Sexual Fantasies and the Theory of the “Sex Script”

Warning: Do not read this if you are uncomfortable with topics about sex, fantasies, sexuality, also sexual assault, sexual abuse, rape, etc.

I want to start a conversation about sexual fantasies and the shame people feel about them. This is a huge topic, like most of the continuing topics I start and sometimes do not finish. (I intend to post more about the stigma of mental illness and the controversy around mental illness and violence, etc. but I’m taking a break from that topic to write about this very different one…)

In this post, which will probably be longer than intended, I would like to introduce the idea of the “sex script” in connection with people’s sexual fantasies. The information I got about this was reading posts on the internet summarizing this book:The Sex Script Hypothesis:
Toward a Comprehensive Theory of Human Sexuality, by James Park 

Here is the link to the website where you can read more about it:

http://www.tc.umn.edu/~parkx032/syn-sex.html

In reading this material, I noticed that I did not agree with some of the conclusions Park makes about people’s sexuality and even about the content of one’s sexual preoccupations. For example, he makes a big blanket statement about men and breasts:

 Female breasts frequently appear in male sex-scripts on all levels: 
Men find women’s breasts of intense sexual interest. 
Some men become sexually aroused when viewing or thinking about breasts. 
And breasts may appear as a strong fantasy object in some men’s orgasms.”

One could read this and get lead on a detour as he is assuming a lot of things that are not for sure true. It is true that for most humans, the breast was the first “preoccupation” we had. It was where we got food and comfort, etc., but women may have just as strong a preoccupation with breasts as men, whatever their sexual orientation, and some men have no interest in breasts or fantasize about other things more often. These blanket statements are annoying, but I still think Park is on to something with his main theory.

The basic idea is that society may create our “sexual scripts” (what is considered stereotypically appropriate for men and women, heterosexual and homosexual, to engage in when they have sex or when they masturbate. The “sexual script” in our society is pretty limited, as you can see by watching sex scenes in most mainstream movies. There is not even a societal “sexual script” (which is a kind of narrative, by the way, and why we can discern society’s limited stories about sex from the mainstream media) for bisexual and transgendered and questioning individuals, as society does not really know what the story might be for such people. 

Anyway his point in talking about “sexual scripts” versus the concept of the “sex script” is to point out the difference. Many people do mostly have fantasies that conform to these limited “sex scenes”, however, I would wager that the majority of individuals who engage in sexual fantasy at any age tend to stray from these limited scripts into their own personal “sex script”. The sex script as I understand it is something that kind of gets “imprinted” into the human brain in the first moments of discovering sexuality and/or engaging in sexual contact with others or with oneself. Basically the majority of people’s sex script is formed during puberty, although some people exposed to sex and sexuality at younger ages, have sex scripts that begin at that time. Thus people who have been molested and abused at very young ages, from infancy up to about age 12, may have very disturbing sex scripts or may have sex scripts that mostly contain the things that they find disturbing and not arousing at all. Thus, some people may eliminate certain sexual activity from their fantasies and sex lives as they find they are repulsed by it. On the other hand, even people who experienced sexual abuse at very early ages may, without their control, notice that they are aroused by all kinds of varieties of disturbing fantasies, some of which involve coercion and/or rape or other events they remember from the abuse.

Basically around childhood all the way to age 20, the human brain is still forming, and there are young ages during which the sex script will get imprinted. So men who identify as heterosexual and report no fantasies about homosexual contact, may still fantasies about looking at other men naked, or masturbating with other men, if they were exposed to this in reality or through pornography that they experienced around the time they were aware of having wet dreams and/or masturbating.

The theory of the sex script is useful in that it explains why some couples are mystified by hearing what the other person gets “turned on” by or fantasizes about. In some cases, a person’s regular sex life, whether with one partner or more, may have nothing to do with their sex script. An obvious and common example involves gender and sexual orientation. Some people notice that they prefer to fantasize about being with the same gender though they have never been attracted to someone of the same gender and only have had sexual experiences with the opposite gender. The same can be true of homosexual men and women who may experience heterosexual sex only in their fantasy life. 

