For a very long time, California psychotherapists have been required to break client confidentiality only when we believe a minor or dependent adult is in imminent danger of serious abuse or neglect or a life is imminently at risk (homicide and/or suicide with a clear plan). Over the years this has enabled us to privately counsel countless men and women seeking help with discontinuing illegal or potentially harmful behaviors, or with diminishing shame and self-hatred over past misconduct. Many of us have helped these individuals develop and maintain healthier, happier, and safer lives – without needing to break our vow of confidentiality.
As therapists, each of us would like to do exactly the right thing in each and every session. However, given the stressful nature of our work, the lengthy and sometimes sporadic hours, the occasional inability to feel secure in our continued income, and even our own not-yet-totally-resolved issues, we sometimes fall a bit short of this lofty goal. Simply put, despite our good training, supervision, and continuing education, we occasionally make errors. A few of the more common therapeutic missteps are discussed below, along with suggestions on how to avoid them. That said, professional organizations have guidelines that are (and always should be) a therapist’s first line of defense in this regard. Plus, without doubt I’ve missed a few things. If so, please add your thoughts on those issues in the comments section. That way, anything I’ve overlooked will still be discussed.
As a therapist, I often encounter clients who say things like: “I don’t know what’s wrong with me. I have everything I want and yet I never feel satisfied. There’s no joy in my life. Maybe I’m just not a happy kind of person. Maybe I’m just a glass-half-empty person.” When I get hit with that sort of proclamation, I typically respond with a few probing questions: “What would happiness look like and feel like for you? How would you know if you had achieved it?” Sadly, much of the time these “unhappy” clients simply don’t have an answer. For them, happiness seems so elusive that they can’t even picture it.
What are L, G, B, T, and Q?
We live in a heteronormative society. In other words, heterosexual relationships are the cultural norm, and anything different is, well, different. Yes it is true that things are changing rapidly in parts of the Western world and elsewhere – evolving societal attitudes about cultural diversity, softening religious dogma, the repeal of DOMA and the military’s “don’t ask, don’t tell” policy, growing intolerance of pejorative terms like “faggot,” “homo,” and “dyke,” legalized gay marriage, and more – but this doesn’t mean that people whose sexual orientation and/or gender identity falls outside the norm suddenly have an easy time of it. In fact, these individuals typically experience, at best, confusion (not just from others but within themselves) about who/what they are why/how they are different. In fact, sometimes even psychotherapists are unsure about what it means to be LGBTQ, and even the clinicians who do possess a basic understanding typically bring a lifetime of cultural bias to the therapy room.
Prior to speaking, along with my friend and colleague Dr. Christine Courtois, at the amazing Psychotherapy Networker Symposium in DC last weekend, I spent several days in New York interacting with one media outlet after another in the service of promoting my latest book , Closer Together, Further Apart, coauthored with Dr. Jennifer Schneider. The book examines the intersection of human relationships and digital technology – a hot topic at present – so it’s generating quite a bit of interest. At the same time, because my other primary area of clinical expertise is sexual addiction, I found myself fielding questions about Lars von Trier’s new film, Nymphomaniac: Volume I, an artistic rumination on active sex addiction in women. For several days straight it was a 24/7 media binge.
Scenario 1: Joan, a 32-year-old working mother of two young children
Joan arrives in therapy complaining that over the past six to eight months she has experienced growing feelings of both sadness and fatigue. She admits to frequent crying jags over what she accurately describes as relatively minor incidents. She also reports difficulty falling asleep, usually because she’s worrying that her children need more from her than time allows. As a result she is fatigued, easily prompted to tears, spaced out, and increasingly forgetful. The final straw for Joan was when she inadvertently locked her toddler son in the family car with the keys inside (requiring a visit from the local AAA truck to free both her son and her SUV). The following day, after a long talk with her husband, who encouraged her to seek help for her general unhappiness, she reached out to a local psychotherapist. After reviewing Joan’s history and stated symptoms over the course of several sessions, Joan’s therapist diagnosed her as being in the middle of a moderate depressive episode. The therapist gave her a referral for medication evaluation, and continued to work with her in therapy – focusing on helping her to better manage stress and to feel more confident as a mother.
