Mental Health Blogs

This is a sad story, but we should have seen it coming. This is the price we pay for war. Why don’t we ever learn that?

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When things come in threes, I write about them. I think, this can’t be an isolated issue, maybe it isn’t random, not if it’s coming in threes.

A guy tells me that he has found a solution to dating anxiety. I’m interested in the solution, I really am. But first, of course, want to know

Why should a guy have dating anxiety?

After all, there are two single women for every single man, probably three. A man can have six eyes and he’ll still be a hot property in certain circles.

Hold constant (control for) any predisposition toward anxiety, anxiety disorders in the past, anxiety disorders in the family, post-traumatic stress disorder, child abuse, obsessive-compulsive disorder; hold all that in abeyance, and there’s still a likelihood, or so I’m hearing, that dating is scary as hell.

I don’t mean to be glib. I understand why people are anxious about dating. It’s the rejection that’s terrifying. Rejection hurts, and the chances of being rejected after a first date are rather high, actually. This we understand.

What’s confusing is not the anxiety, but what men are doing now to resolve it. To resolve dating anxiety, men are taking Viagra. Young guys. We’re not talking just the Medicare set.

Apparently they’re sure that women expect a really good performance in bed. Nobody’s watching Oprah or Dr. Phil, or Dr. Laura or Dr. Ruth, not as much as we once thought. If they did they would know that a good sexual relationship does not depend upon a good performance by anyone.

On television, thankfully, and even in most of the books in the self-help section at the book store, we learn that a woman is supposed to be responsible for her own sexual satisfaction. If she’s interested in this, sexual satisfaction, and she should be, since this is great marital glue (don’t get me started, I don’t know if it works as glue if you’re not married)

(a) she should try to connect with her partner while she’s alert, not about to fall asleep,

(b) both of them should focus on their sensuality, wake up the brain, stimulate all five senses,

(c) she, especially she, since he’s had his sexuality in his hand since he learned how to urinate, but she should get to know her body, understand what makes her happy (I know, I know this is an unpopular suggestion, especially for some people who have religious concerns, one day we’ll give it more time) and

(d) if she wants him to feel he’s doing something, then she has to tell him what to do to pleasure her.

True story. Guy calls me for marital sex therapy. He says,

“She’s too small. Maybe we need a pelvic floor therapist, or maybe you. The doctor thinks we probably need a sex therapist like you, but I think a pelvic floor therapist.”

I haven’t a clue what this is, a pelvic floor therapist, am hoping this is a sex therapist. This young man has called me many times before, but we’ve never met. He’s never satisfied with my telephone assessment of the situation, yet I still hear from him every six months or so, feel we’re old friends. (He could be a she, or maybe an avatar, we’re not outing anyone here).

I reply,

“There’s no too big or too small. You need a relationship therapist, one who understands sex therapy, or a sex therapist who understands relationships.”

“No, she’s too small.”

End of conversation. No too big, no too small. At least one of us is clear on this.

That had to be said, that there’s no too big, no too small. A couple has to manage with what they have and can, should, try to enjoy the process, try to figure it out. Somehow.

So if size doesn’t matter, then what does?
You guessed it:
(1) communication,
(2) discussion of mechanics and myths about sex,
(3) practice at home, and
(4) resolution of emotional interference.

Why would anyone think that you can have all that, and what you don’t have can be resolved, all on a first date? Surely it takes a long time to get any one of the four right, let alone all four. Most couples who come to a sex therapist have been working at it a long time and have given up. They’ve already spent a few years getting to know one another, getting to know one another’s likes and dislikes, exploring and talking day after day, year after year, and even then, it just isn’t working. They know there’s baggage, too, that is in the way, even secondary trauma. We’ll never get it right! There’s something really, really wrong here!

This isn’t second nature, really, a sexual relationship, or any other kind of relationship, to tell the truth. But we’d best focus.

Sexual behavior as a couple is learned, and it is learned in process, from one another, since there are two of you. And you both have baggage, attitudes, histories. It can years to learn to communicate in certain areas, about certain things, without fear, embarrassment, or anxiety, for some of us. And people get so angry at one another! When we communicate anger, intimidation, power, or dominance it can be a huge turn off (I know, I know, the exceptions).

And there are many of us who are depressed, and nothing kills libido like depression, nothing; and past traumas, too, like incest, or other sexual abuse, abortions, not sexy. Really not.

Then there are the mechanics of sex, the how-to’s, and these are, perhaps should be, trial and error, too, and there’s a lot of room for error, so it can take years, without direct communication, without straight talk, honesty, to develop a mutually satisfying sexual relationship. The joy is in the process, really.