I think the main important take away about this, while I want to post about many sub topics, is that the theory of the sex script is most useful for people who have not been able to talk to their partners about their sexual fantasies due to feelings of shame or fears of disgust and rejection by the partner(s). Realizing that your sex script was formed years before you met this person or persons you may be married to or committed can be liberating for this group of people and form a bridge for how to start talking about their fantasies with their partners and sharing. 

It is well documented that people who share their sexual fantasies with each other and have interest in each other’s fantasies tend to have a freer more open and perhaps satisfying sex life with their partner(s). It is never too late to start sharing these “dark secrets” with the people you are sexually intimate with. It needs to be done in an atmosphere of acceptance. The sex script provides the help for such discussions. Knowing that one’s partner may have had sexual experiences with others before one met the person is very different from accepting that one’s partner’s brain was exposed to certain aspects of sexuality in the actual reality of a “strange” sexual experience or exposed to watching or seeing some kinds of sex that are foreign to the other partner. There is some kind of strange assumption people sometimes have that their fantasies are probably similar to their partner’s, or an assumption by people who don’t really engage in fantasy, that their partner is not that preoccupied with it either. There is a lot of misplaced jealousy going on about sexual fantasy and erotica and pornography. There is a great scene in the movie “The Kids Are alright” where one of the kids finds their mothers’ stash of gay male porn and is shocked and freaked out. It may have been a scene where the kid walked in on their parents watching it; I can’t remember. What was great about it was the explanation one or both of the moms gave which was quite brief but pretty groundbreaking for a lot of people who did not know this. Basically she said “Just because we are lesbians doesn’t mean we only like watching women together in our choice of porn..” Anyway, it introduced the idea that sexual orientation and erotica, pornography, and fantasy and even couple’s engaging in watching something together, may have nothing to do with the sexual orientation or gender of the people having these experiences.

There is documentation that  “rape” fantasies are very common. What is interesting about these studies done on women with such fantasies, is that women who fantasize about being raped are actually quite healthy in their sex lives with others and also, that they tend to have a wide variety of fantasies, of which the rape fantasy is only one. So people’s assumptions that rape fantasies are unhealthy are unfounded. It must be emphasized of course that fantasy and reality are extremely different. When a patient tells me about what they consider a taboo fantasy (incest, for example, or random stuff like rubbing up against people in the subway), these are part of their sex script, not their real life. A person may fantasize about all these taboo topics, as well as violent sex and anything else that comes to mind that one might be uncomfortable with oneself. “Why am I aroused by this stuff that is illegal or bad?” Because it is part of your sex script, which you have little control over. When you can understand that fantasy is really a place where “anything goes”, you can be accepting that your partner likes to think about other people, objects, situations etc. that have absolutely nothing to do wtih you or your sex life with your partner, you really have reached an understanding of the concept of the sex script. Healthy couples not only like to share their fantasies, sometimes act them out, or even masturbate together while sharing them, or watch erotica that their partner likes to watch even if it isn’t their “cup of tea”, but also enjoy that their partner shares their sex script with them. Perhaps this is an even more intimate experience than sex itself. It is common for people to notice that they have to ask their partner to do specific things to turn them on or give them an orgasm; most people are not mind readers or body readers, and some people report the best sex to have been with the same person they had bad or mediocre sex with. The difference was the level of openness and communication about what they liked from their partner but also about showing their partner what they like to imagiine, watch or read when they are alone and aroused. It is true that most of “sex” is in the brain, so it makes sense that talking about or showing one’s partner about one’s “sex script” will be helpful. It may be difficult to hear that your partner imagines having sex with specific other people or strangers or having the kind of sex you do not have together, but this has nothing to do with possibiilites of “affairs”. A person can be extremely faithful to their chosen partner or partner(s) and have fantasies that involve behavior that violates whatever “contract” they have about their sex life. And again, this is because we do not have a lot of control over some things that make us sexually excited, and images that we watch or that just enter our brains in adulthood, but we always have control oer our behaviors in reality.

