Yesterday's intercourse

I have become very interested in how couples therapists can better integrate sexuality into couples therapy. Sex is sometimes viewed by therapists as very separate from other elements of the relationship or else as a by-product of relationship rather than an important and complex sub-system of peoples relationship. I have been looking for professional writing about integrating sexuality and couples therapy and came across the work of the late researcher Harold Lief. That lead me to this gem. It feels both so far away and so familiar. I don’t know whether these folks are actors; they are so extraordinarily real seeming but they hit so many of the familiar points in this situation that it seems scripted. So much has changed since this video was recorded but so much has remained the same both in couples lives and couples therapy.

The paradox of the sexy guitar player

Clients often talk about finding their partner sexiest when that person is intensely engaged in something that they love; music, art, intense conversation. It makes sense. They are vital in those moments, they have a kind of intensity that is alluring, particularly if they are good at what they are doing. The musician is a great example. Is there anybody sexier than a rock musician?

This presents a problem. Interrupt the flow of the music to try to connect erotically and 1. the thing that made the other person sexy ceases and/or 2. the other person is deeply engaged with something and the interruption may feel very unsexy to them.

Another dimension to this paradox: Can I accept being the object of my partner’s desire? Amanda Luterman talks about Erotic Empathy; the ability to believe I am sexy to my partner. That can be a lot harder than it sounds. Is it easier for me to desire someone else when the focus of that intensity isn’t on me? Does someone else actively focusing on me erotically shut down my eroticism? If I find someone sexy while they are playing guitar but not when they are actively seducing me, how will I ever take yes for an answer?

The Freier Problem

Freier is a Yiddish word in common use in Israel. It’s hard to translate. Roughly it means “sucker”, but with a particular connotation; you aren’t a sucker because you are dumb or unlucky but because you follow the rules when everyone else knows that the rules are only for freiers. While a person might be proud to be called upstanding, moral, law-abiding nobody wants to be a freier. (For a great discussion of three possible origins for the word see Balashon’s post).

The word captures a complex set of tensions that people struggle with in relationships; familial, work, neighbourhood etc. People generally want to view themselves as good. But they also desperately do not want to be the last person upholding a norm that everyone else gave up on a long time ago. I roll my eyes or huff indignantly if one person cuts in line, but if there is no line, just a bunch of people shoving, then standing and waiting just feels foolish. If I am honest about how much I earn when I file my taxes I may feel good about doing my part, but if I learn that no one else is being honest, then I start to feel contempt for myself.

Philosophers have discussed situations in which collective action will offer a big benefit but individuals may act to pursue lesser gains at a cost to the whole. Two examples are “the Stag Hunt” or “the Prisoner’s Dilemma.” In those scenarios if someone loses, the loss is material and the players have no way of communicating with one another.

But I often see couples facing “the Freier Problem.” They can talk to one another. The material costs of investing in the relationship are relatively low and the material costs of getting their elbows up and fighting more is high. Yet each of them sits there looking at the other person to make changes. Why double down on behaviour that they know hurts the relationship?

When I ask people they say; “It will be so humiliating to be the only one working for this relationship.” And that is what makes Freier problems so tough. The cost of being a freier is psychological more than it is material. A much more important force than material loss is at stake; the fear that I will despise myself or be viewed with contempt by my partner or my community.

We are facing a whole variety of Freier Problems as a society. Public health measures against COVID-19 are a perfect example. Yes, there are real costs in either complying with restrictions or not. But much of what drives people is the fear of being seen as badly behaved or contrariwise, the fear of being a freier, being the last person to wear a mask, to stay home from work, to maintain social distance.

COVID Coping

• Compassion for self and others

  Sometimes we mistakenly think that the choice is between a bad situation and a better situation if we just kick ass hard/often enough. If you have tried frequent, emphatic asskicking and it hasn't worked, consider that the choice is actually between a bad situation and a bad situation made more unpleasant by a lot of ass-kicking. -> you are hereby forbidden to use any part of this material for self-recrimination. 

• Improving sleep 

  Regular bedtime and wake time

  Your bed is for sleep, not for work or fretting

  If you are awake for more than 20 minutes move to a quiet spot, read a book until you find you are nodding off

  No screens in bedroom

  No screens 45 minutes prior to bed

  Reduce caffeine, alcohol. 

• Time outdoors, preferably in nature. Plan for winter. 

• Regular exercise

• Reflective practice.What it looks like

  regular

  attendance to inner states while serving to “unstick” us from inner states

  can be; regular exercise, prayer, meditation

• Reduce drug use

  includes caffeine, pot, alcohol.

• Work hygiene

  if you have trouble getting started, begin with 20 minutes of work

  have work hours and a quitting time

  have a dedicated work space

  work outside of your home if possible

• Social media (if you must)

  take frequent breaks, you can always go back to it if you want after 1/2 hour

• Managing worry

  Compassion for worrying parts of ourselves; they are doing a very important job. They need coaching. 

