Category Archives: General

My supervisor doubted whether I should be a therapist!

“Dear Jon, My past supervisor doubted whether I should do therapy. Now as I begin a new placement, I doubt myself and I’m afraid of how I will make mistakes and that I will become anxious with patients. What if I stutter to death? What if I mess up?”
All of us have had doubters in our lives. Their opinions mattered to us. I have had doubters in the past say that I had “shit for brains” and that I was a “dumb shit”. I had a music teacher who said that I sounded “like hogs rooting in the mud in a barnyard in Iowa.” Doubters doubt all of us.
Even though they are gone, we can always bring them and their opinions into the room to torture us. We can always misuse our memories for the purpose of self-punishment. This will be true no matter how much further training you or any trainee seeks. Let’s face it: you have decided to break the law of the doubters and discover your potential instead. When we break their law, our anger rises. When our anger rises, we might protect them by continuing to doubt ourselves, punishing ourselves for having broken their law. But we must leave their prison if we are to become free.
When you start seeing patients, your anger will rise toward previous doubters. You may protect those doubters by letting the anger go back onto you in the form of self-doubt. That will probably happen for a while. You will not always know what to do (like all therapists at all stages). And at those moments, you might punish yourself for not knowing what to do (the failure to be omniscient). You might stutter with your first patients. That will be a sign that you are anxious in front of your former therapist, when in front of you will be a patient even more anxious than you are! And for some patients your anxiety will be a relief: “Oh. Thank heavens. My therapist knows what it is like to be anxious. She will understand me because she is a suffering human too!”
Now, as for stuttering to death, what will die? You? No. What will die will be a perfect image, an image of a supremely calm figure, an image without flaws, an image that is omniscient, an image that every mind creates but no one has ever become. As you begin to treat humans in therapy, you will begin to accept yourself as a human, someone who gets nervous, who hates herself at times, who can have irrational ideas, who stutters, who….you name it.
Patients don’t need ideal therapists; they need real people. They need you: your compassion, your understanding as a fellow sufferer, another imperfect person who messes up—your humility. If we needed to be “cured” before doing therapy, no one would be able to do therapy. The more you embrace your flaws, your neurosis, and your humanity, the more you will be able to embrace the flaws, neurosis, and humanity of your patients. They don’t need you to be ideal; they need you to be real. They don’t need someone who sits up above them on some throne; they need someone who can sit next to them on the ground.
You worry you will mess up. I guarantee it! I have messed up many times. I still do. And I am sure I will mess up in the future. In life, we mess up. We mess up in friendships, in love, and in therapy. That’s what we humans do. And through our mistakes, we learn, we apologize, and we try again. There is no other way. We don’t become perfect and then magically go through life handling everything just fine. We make mistakes, learn, make more mistakes, learn, and repeat the cycle. That’s how we learn: through living.
You worry you will mess yourself up. I guarantee that too! Therapy messes us up. We get stirred up. And that’s also how we learn: through living. But, to be clear, we don’t get messed up in therapy. Our illusions get messed up. When emotions and the truth mess up our illusions, we might think we are getting messed up, when our former illusions, ideas, and lies are getting messed up. And, as a result of this messy experience, we grow. This happens repeatedly through the life cycle of therapists. Countless times I have been overwhelmed with some feelings, some puzzling experience, some mess with a patient. And over time, by living through it, I learn something more deeply about myself and my patients or my supervisees.
So I invite you to join the rank of humans who do therapy: people who don’t always know what to do, people who make messes and learn from them, people who get messed up by these experiences, people who get scared: therapists.
Thanks for sharing your concerns about being human,

Can one undergo therapy for sexual addiction?