Perhaps the next post on this topic needs to be about pornography and relationships, as this is a big  deal with a lot of couples, and a lot of hurt and pain could be avoided, if people were more educated about the concept of the “sex script”…

This week’s post: Celebrities Help With Society’s Progress in Understanding Mental Illness

I am still interested in raising more questions about society’s views, perceptions, misconceptions, stereotypes and prejudices regarding mental illness, as well as asking, “How far have we come in a positive way?” because it is true that we are improving.

Let me make this post more reflective of some positive progress in our society in understanding mental illness. Recent disclosures of celebrities regarding their struggles have been invaluable. Like it or not, celebrities can have a huge influence on citizens’ thoughts and perceptions, regarding everything from attractiveness to mental illness. (Of course, Angelina Jolie’s recent public revelation about her double mastectomy has been instrumental in helping women cope with the possibilities of developping breast cancer, and I even know people who, after hearing about this, decided it’s about time I go get that mammogram I’ve been avoiding. How amazing and wonderful!)

Catherine Zeta Jones comes to mind as the most recent “celebrity confession” regarding serious chronic mental illness. She suffers from Bipolar 2 Disorder, which is less severe than bipolar 1, but her mere talking about her struggles and explaining them even went further to educate people, because the vast majority of people do not even know what Bipolar 2 is or about its existence, so one could argue that though she has a less severe form of Bipolar Disorder, she has been couragesous and invaluable in helping people understand how complicated Bipolar Disorder is and also even more importantly, that many people who have any form of Bipolar Disorder are able to function and contribute greatly to society. The mere fact that many individuals with Bipolar Disorder are “in the closet” about it at work and in other arenas, reveals how easily those people who are taking their medication and other treatments are able to “pass” as not having any type of mental illness.

Wow! How timely. I just googled her and bipolar and she has just the other day, emerged from going to a treatment facility for Bipolar 2. Here is the article in the LA Times:
http://www.latimes.com/entertainment/gossip/la-et-mg-catherine-zeta-jones-bipolar-treament-completed-20130523,0,2772184.story

Actually she first revealed her struggles with bipolar a while ago. In fact, she was “outed” in the fall of 2012 and discussed her struggles in her cover issue interview in InStyle magazine, so actually it should not have come as a shock that she sought out treatment very recently, as most people knew back in fall 2012, as InStyle magazine is pretty mainstream:
http://www.usatoday.com/story/life/people/2012/11/13/catherine-zeta-jones-instyle-cover-helps-defuse-bipolar-stigma/1703053/

Zeta-Jones is not the first to discuss her struggles with mental illness and really help dispel a lot of stigma about it. I don’t usually like to quote from Wikipedia as it is so easy to just go there for info, and I like to cite a variety of websites, but they do have one of the most extensive lists of celebrities who have suffered from some form of schizophrenia:
http://en.wikipedia.org/wiki/List_of_people_with_schizophrenia

There are many celebrities who have talked about their battles with depression, whether as a teenager or adult. Kirsten Dunst was all over the news in August-November 2011 talking about her most recent bout with depression. I learned about it from watching of all things, the E channnel’s coverage of Celebrities with mental illnesses. This supposedly “superficial” channel about celebrities actually did a great show quite a while ago and extensively covered the range of disorders from eating disorders to depression to anxiety, bipolar and also drug/alcohol abuse. I just looked it up and it came out in 2008; I remember watching the show and I really thought it was a great way to help people understand mental illness and related disorders and see that wealth and fame have nothing to do with mental health. This is the summary of that show:

“Celebrity Crises: 10 Most Shocking Mental Disorders is an American television entertainment special produced by E! Networks which documents the mental trials and tribulations of some of Hollywood’s biggest stars.

The special originally aired in the USA on E! Entertainment on 22 August, 2008. It is 50 minutes long.
Synopsis

When Hollywood stars are diagnosed with a mental health ailment it’s big news. From rumours about Britney’s bipolar disorder to Heath Ledger’s bout with depression, phobias and mental illness are getting more attention.

But of course, mental illness can affect anyone. Close to 58-million Americans — about one in four adults — suffer from a mental disorder.

From eating disorders (Mary Kate Olsen) to depression (Heather Locklear, Kirsten Dunst, Mia Tyler, Jim Carrey, Heath Ledger), to cases where stars have harmed themselves (Christina Ricci – cutting) this one hour special will explore ten troubling mental disorders, with interviews from doctors, psychologists and the stars themselves.”

