Your partner wants an "open" relationship and you're unsure if you can handle it or even want to try

What exactly is sex therapy?
List most other forms of psychotherapy, sex therapy is exclusively talk therapy, which involves meeting with a therapist on a regular basis to talk about how to overcome whatever problem a person has identified. In exchange, the sex therapist shares his or her knowledge of human sexuality and expertise in working with sexual functioning and relationship challenges. Sex therapists are trained to diagnose the psychological origins of sexual issues and work to find solutions. This will often mean collaborative relationships with physicians whose specialty is sexual medicine.

Once the ice is broken and people feel more comfortable asking me about the work I do, they frequently ask if sex therapy involves me touching my clients in some way. The answer is a resounding NO! Despite common misconceptions, sex therapy does NOT involve sexual or physical contact between therapist and client. (Masters and Johnson used sex surrogates in their pioneering work in the 50's but this practice has long since been discontinued.) Sex therapy NEVER involves nudity, sexual contact or sexual touch between the client(s) and the sex therapist.

As with any form of therapeutic relationship, an ability to feel comfortable with a therapist is half the battle. Most sex therapists, including myself, take an extensive sexual history about you and your life. They ask questions that you may not be used to answering. Given that most folks find it embarrassing to talk about sex, it's even more important that you find a therapist who puts you at ease and with whom you can begin to talk freely.