Then there’s that whole trust thing. Sex and trust go together. How are you supposed to have that on a first date? A second date? Surely you fool yourself, you say, Oh, this person’s had that vasectomy, and then, surprise, he was kidding. Or she says, You’re the only one, and she’s checking her phone. You get hurt and your trust issues get worse, not better.

This is why people like me don’t even feel it should be happening without commitment, sex. Crazy, I know, and so unpopular, so unreasonable, that this is likely not going to catch on. But it’s too important, sex, too integral to what makes a healthy couple healthy, content, establishing a good relationship while naked. The reality of sex is that it exposes us. Who wouldn’t be terrified, seriously?

Let’s draw a parallel to aggression to explain this phenomena, the pressure to satisfy the girl, the pressure to have sex in general, no matter the status of your relationship.

It’s compelling that the Saw movies are in their seventh year. Every year there is another one of these very, very violent, horrible, graphic movies. People go to them, we think, to master their fear of violence. If you see the film often, or you see a new one every year, eventually it doesn’t upset you, the thought of cutting off your own leg, and well, you’re tough. You’re strong. You’ve desensitized to your fear.

Some of us would disagree, however, that this is what makes a person strong. If this is what makes a person tough, seeing violence and not feeling anything, not being affected, then that person’s definition of strong is perverted.

The corollary is sex. We can regard this fascination with sex, this insistence upon it, because it is supposed to be a loving act, the flip side of violence. And we can see the obsession with it in the same way. Have it often, have many partners, do it perfectly, and at some point you will be immune to the anxiety, the embarrassment of taking off your clothes, of someone seeing you for who you really are.

That’s pretty sad, isn’t it? In a good relationship, one that is trusting, loving, caring, and kind– taking off your clothes might still be embarrassing, but it’s a good kind of embarrassing, a shy kind of embarrassing, even, an intimate one.

You might say, for example, “I’ve gained five pounds this winter,” and your spouse will say, “Don’t ever lose them! I love them! I love these pounds!” For he knows that you are responsible for your own weight, too, and he doesn’t want to work your program, he just wants to make love. And he loves you.

And in a good relationship, one that is committed, you are staying the night, so staying the night isn’t even a question, it happens all the time, it’s not a big deal. So theoretically, if you have that, commitment, you can roll over when you’re both a little tired of sex play, and say, Goodnight, even if everyone’s not completely satisfied, and it’s okay.

But not anymore. Oh, no. Committed or not committed,

NO! YOU (I) MUST BE SATISFIED OR FORGET IT! WE CAN’T POSSIBLY CONSIDER GOING TO SLEEP YET!

Where are people learning this?

This dysfunctional pressure to reach orgasm is perhaps a reaction to what could have been the rule, perhaps even as recently as forty years ago, a covert rule that men didn’t need to concern themselves with female satisfaction. Nice girls didn’t like sex. So slam-bam, thank you ma’am, theoretically ruled. But perhaps that whole thing was a myth, that men who loved their women ever even did the slam-bam, thank you ma’am thing. Yet the reaction formation for sure is alive and well.

Now, men have to perform, their needs are important, but hers are, too, and she’s demanding a performance, or so some of the guys feel. The guys are thinking they have to be studs again. THEY have the secrets to female satisfaction, and if they don’t, well, no second date. So of course they’re anxious, because in their minds, and apparently in hers, too, what makes it great, sex, is that erection.

Zachen v’aitzen Columbus. (Yiddish for, What in the world is wrong with this picture? Don’t ask me for a direct translation. Find my mother, ask her.)

This is fantastic news for the makers of Viagra and Cialis. Forget that only one woman in five has orgasm during intercourse, anyway, with or without these drugs. Forget that without an intimate understanding of a partner’s arousal, physiology, and how much he or she had to eat, meaning how extended, distended, in other ways one might be, that there’s no way one partner can help the other achieve orgasm. Forget that foreplay should take a half an hour, intercourse maybe five minutes, maybe ten, or it’s going to hurt, certainly will irritate her. None of this matters. It’s all about Mr. P.

It shouldn’t baffle us that the importance of sex has taken on such magnitude that a man will take a medication that could be dangerous, just to be sure to please a date. This is horrible and is indicative of a related issue, that we have grown accustomed to instant relationship gratification (hand me my phone, please, I need to read my email NOW). She wants it now. Or so he think. Why waste time?

Nobody’s taking the time to nurture the relationship.

And the joke is that people think they can nurture their erection, their arousal, without it.

therapydoc

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via HITshrink:

Two feet of snow and Baltimore comes to a screeching halt. How to get the doctors to the hospital? This is where telepsychiatry can be very helpful. However, there are still so many impediments to using telemedicine (billing, liability, documentation, technical) that we are *still* unable to use it when we need it. Like today, where the hospital will have to send a 4×4 to pick up Dr Chandran to get him to the hospital.