The show may not have been extensive and totally informative about all these disorders. Who could do that in 50 minutes? However, it was great in scope and just introducing these different issues to the public.

There are also people in politics who have a lot of power to help the public understand mental illness and decrease the stigma and shame. There are also pioneers in the mental health field, such as Kay Jamison, who is not only an expert on mood disorders but wrote a great memoir of her own struggles with Bipolar 1 Disorder, titled “An Unquiet Mind”. The fact that she is well known for her own “coming out” about her personal struggles, indicates we still have miles to go in decreasing stigma, as we see that in the field of mental health itself, the majority of psychologists, psychiatrists, psychotherapists that suffer from any mental illness do not actually feel safe disclosing about their personal struggles. Another author and therapist who has written some great personal accounts of her own struggles is Lauren Slater. Her work is more on the edge and less well known to the general public, but she has written many interesting books about a variety of struggles.

So, in closing, I do believe that some of the best ways to educate the public about mental illness is through the mainstream media, whether it be a celebrity disclosing their struggles and talking openly about their treatment, or even films that attempt to focus on the topic, whether documentary TV shows like the one mentioned above, or the many biopics and fictions films about mental illness, such as the film “A Beautiful Mind” and the TV shows “Homeland”, “Six Feet Under” and “The Sopranos”, as well as numerous others. Even when such films or tv shows don’t give a totally accurate depiction of a specific mental illness (see my reviews of “Silver Linings Playbook,” they are still contributing to the more healthy dialogue that we need to have about this topic. A little misinformation is worth it if the subject at hand becomes more familiar to the general public and helps people view this topic with more compassion and less judgments…

Great Website: The Broken Light Collective

I don’t know if I’ve talked about them before on my blog, but I’ve been very excited about the “Broken Light Collective” blog website and what they are doing for people affected by mental illness, and in addition as an added bonus, as a way to educate the public about mental illness. This is a really impressive endeavor as it is much more than a blog. It is very moving and somehow allows people to be vulnerable and feel safe as well as able to express their own unique voice…

This is a WordPress blog started by people who wanted to post daily photos by people with mental illness. I’m not sure what got them focused on photography as the medium of choice, but it works extremely well on the internet, and nowadays with phone cameras etc., non professionals can express themselves skillfully through the art of photography and manipulating photos to create an image. There are so many options: just a snapshot caught at the right moment, a photo reworked in Photoshop to heighten it in some way, even photo collages… The only thing any of the photos all have in common is a search for the Truth about Life, as experienced by the photographer/individual.

Broken LIght Collective is a beautiful name for this simple idea. Follow the blog. and every day you will see a new image, completely unique, made by someone struggling with a mental illness or less often, someone very affected in his/her life by a loved one’s struggles with mental illness, and of course, many people fit both of these descriptions. If you are interested in studying mental illness, this is a great blog to follow to learn from the people who are struggling with it every day of their lives. They have a lot of wisdom and battle scars, not to mention the courage of putting themselves out there and showing a part of themselves through their photography.

This is to me, in a sense, art therapy at its best — a form of community art therapy or photo therapy or whatever you feel like calling it. It is an example of healing through creativity and sharing, which I think is a very important component of this original and thoughtful and sensitive blog/website. I believe strongly that creative acts and sharing of one’s creations coupled together promote the most healing as connecting with others who are sensitive to one’s struggles and/or struggling with similar issues is most healing of all. This is not to elevate or promote the idea of connecting as being social. This website is great for people with “social anxiety” which I am starting to doubt is a real “Disorder”. Anyway it is a great form of therapy through community combined with individuality, something very rare to find in the “physical world out there” in our daily lives, but perfect for the internet. In the case of the “Broken Light Collective”, the therapeutic healing aspect of this endeavor is accomplished through as a supportive community which gets formed through the people’s efforts, much like the AA model, however without any philosophy or approach to recovery. Just an interest in telling people’s stories through words and pictures. Thus the strong community of sensitive people does not require a therapist to be present, although some of the interesting “profiles” are of psychotherapists and healers of one kind or another sharing their own struggles with mental illness.