  Office hours for worries. “The office is closed. Please come back at 10:45 tomorrow morning.”

  Describing; “I am feeling worried”. “I am thinking about my exams.” 

  Write worries on stickies, place them on a piece of paper divided in half; left side is “In my control.” Right side is “Out of my control.” If there is a worry that you want to put in between, subdivide the worry until you are clear about what is in your control and what is not in your control

  Worry as “dealing”. Am I mistaking worrying for doing something useful?

  Set times to revisit decisions. Don't rehash at unscheduled times. 

• Maintain connections. 

• Don't focus on happiness, focus on doing good for yourself and others. 

Doing the same thing but harder

When I was training to be a couple and family therapist, a beloved teacher of mine, the late Darrel Johnson, said that young therapists often go into a first session with the idea that you need to be super deft and subtle because a family or a couple is such a complicated and delicate system. “But after fifteen minutes, you realize that you could set off an atomic bomb and they would still be having the same arguments they have always had.”

It is funny how much doing therapy during the apocalypse is like doing therapy the rest of the time. The people who were ambivalent about their relationships before are still ambivalent. The people who were stuck or angry because of childhood trauma or neglect are still stuck or angry. Workaholics work too much , they just do it from home. People who nagged, nag. People who shut down, are shutting down. I reflect on this to clients sometimes; “Wow. So much has changed in the world around us, with all of us having to face how contingent our lives are, how little control we have over so many things, and you are still FILL IN THE BLANK. What can you tell me about that?” Which of course, is me doing my therapist things, but harder; “How did you feel when Karl said that he is the one who always has to fight the zombies?”

Two examples from the larger context:

In the midst of a pandemic that has hit the Montreal health care system particularly hard, in the CIUSSS where I work, we got a new form to fill out. I was amazed. In the midst of an all-hands-on-deck sirens-blaring DEFCON 5 emergency, someone said, “What we need is a different form for telehealth interventions.” And someone else made it. And somebody checked the translations. And a committee had an agenda item during a zoom meeting and approved it. This when they cannot get enough people to go and work in old-age homes.

The second example; a week after protests erupted all over the United States because a policeman killed a black man by kneeling on his neck during an arrest, another cop was filmed kneeling on the neck of someone he was arresting in Seattle. People in the crowd shout at him to stop. They shout over and over again, enraged at what the cop is doing but also amazed at the obliviousness, the determination to do the same thing that got us all here. He cannot or will not change. A whole country is on fire because of this and not only does it not prompt him to change, chances are, it probably deepens his commitment to his stereotyped response.

Probably there are people who gained a whole new perspective on their problems because of COVID out trying to live their lives differently and not coming to therapy. One client told me as much. “My stuff with my partner seems like pretty small potatoes now.”

But so much of what I see both in my clients, in myself and in the world is a dogged determination to do the same thing but harder.

"The same brain"

A client of mine who is a recovering addict once told me that in 12 step programs they say that the brain that got you into the problem can't get you out. We repeat our patterns even when it becomes ridiculously clear that what we have always done isn't working. The Quebec and Canadian governments have announced spending for mental health programs related to COVID-19.

I am glad when society recognizes the importance of mental health but I am sceptical that the brain that got us into this mess will be able to get us out. If a mental health pandemic is the likely outcome of COVID, governments will no doubt be as well-prepared as they were for the first one. 

I have been getting come-ons asking me to work for some big consortium or another as a therapist. They are gearing up to fill government contracts. Private companies such as employee assistance programs will get lucrative government contracts to deliver short-term, manualized therapies, like cognitive behavioural therapy, much of it on-line. Such a program - iCBT- is already being fast-tracked here in Quebec.

Governments use a medicalized approach to mental health because that is what they have always done; they use the brain that got them into so much trouble in the first place to try to get them out. A medicalized approach means dealing with something when it is already a near-disaster and hoping you can shave a few pennies off the enormous cost. Trying to scrounge up PPE, finding ventilators, drafting health-care workers to come back to jobs when they are scared. This is the equivalent of giving somebody triple bypass surgery when they are gravely ill due to preventable coronary disease. This medicalized approach is hugely expensive, so governments and health care funders such as insurance companies cut corners wherever they can, which means bad outcomes on top of poor planning. It is the epitome of penny-wise pound foolish, and about as scary as that other Pennywise.

A public health approach, by contrast, gives people at risk of coronary disease access to gyms, healthy food, smoking cessation programs etc. It means building long-term care facilities that actually deserve to have the word “care” in their name and having a well-trained workforce that can make a good living off of their work so they don't need to work at two or three jobs etc.

We know what promotes mental health: stable, affordable housing; loving relationships with emotionally healthy people; loving, positive communities; a sense of purpose. And when things go wrong, we know what makes for good therapy: a therapist who forms a solid, caring relationship with a client, who works towards the client's goals, and who attends to the relationship. Not rushing clients through a prescribed series of exercises. Not attending to a manual rather than a person.