A broader term for distance mental health services is Telemental Health services, or TMH. Proposed new regulations were released last week that would permit and regulate TMH under the public mental health system (aka Medicaid) in Maryland. Unfortunately, the way it is currently written would not permit me to “see” inpatients on our unit from home during a blizzard. Still, it is a step in the right direction.

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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I apologize for being silent for a couple of days on here, but I’ve been working 12 to 14 hour days–weekends included–since early January and my brain has turned to mush. Why so much work? Let’s just say that over the last few weeks I’ve developed a rich appreciation for something conservatives and small business groups have told me during my reporting career: “There’s too much red tape and bureaucratic nonsense involved in starting and running small businesses. It’s an economic disincentive.”

I’d thought for years that they were overstating the case for political reasons. I don’t think that way anymore. There is far too much red tape and far too many hoops to jump through in starting a small organization of any kind–even one like Sensible Washington, which as a PAC is exempt from many reporting requirements–for many people to give it a go. Government red tape, bank red tape, etc., etc., and on and on it goes. It becomes mind numbing after a while.

I hope some time this weekend to pen a few posts, but for now my body and mind are screaming for rest. And less red tape.

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I often get calls from patients who want to come in “as soon as possible.” Especially new patients, but sometimes established patients. I try to be as flexible and accommodating as possible, but sometimes it gets a bit inconvenient. Now I’m in confabulation mode, but I’m curious about readers’ opinions of how one should respond to emergencies. Often, I offer an appointment asap and the person requesting it can’t make it and asks for another time. So it becomes a bit of juggling of priorities. And I’m left wondering how much the doc should be thinking about juggling (if at all). So let me fly some scenarios by you, and I’m curious as to what you think. The details are all confabulated, but the essence of the stories have gone down in some form over the past few years.

For both the doc and the patient, I’m going to use the example of a hair appointment as a non-urgent but meaningful conflicting issue. It can be hard to schedule hair appointments, they take a while so they aren’t that easy to reschedule, and someone else is inconvenienced (the stylist) by a change, and the consequence of delaying the appointment is meaningful (ya gotta live with ugly locks until you can get rescheduled). For the sake of my confabulation, you don’t have to pay for a missed appointment, and it’s hair, life goes on even with a bit of frizz (tell me about it).

For the sake of the uncontrollable, I’m going to use the car breaking down– no one asks for this, it throws a miserable wrench in life, it’s unanticipated, and if you can’t get there, you can’t get there. It could be “I was in the ER with chest pain,” or “my husband locked the deadbolt and took the keys to work (and oh, we live on the 10th floor so I couldn’t crawl out a window”) but the broken car is the example of beyond someone’s control to a reasonable degree.

Story #1) So patient calls and wants to come in emergently (asap). I look at my schedule and I have lunch time free, I finish at 3, and I have a hair appointment at 4. I offer 12 noon. Not good, patient has a hair appointment at 11:30, can I see her at 4? I can’t (though I don’t say that it’s because I have a hair appointment). What’s a shrink to do?

Story #2) Patient is having an emergency. Ah, a few days ago I came to see pt outside of regular office hours because pt was so clear it was an emergency and it couldn’t wait until next available appointment. It was an emergency and I remained worried about pt. Pt canceled follow up appointment because his car broke down, but it was still an emergency, so could I meet him later in the day when relative would be home from her hair appointment and could bring patient? I quietly think: it’s an emergency, relative knows it’s an emergency. Can’t relative cancel hair appointment? But it’s been presented as this is something that would either be unacceptable to relative, or pt would be uncomfortable asking this of relative (and this I understand). Patient asks if I can move appointment to later in the day, a time I’m usually in the office. Oh, but I didn’t have any appointments scheduled that particular day that late in the day, and I scheduled….you guessed it…a hair appointment! We looked at our schedules and couldn’t come up with another time for many days and this is what we scheduled for.
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Do you want to know what I did? In the first scenario, I offered the patient a half appointment at the end of the day, and I was a late to my own “hair appointment,” but every thing got done. I felt a little uneasy about it because– The patient’s other obligation actually felt a bit less conflicting then an actual hair appointment, and let’s just say my own obligation got short-changed, and the issue at hand wasn’t a psychiatric emergency.
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In the second scenario, I felt more conflicted. I know the patient wanted to come and he was out of control of the some of the scenario (? did he ask relative to skip hair appointment? Did he offer to drive another family member to work and borrow their car?). If this same patient had called and did not already have an appointment for that same day, and if my schedule was completely booked, I would have come back in the evening after my new doo to see him.

So what do you think?

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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Richard writes:

Given the popularity and prevalence of twitter, I put together a list of 50 different doctors on Twitter that you can follow to potentially get some insight on their medical lives. If you wouldn’t mind, could you share my list with your readers?