So please go check out the blog and follow it!

Inspired by the Broken Light Collective, I would like to do something similar with art in all other media excluding photography and post a picture a day of art work with the person’s story. I’m thinking of calling it the Shadow Brush Group and would model it on the philosophy of Broken Light. It would just be a place where people instead of sharing photos, share photos of paintings, drawings, mixed media, sculpture, crafts, fiber arts, environmental art, even short poems.

Note: For the Broken Light Collective people can choose to post on there with their real names and also are able to post with a pseudonym to keep their privacy… There is no judgment either way, just an invitation.

Musing on Relationships, Culled from Marilyn Monroe’s Writings…

I am reading “Fragments” by Marilyn Monroe, which constitutes notes, poems, musings, diary entries, etc. I have long been fascinated by her for many reasons, psychological reasons being the obvious focus for this blog.
In publishing these fragments of writings in 2010, the editors and publishers wanted to show a very different side of this very complicated person, and they succeed. One of the interesting things about the photos in this book is that they show a lot of photos of Marilyn reading all kinds of books, and she was actually a voracious reader who tackled Dostoevsky and James Joyce’s Ulysses. It is even stated in the book that she liked having pictures taken of herself reading. This was no Sarah Palin pretending to read a newspaper. Those who were close to her knew she had a sharp curious mind and loved reading. Seeing these photos did make me reflect on present day actors as well as past ones. I couldn’t think of any who especially liked to be pictured reading. There is something interesting about a photo of a woman reading a book, especially this woman who was so in touch with the camera. In most photos of her she is looking at the camera, but in these she is dressed fashionably but casually and seen sitting or standing in a casual position in a homey looking environment, and her eyes are on the book, so there are two subjects to the picture. There is the mystery also of what page she might be on and what words age might be reading when the photo was taken!

Anyway, it is quite interesting to read her fragments, many of which are poetic and quite beautiful, while others are filled with insecurity, loneliness and the desire to improve herself. Some are even directly related to her being in psychoanalysis. I’ve been looking through the book for something to quote somewhere and finally found something for this blog rated to a recent post I wrote about relationships. It is very thought provoking and both sad, realistic and somehow hopeful, which is a curious combination, but not so strange when touching on the subject of childhood and attachment. So here it is; please react and comment if you are moved to do so…

“(page 131) re relationships

Everyone’s childhood plays itself out
No wonder no one knows the other or can completely understand. By this I don’t know if I’m just giving up with this conclusion or resigning myself-or maybe for the first time connecting with reality-

how do we know the pain of another’s earlier years let alone all that he drags with him since along the way at best a lot of lee-way is needed for the other-yet how much is unhealthy for one to bear.

I think to love bravely is the best and accept-as much as one can bear”
(words underlined in this passage: plays, much, unhealthy)

Quick reactions. I found this to be very truthful and really focused on relationships that are very mature and/or deep, those moments when people become unsure and unsettled by what they observe in themselves and their partner. It raises some interesting questions for couples who are examining their relationship or in couple’s therapy: “what are the parts of your partner that you do not know or want to know better but seem buried under a lot of pain?” ” Do you think you can share your own childhood painful parts with your partner, and if so, can you use this to better understand your child selves within the relationship?” “Do you give “lee way” to each other for all that emotional baggage you still carry?” “How much can you each bear of this part of yourself and of her/him?” “Are you afraid of it and avoiding it, or are you bearing too much of it to the point that either of you can recognize it is unhealthy?” “Or, are you asking too much of your partner and wanting ir demanding him/her to bear an unhealthy amount of this early pain in the relationship as it is right now?” “Do you feel that you love bravely and strive to accept what you can reasonably bear in each other?” “What does it mean for you to love bravely?” “Have you ever done it or do you shy away from it?”

As a side nite the word “lee-way” is quite interesting, with origins in the concrete meaning of a sideways drift if a boat or plane. The best definition I came across that seems to fit her use of the word was “leeway – a permissible difference; allowing some freedom to move within limits.” Just thinking about this word and this definition, well, what a perfect word to encapsulate a bug part if intimate relationships: the balance between acceptance and tolerance of difficult aspects of the other while at the same time having reasonable limits, thus capturing the combination of surrendering as well as separating/having boundaries… Real food for thought in just a few short sentences…

Mental Health Awareness Month Post Number 2!