This wonderful question was forwarded by one of our readers. There are many treatments offered today for sexual addiction. Here, we will look at this from the point of view of a psychodynamic therapy: ISTDP.
When someone presents with a sexual addiction, the first thing to remember is this: sexual addiction is a symptom! Rather than get focused entirely on the symptom, we want to find out what feelings he struggles with in relationships, where his anxiety is discharged, and what defenses he uses. Then we can see how his defenses create his symptom of sexual addiction.
On the simplest level, as the psychoanalyst Heinz Kohut pointed out decades ago, a sexual addiction is often a compulsive mechanism to discharge unregulated anxiety. Thus, helping this group of patients recognize anxiety in session and regulate it can be an essential step in gaining control over this defense. Then they can recognize and regulate their anxiety rather than discharge it through compulsive masturbation or sexual activity.
Since they are so focused on their sexual addiction, they do not usually recognize their anxiety in session. So it’s important to block their defenses of discharge in session to draw their attention to their anxiety.
1) “Notice how your voice is racing? That’s often a sign of anxiety. If we slow down for a moment, where do you notice feeling anxiety in your body right now?”
2) “Notice how you just talked over me (impulsive speech)? That’s often a sign of anxiety. If we slow down for a minute where do you notice feeling anxiety in your body right now?”
3) “Notice how you are jumping from one topic to another? That’s often a way to talk over what makes us anxious. If we pause for a moment, could we see where you are experiencing anxiety in your body right now?”
I find that therapists often ignore these defenses of discharge which avoid anxiety and which are the precursors to using sexual activity to ignore anxiety.
When the patient can see his anxiety and regulate it, then we start exploring the feelings underneath his anxiety IN THE SESSION. Why with the therapist? The patient is anxious with the therapist, using racing speech, impulsive speech, raising his voice, or diversifying, all to ignore the anxiety triggered by feelings with the therapist. Thus, we want to find out what feelings are triggered in the therapy relationship that evoke his anxiety, and lead to discharge.
If he can learn to identify what he feels without flooding with anxiety, his defense of sexual acting out is no longer necessary!
Sexual addiction is a way to discharge and ignore anxiety when feelings rise in relationships. Rather than tolerate the gradual rise of mixed feelings that always occurs in romantic relationships, this group of patients rushes to sex to get rid of the anxiety. But rushing into sexual relationships, a defense, creates an entirely new set of problems. And since anxiety keeps rising in relationships, sex keeps getting used as the defense to discharge that anxiety.
These patients mistakenly think they simply have a “large sex drive.” But the size of one’s sex drive does not explain impulsivity, compulsivity, anxiety, and the patterns of feelings, anxiety, and sexual defenses. They do not have a “large sex drive”, they have a large amount of anxiety which requires a large amount of sex to discharge it.
Now let’s go back to an old post of mine on “the universal addiction.” We are all addicted to not being here now with what we feel. Drugs, booze, and sex are all ways we try to get rid of what we are feeling. So, in that sense, sex is not really the addiction. Sex is just a tool this group of patients uses to deal with their fundamental addiction: help me not feel what I am feeling right now!
Since the patient is unable to bear the feelings that rise quickly in relationships, he uses sex as a way to discharge anxiety and to distract himself from psychological intimacy through pursuing an alienated form of physical contact.
And since this happens in most of his relationships, the same feelings and anxiety will be aroused in the therapy. Initially the patient will be anxious. Then we will see rapid speech. Then talking over you. Then talking about his sexual partners. And then perhaps even talking about sexual feelings toward you. What you see here is an escalating series of defenses that become more primitive the more his anxiety rises. Thus, it becomes essential to block defenses, and then identify and regulate anxiety as soon as you can to stop the escalation of anxiety and regression of defense in the session.
As you identify and regulate his anxiety, help him identify the feelings that trigger his anxiety. Once he can identify feelings without having to use the defense of sexualization, you will have decreased his impulsivity a great deal. Be careful, though! When you block his defenses and identify his anxiety, his anxiety may go into cognitive/perceptual disruption. This group of patients has a very low capacity to bear feelings and anxiety. That’s why they resort to sexual acting out. So when you block their impulsive speech, anxiety will rise and may go into cognitive/perceptual disruption, and then you can regulate his anxiety using the graded approach that I have described in Co-Creating Change.
Keep your focus on anxiety regulation and identification, so the patient can pay attention to and regulate his anxiety. Gradually increase his capacity to bear feelings without have to use discharge or acting out to rid himself of those feelings. As you increase these capacities, the patient’s use of primitive defenses will decrease and eventually disappear.
All models of treatment of sexual addiction realize that we must build capacity in the patient to bear feelings without acting out. Hopefully, this outline I have provided here gives you the rational and techniques we use when helping this vulnerable population.