If you know of any other physicians that you follow on twitter, I’d love to add him/her to the list. Just leave a comment on the blog.

http://blog.onlinecollegeguru.com/health-care/50-doctors-to-follow-on-twitter/

Richard, Richard, Richard, oy~! Where is ShrinkRapRoy on your list? Where is ClinkShrink?
( I don’t twitter or go tweet tweet very often so I won’t care that I’m not on the list).

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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There’s an OK-ish piece in the New York Times today, penned by a psych nurse in Portland, Ore. It concerns a young woman admitted to a psych unit in that city–without name and history–and the nurse writing about her progress and such. The article really doesn’t go anywhere although it does make the adroit observation that there are few “ah ha” moments in psychiatry (Breaking news!) and it’s one of those pieces that I scratch my head about and wonder why it was appealing to an editor.

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Yes, therapists have issues too. Anxiety was never mine until a few years ago. Prior to that I could intellectuallly understand that people said they were experiencing anxiety and panic, but I couldn’t fully appreciate how bad it felt, until I had my own.

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Male homosexuality doesn’t make complete sense from an evolutionary point of view. It appears that the trait is heritable, but since homosexual men are much less likely to produce offspring than heterosexual men, shouldn’t the genes for this trait have been extinguished long ago? What value could this sexual orientation have, that it has persisted for eons even without any discernible reproductive advantage?

One possible explanation is what evolutionary psychologists call the “kin selection hypothesis.” What that means is that homosexuality may convey an indirect benefit by enhancing the survival prospects of close relatives. Specifically, the theory holds that homosexual men might enhance their own prospects by being “helpers in the nest.” By acting altruistically toward nieces and nephews, homosexual men—bachelor uncles in effect—would perpetuate the family genes, including their own.

Two evolutionary psychologists have been testing this idea for the past several years on the Pacific island of Samoa. Paul Vasey and Doug VanderLaan of Lethbridge University, Canada, chose Samoa because male homosexuals there—called fa’afafine—are widely recognized and accepted as a distinct gender category, neither man nor woman. The fa’afafine tend to be effeminate, and to be exclusively homosexual. This clear demarcation makes it easier to identify a sample for study.

The researchers have shown in past research that the fa’afafine behave much more altruistically toward their nieces and nephews than do either Samoan women or heterosexual men. They babysit a lot, tutor the kids in art and music, and help out financially—paying for medical care and education and so forth. That’s interesting in itself, but it’s unclear just why they behave this way. What’s going on cognitively that supports such avuncular acts. In their most recent study, the scientists set out to unravel the psychology of the fa’afafine, to see if their altruism is targeted specifically at kin rather than kids in general.

They recruited a large sample of fa’afafine, and comparable samples of women and heterosexual men. They gave them all a series of questionnaires, measuring their willingness to help their nieces and nephews in various ways—caretaking, gifts, teaching—and also their willingness to do these things for other, unrelated kids. The findings, reported on-line this week in the journal Psychological Science, lend strong support to the kin selection idea. Compared to Samoan women and heterosexual men, the fa’afafine showed a much weaker link between their avuncular behavior and their altruism toward kids generally. This cognitive disconnect, the scientists argue, allows the fa’afafine to allocate their resources more efficiently and precisely to their kin—and thus enhance their own evolutionary prospects.

But these aren’t your garden variety uncles. From an evolutionary perspective, you can’t make up for not having any offspring just by giving a toy to your nephew, or tossing a football with your niece once in a while. Indeed, to compensate for being childless, each fa’afafine would have to somehow support the survival of two additional nieces or nephews who would otherwise not have existed. In short, the fa’afafine must be “super uncles” to earn their evolutionary keep.

Do these findings have any meaning outside of Samoa? Yes and no. Samoan culture is very different from most Western cultures. Samoan culture is very localized, and centered on tight-knit extended families, whereas Western societies tend to be highly individualistic and homophobic. Families are also much more geographically dispersed in Western cultures, diminishing the role that bachelor uncles can play in the extended family, even if they choose to. But in this sense, the researchers say, Samoa’s communitarian culture may be more—not less—representative of the environment in which male homosexuality evolved eons ago. In that sense, it’s not the bachelor uncle who is poorly adapted to the world, but rather the modern Western world that has evolved into an unwelcoming place.

For more insights into human nature, visit the “Full Frontal Psychology” blog at True/Slant. Excerpts from “We’re Only Human” appear regularly in the magazine Scientific American Mind. Wray Herbert’s book, On Second Thought: Outsmarting Your Mind’s Hard-Wired Habits, will be published by Crown in September.

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The lyrics of an old song and the words of a new client crashed into each other yesterday. I was reminded of one of the reasons men and women fail to have healthy relationships – unrealistic expectations.

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