Ok. I’m interrupting my attempt to get deeper into the issues around money and therapy because I have until the end of May to do my part in raising awareness around mental illnesses and the paths to mental health and stability…

I think this is too great an opportunity to pass up. On my personal Facebook I pledged to post at least once a day a fact or question to do with this subject. Then I decided to do the same on my LinkedIn “share” with connections. I am in too many professional LinkedIn groups to post on all of them! Then I decided to post about it on my public Facebook Artist Page. In fact after I’m done with this post I will announce it on my Artist Page.

I confess as a therapist and human who works closely with people on their very personal paths towards health and real soul fulfillment, feeling myself to be, or at least aspire to be, a sort of modern times Shaman or Doctor of the Psyche, I am really excited about this discovery that May has been Mental Health Awareness Month for over 50 years! How dare they not tell us in grad school or at our jobs and internships! How many therapists know about it??? Check with your therapist and/or psychiatrist to see if s/he knows about it! Spread the word! Thank goodness for the Internet and social media, as they help us raise awareness of such an important topic. There is just too much stigma out there about mental illnesses and so much ignorance. Why do health insurance companies still limit outpatient mental health treatment to 20 or 32 visits a year!?? How dare they set a limit on something so important in such an arbitrary manner! I’ve never had a patient with a mental illness who was invested in his or her therapy, who thought 20 visits or 32 sessions was enough per year. That has to change. What would people with one kidney do if they limited their dialysis visits per year? Unthinkable…

To get back to the point, though I don’t think I’ve strayed that far, in this post I will do what I’m doing daily on Facebook and LinkedIn: I’m going to make a list of ten questions or lesser known facts about various mental health issues. By mental health I include addiction, eating and personality “disorder” issues as well as trauma of various kinds and healthy positive behaviors related to this topic…

1. The relatively new phenomenon of personal blogs about how a person is living day to day with his or her symptoms and feelings about having some type of mental health issue is a wonderful way that people can see up close the courage and strength it takes for people to face their life day in and day out, struggling with staying healthy. It’s also a great testament to how far we’ve come with medications that work for people and with diagnostic criteria that help people come to terms with and manage their daily self care. Of course there is a lot more to improve with medication and treatment, but these very raw personal and honest blogs out there are a great way for people to feel less alone with their particular struggles. For some, the blogosphere is the only community they have and place they feel safe discussing such personal issues and struggles. So I start with a very positive aspect of mental health awareness by saluting all you people out there blogging about your struggles and triumphs. I follow many great blogs of this type and hope to find many more…

2. Schizoaffective Disorder: how many of you have heard of it? I first learned about it at an internship at a Continuing Day Treatment program long ago, so I have worked with individuals given this diagnosis. The term was first coined in 1933, but I have a feeling most people haven’t heard of it unless they have it, know someone with it, or work in the mental health field. You can find very particular detailed explanations of it on the Internet. I would describe it as bipolar and mood disorders meets and marries schizophrenia types of symptoms. What a challenge to be dealt this card! You have some sort of mood instability, whether primarily depressive, manic or both, as well as possible psychotic episodes, paranoia, hallucinations and delusions. For a really up close and personal account of it, read the memoir “The Quiet Room” by Lori Shiller. There’s still a lot of controversy about this diagnosis, and it comes up in this very moving book. In my experience, I think this diagnosis can be helpful to people suffering from such a confusion of symptoms because usually Bipolar Disorder and Schizophrenia thankfully now are seen and recognized and treated as very different because they are completely distinct. In the past people with either of these illnesses were lumped together , but we know a lot better now. However, there are some people who suffer from symptoms described by this “cross sectional” type of disorder. In my experience it really does exist, and the diagnosis is helpful, as people can be treated with both a mood stabilizer or anti depressant and an antipsychotic type of medication that people dealing with schizophrenia take, and they can have potential relief of their mix of symptoms and also begin to experience themselves as functioning at a much higher “level” in their lives which can be greatly improved and a lot less painful and confusing…