It is expensive and takes time and creativity to build a society that offers quality low-cost housing in livable neighbourhoods and lively, caring, inclusive communities. It can take time for a person to feel heard and cared for enough by a therapist (or a family doctor or a teacher) to talk about what is hurting. Government will cut mental-health promoting programs and pay big companies that say they can fix a hundred people with anxiety or depression as if they were manufacturing widgets. I know because that is how they have dealt with health for 20 years. That is how we have arrived at such a disastrous situation today in Quebec. If past behaviour is any guide, these companies will deliver off-the-shelf therapies in 12 sessions at the low, low cost of only $2000. That's cheap when you compare it to10 years of subsidized housing for a family with young kids. But the cost of medicalized responses to mental health care add up quickly over a lifetime. They come when the problem is already harder to treat. For the cost of four courses of short term manualized psychotherapy, two psychiatric hospitalizations, two courses of addiction treatment, a year and half of anti-depressant medication and a three-month burnout leave from work you can buy a lot of subsidized housing.

You don't fix problems of human connection by building a less connected, less humane society. 

"You can't do affect with a still face"

A client recently pointed me in the direction of Diana Fosha and her work on trauma recovery. She comes from a psychoanalytic perspective which is very different than my own training and orientation, and I didn’t know anything about her so I went online and did a little digging. I read a little of her work and I saw that she has her own method called Accelerated Experiential Dynamic Psychotherapy (AEDP).

I really like to hear a therapist talk about their work. It is hard for me to take seriously the insights of a therapist who seems like a jerk, to whom I wouldn’t send a friend or loved one. Hearing the person talk gives me a sense of what it would be like to sit in a room with them as a client. I found this example.

She was warm and personable and very smart and it seemed clear that she spent a lot of time with actual clients and was not solely involved with research. I left the video on while I tidied up in the kitchen. At 7 and a half minutes she said something that made me put down the dishcloth, go over to my computer, and scan back and really listen. And then listen again. She was talking about therapist neutrality and she said: “You can’t do affect with a still face.”

There is a lot in this. Affect is the outward expression of emotion, both what a person says verbally about their mood and all the subtle clues we give off about how we are feeling. So right away she is talking about a therapist who isn’t only focussed on what I say about how I feel but on what I express about how I feel, unmediated by words. One of the limits of talk therapy is talking. It seems pretty evident that some stuff in our minds is harder to get at by talking. Most people have the experience of trying to share an experience with someone else and finding words are insufficient. Therapies that rely only on talk miss important dimensions of human experience. Unfortunately, many manualized therapies are very cognitively oriented, so they often leave out what is harder to articulate or even inarticulable. Psychoanalytic therapy is notoriously ‘talky’ as the client or analysand talks to the quiet, almost silent analyst and slowly, slowly moves to articulate what has been unarticulated, the realm of affect.

The still face is a reference to Ed Tronick’s work on attachment. Briefly, Tronick developed the still face experiment as a way of evoking attachment responses in infants by having the mother show no affect. The video can be hard to watch, so be warned.

Fosha is connecting the affectless parent in Tronick’s experiment to the neutral therapist who refuses to engage on an affective level with a client. This prompted me to think about when I do and don’t connect affectively with clients, when I allow myself to be an engaged, caring part of a two person system, and when and how I hold myself back. It can be hard, now that I am doing therapy remotely, showing concern, caring, warmth to a screen or sending positive regard through a telephone line. Watching this reminded me of how healing the presence of a caring, capable other can feel.

I work on a Mac. I know that when I look at my client’s face, I am not actually looking directly at them and I worry about deepening what can already feel like a gulf. But above my screen are the little round green light and round camera lens. We are so hardwired to find faces that if I squint my eyes, the two odd circles can look like a mismatched pair of eyes, my client’s real eyes, not their virtual eyes. That’s where I look sometimes when I particularly hope to pierce through the ether and isolation and send my client closeness, warmth and regard in the hopes of healing.

The Virtues of Patience

I like goals in therapy. I tend to be more directive than other therapists and I have had plenty of clients who have benefitted from 6, 4, or even 1 session of therapy. And I have seen the opposite; people who continued in therapy after they have had as much benefit as they are likely to get.

We are all confronting how much patience we do or do not have and how our just-in-time, efficiency-oriented society has left us collectively and individually under-equipped to meet the medical and psychic challenges of corona virus. This article by Jonathan Shedler and Enrico Gnaulati seems particularly apropos in identifying how penny-wise-pound-foolish thinking in health care, and a general culture of impatience, has pushed psychotherapy away from long-term therapy even when it is indicated.

Academic researchers promoting brief manualized therapies tell us therapy is finished in 8 to 12 sessions. But if we believe the expert therapists—psychologists and psychiatrists of diverse theoretical orientations with an average of 18 years of practice experience—meaningful therapy has barely started.

Sometimes when governments or insurers seek to save money in health care, they end up making an efficient system for achieving poor results.