In two previous posts I’ve written about clinician prejudice toward sex offenders and ways to effectively treat sex offenders. It was satisfying to see these blogs being well received, and it is my sincere hope that this effort has helped in some small way to pull back the covers on a topic that is often avoided, overlooked, and/or flat out ignored by the therapeutic community. This third and final (at least for a while) blog on sexual offending is intended to briefly address a few remaining offender-related topics.
Eyes Wide Shut
Sex addicts – men and women who obsess about and compulsively abuse sexual and romantic behaviors to the point of self-harm and/or harm to others – frequently appear to be quite functional in other areas of their lives. Unfortunately, as with most active addicts, these individuals are often out of touch with the unforeseen costs of their addictive behavior patterns until a related crisis emerges for which they seek help. Ignoring signs that most others would not miss – STDs, workplace trouble, related chemical dependency relapses, broken relationships, etc. – sex and love addicts place the compulsive search for sex and romance at the top of their priority list without a second thought. In fact, when confronted in the early stages of treatment with something as elemental as an adult sex and relationship history, many sex and love addicts are shocked to “discover” the extent and depth of their acting-out behaviors. This is their denial. It is almost as if they refuse to see, or are unable to integrate into their conscious thought process, the destructive effects of their sexual and romantic activity not only upon themselves, but on those who love them.
Cross and Co-Occurring Addictions
Individuals who are cross-addicted are people who switch from one addiction to another—for instance, Suzanne stops drinking alcohol, then gains 40 pounds in three months, replacing booze with compulsive eating. People with co-occurring addictions struggle with multiple addictions at the same time—for instance, Eric smokes pot morning, noon, and night, and also plays video games for eight to ten hours each day.
Cross and co-occurring disorders are especially common with sex addicts. In one survey of male sex addicts, 87 percent of respondents reported that they regularly abused either addictive substances or other addictive behaviors. Considerable anecdotal evidence suggests that for a majority of sex addicts with a co-occurring addiction the secondary drug of choice is crystal methamphetamine. Sex addicts also use cocaine, crack cocaine, and almost any other stimulant—but crystal meth is usually cheaper and more readily available.
Consider Brad, a married, 38-year-old lawyer:
Stepping It Up in Treatment
Sex addicts, like many in early addiction recovery, are often highly resistant to the idea of attending 12-step recovery meetings. Their reasons are myriad and usually without merit, though they sure can sound convincing on first listen.
Basically, it boils down to this: individuals who hang out in adult bookstores, cruise local red light districts looking for prostitutes, download hard-core pornography on work computers and masturbate in their office during business hours, post hi-definition photographs of their exposed genitalia on dating websites, and openly announce their extramarital availability on Ashley Madison (with a face photo but without a second thought) are the same folks who become very concerned about being “spotted” at one of “those” meetings.
“What if someone sees me there and thinks I’m a pervert?” they fret. Never mind the fact that these meetings usually take place in churches, school classrooms and local businesses after hours with no neon signs announcing what’s going on. Resistance to change is what it is, and even though sex addicts invite risk when acting out, they are risk averse in terms of being seen in 12-step sexual recovery meetings like SAA, SLAA, SCA, SA, and SRA.
It is therefore up to the addiction therapist, when working with a 12-step-averse client, to bring the themes, neurobiological rewiring, and experience of 12-step recovery into the treatment arena—especially in a group therapy setting. Once the sexual behavior problem has been clearly assessed and client/treatment goals and expectations aligned, sex addiction treatment is well served by the therapist initiating discussions on themes like surrender, feeling out-of-control/powerlessness, developing personal integrity, asking for help, accepting responsibility, turning it over, establishing accountability, etc., all within the framework of cognitive behavioral treatment.