3. So, on the topic of mood stabilizers and “anti psychotic” medication, otherwise referred to as “psychotropic” medications: In contrast to what I said above, it can be confusing for people suffering from Bipolar Disorders, Schizoaffective Disorder, or other schizophrenia related disorders on terms of the wide variety of medications currently used to treat such illnesses. On the one hand, modern medicine has put to rest the confusion of what used to be called “manic depression” and “schizophrenia.” We all know now how different these are, but some of the medications treat both types. The difference is in the dosage. Old fashioned medications like Haldol, as well as the newer “anti psychotics”, such as Geodon, Risperidol, Seroquel, Zyprexa and many others, are prescribed for any form of psychotic episode, as well as being maintenance medication for schizophrenia and related “schizo” type disorders. To make matters more confusing, people with Bipolar Disorders, for whom a typical mood stabilizer like Lithium or Depakote, just to name 2 main ones, does not help enough to stabilize moods, can now take such medications as Zyprexa or Seroquel as mood stabilizers, usually on lower doses than for schizophrenia type symptoms. Some people with a kind of Bipolar Disorder take a typical mood stabilizer, as well as one of these other meds, and as well as an anti-depressant and other medications such as those for anxiety, which are in a totally different classification. So we’ve come all this way in distinguishing Bipolar type symptoms from those of schizophrenia related illnesses, and yet the same medications may be used to treat both. A little confusing. However, it is great that these other medications were discovered to have mood stabilizing properties, as some people need to take them instead if or alongside their regular mood stabilizers. Seroquel is also considered to have anti depressant properties, so probably some of the others like it also do.

4. While in my experience with working with people who suffer from very serious mental illness, mood stabilizers and medications like them can really be miracle workers for those suffering from Bipolar type issues in that, once the right medication or combination is found, people who take their medications daily can experience a great relief of symptoms and a sudden experience of real stability, those suffering from “unipolar” depressive illnesses such as dysthymia and major depression, tend to have more struggles with their medications. There are the lucky people who find the right anti- depressant and get relief; unfortunately of those people there is the group who after 6 months to a year find the medication no longer works, and they are plunged into a depressive episode and have to try some other anti-depressant(s) to see if a different one will work. For others, none of the different types of anti depressants out there seem to work. Some women in the latter group find a doctor who decides to try the more innovative treatment of using hormone medications to treat their depression. I read an interesting article about this a few years ago which really amazed me, as many people I know who suffer from mood disorders tend to complain that they can’t take birth control pills because it sets off depression. Others take hormones for birth control alongside their other meds without any trouble. Thankfully now there is a small group of women who take only hormonal medications to relieve their depressive symptoms! What a great medical breakthrough!

Ok. I have not yet reached number five and this post turned out to be much longer than I expected. So, the above is my food for thought on this topic thus far. I pledge to reach number 10 before Mental Health Awareness Month is up!!!

Money and Therapy; A Very Confusing Topic

I just wrote a long draft for this post, and it disappeared, so I am very frustrated. I will try a shortened version of what I had in mind.

I started by describing a lot of potential scenarios (in private practice as opposed to clinics or training institutes or agencies) for therapists and patients to raise questions such as the following:
1. What is it about the exchange of money for therapy that directly affects the therapy?
2. With insurance companies often paying the bulk of your therapists fee, does your copay to your therapist hold any meaning for you or your therapist?
3. Is there such a thing as too low or too high a fee?
4. What does it mean for the therapy for a patient to be paying a very low fee over a long period if time due to real financial hardship?
5. Is the therapy compromised or changed when an outside party such as a parent or friend pays for all the therapy?
6. What is it like as a therapist to be mistakenly seen as very wealthy by your patients due to some misconceptions about therapists in private practice and their incomes?
7. What is it like for a therapist to have a patient who makes over twice the therapist’s income?
8. Is it wrong for a therapist to let a patient who has money problems and is paying a low fee get very far back in payments to the therapist and owe months of therapy? Who should bring up the topic?
9. Is there something strange about this scenario: therapist goes to a supervision group and pays a monthly fee 30$ more than the fee s/he charges her own supervises in the supervision group she runs.
10. What makes most therapists say no to bi-weekly (2 times per month) instead of weekly sessions and what makes a few therapists accept this scenario as well as a low fee due to the patients’ financial hardship?

In the world of many therapists the whole topic of the fee and sliding scale and how to handle the negotiations of it is hotly debated. Some say if you don’t pay attention to the fee and how it is paid you are avoiding a lot of important issues. Others have a philosophy of really using the sliding scale fee and accommodating people other therapists would never work with. I confess I fall in the category of those, the ones who lower their fee to accommodate patients with little money and at times I accept a patient coming only twice a month. In most cases it is a patient who has been coming weekly for a long time but not always. There are other reasons I have accepted this type of patient besides money issues though I agree with most therapists’ opinion that much more can be accomplished with the regularity and structure of weekly sessions. I also would never run a supervision group that did not meet weekly as I think the group process works with weekly meetings and consistency and keeps the group functioning for support as well as clinical issues.

Many years ago I read in the New York Times magazine a profile of a British therapist. I don’t remember his name or why the article was on him but I do remember him saying, ” I strongly believe that therapy should not cost more than (don’t remember the amount but it was equivalent to about $80 which these days might be around $120 as this was written around ten years ago)…” anyway I was really struck by his point. He actually thought there was a limit to a decent fair fee for his services despite his education, training and experience. Sort of like saying an ice cream cone from a truck shouldn’t cost more than 3$. This was and is very unusual in our profession to actually say that it’s indecent to charge more than a typical amount such as $100-$120 per session as your highest rate. Putting a limit on the value of therapy. Most therapist’s focus much more on the difficult issue of, can this particular patient afford to pay my highest fee and if not what can they afford. On the patient’s side, I have seen people say I don’t want to pay you less than such and such as I don’t want you to feel disrespected so this is what I could afford to pay you.

I admit I had a conversation with someone about couples therapy and how insurance companies often pay too little for it. Yes, some therapists charge more for couples than individuals. The reasoning is that couples therapy is much more difficult to do, which I think is definitely true. In addition, most couples don’t stay in therapy that long with some exceptions. While it is not unusual to have a patient in therapy for five years or more, the average couple dies not remain in therapy that long. I could diverge into a discussion of couples therapy but that is for another post. I will add that it’s not unusual for a couple to go to a couples therapist and end up with one partner continuing with the therapist individually and thus stopping their couples sessions. It is one way people kind of accidentally find a therapist they like for individual…

Back to money. The idea of going to someone’s office to share intimate details of your life and expose your self in various verbal and nonverbal ways is hard for some people to wrap their head around. Usually the boundaries of not knowing much about your therapist helps with this scenario and makes the whole money transaction make more sense to most patients. I am going to a doctor of the mental, emotional and spiritual body so of course I am paying as I would for a doctor of the “physical” body. This is how I would explain the process to a curious and puzzled Martian.

People may notice they are sometimes treating their therapist like their mother (transference) but it helps to have the distance and strangeness of the personal information mostly flowing one way, from the patient to the therapist.

I admit or confess to sometimes wracking up a large bill with a patient who is on a low fee and having a very hard time confronting the patient about it. It certainly would be easier if the patient brought up the topic. Confronting someone who has a job they work hard at and are paid little for who has loyally stayed my patient when s/he could have found someone in network on their limited health plan and now owes me for quite a few months if therapy is not easy. I also have a patient who left therapy suddenly owing me about $300. She has paid off most of it but still owes enough that I need to chase after her every once in a while.

The majority of my patients not using their insurance pay me some fee lower than my regular fee and pay it on time.

The one insurance company I am in network with pays me a little more than half my regular fee. What does this mean? Probably that the insurance company undervalues my work in a much more insulting way than any patient is capable of doing. It says with your license, level of training and experience we agree to pay you almost half your fee. If course experience usually doesn’t mean much to the insurance companies nor do they raise your fee according to inflation and cost if living.

Raising your fee is another big topic which a lot of therapist’s struggle with.

Money and therapy: big topic to be continued in the next post!