WHAT KIND OF a book would this be if it didn’t include a chapter dealing with sex and the mentally ill? Just as a mental health professional will have to deal with the issue of suicidal ideation in their practice, so too will they have to address the issue of sexuality in their practice. Now sexuality is part of human expression, a natural instinct, so it is no wonder that people with various forms of mental illness would still desire these natural inclinations. But hold on—the following vignettes may not be what you imagine.
UNDRESSING
As an intern we had very strong training experiences dealing with clinical interviewing. This was and is necessary because this area of clinical practice permeates our profession. Some years ago there was a study of clinical psychologists, asking them whether or not they performed various aspects of practice. The survey included questions on interviewing, testing, and research. A total of 95% of the respondents reported that they used clinical interviewing.
I would address this study in my assessment courses in doctoral training and question what the 5% of those respondents who reported they did not use clinical interviewing as an assessment tool were using in lieu of it. For years I could never come up with a reasonable response to that question until, one day, I guessed that these respondents went into administration and no longer saw patients, but still considered themselves to be clinical psychologists. I can think of no other reason for them responding in this manner.
During our internship we were required to conduct a clinical interview weekly. The process was as follows. Two interns were in the room, along with a supervisor and a patient from the mental hospital. One week, one of us would conduct the interview while the other sat silently and took notes. The next week, the interns reversed roles. The person who was interviewing was required to ascertain the source of the problem—not just diagnose it, although that was required too. In addition, we had to judge the person’s strengths and weaknesses, major psychological issues, and suggested avenues for amelioration. We could not leave the room until the supervisor was satisfied that the interviewer had accomplished these tasks. During the training of doctoral students later in life, I emulated these tasks with my own students, and drew upon these personal experiences as an example to follow in their training. After the interview was completed, we met with the supervisor and “processed” the interview. We addressed what the intern did well and ways to address problem areas within the interview.
One day, an intern was interviewing a male psychotic patient, about 27 years old. After several hours, the interview was getting nowhere. It was 4:30 PM and we (the interns) wanted to go home. But the supervisor wasn’t satisfied and took over the interview. Finally, at 7:00 PM—some 2½ hours later—he was able to break down resistance and get at the source of the patient’s difficulty.
Anyway, one week, it was my turn to take notes and my fellow intern was scheduled to do the interview. The patient was a 45-year-old African-American female whose psychosis was evident. She had come to the psychology department in the basement with concrete floors in all offices. She was dressed in a hospital gown, and as we would learn shortly, nothing else. During the interview, the patient told the intern that she was a housemaid in one of the affluent suburbs and said she would demonstrate how she did her work. Suddenly, she rose from the chair, threw off her hospital gown exposing her nude body, knelt down on the floor, and proceeded to move an imaginary rag in her hand around the floor, as if she was scrubbing it.
Needless to say, the interviewer and I were stunned. The interviewer didn’t know what to say or how to proceed. I was glad that I wasn’t conducting the interview. With much clinical experience behind me, should that ever happen to me again, I would tell the patient to put her clothes back on and sit down so we could continue talking. But then, we were novices and at a loss on how to proceed. Meanwhile, the supervisor sat there and said nothing. I continued to remain silent, but eventually felt that I had to “rescue” my colleague, so I said to the patient:
“You seem a little anxious. Would you like a drink of water?”
“Yes.”
So I left the room, found a container, went to the water fountain, filled up the cup and returned to the room. By then the patient had put her robe on and was seated in the chair and talking to the intern.
Needless to say, that particular moment occupied a large amount of time in processing the interview. The intern expressed perplexity at the event and admitted a sense of inadequacy in dealing with it. I, on the other hand, felt I had acted appropriately, and “saved” the moment.
“Yeah, Craig,” said the supervisor. “You were so cool that you took the earliest possible opportunity to leave the room. So I ask you, who was the one in the room that was nervous?”
I must admit he was right. And he admonished us that we were quick to see how the patient revealed herself physically, but slow to see how she revealed herself psychologically. He forced us to process and understand why she disrobed at that particular moment in the interview and what was she trying to show amidst her psychosis. It was a good learning experience.
WARD AROUSAL
After I completed my internship, I was assigned to a 50-bed all-female ward. The staff had one male psychiatrist, in his 60s and never married. The others were all female—a social worker, a nurse, psychiatric aides, some time later a vocational rehabilitation specialist, and even later. a female physician. Now here comes a young male in his 20s.
I had made contact with this ward during my internship and thus had established some relationships with the staff, and even with a few of the patients, because most of the patients in my therapy group came from there. I felt comfortable there, where the psychiatrist was mainly interested in giving medication and left all other functions to his staff.
The main therapeutic modality used on this ward was medication with milieu therapy. I introduced regular group therapy and tried to do individual therapy with those few patients who were amenable to it. The other main function was case management (e.g., arrange for discharge and follow-up procedures).
As part of this milieu therapy, the staff held regular community meetings with the patient. We also had “patient government” where patients elected someone to lead the meeting (e.g., a president) and a sergeant-at-arms to maintain order during the meeting.
Now you ask, what does all have to do with sex? Well, on a Monday morning, I reported to work for my first day assigned to that ward. We first had to go to the psychology department office to sign in, but most got there early to have a cup of coffee and discuss the weekend’s events. At the appropriate time, everyone, except the chief of psychology and his secretary, reported to their wards. I walked the short distance up to the fourth floor (there were no elevators in the building).
The staff was expecting me, and they discussed various issues of the day, all related to patient care matters. Then, on Monday morning at 9 AM, there was a community meeting. All staff was required to attend (although the psychiatrist attended at his discretion, and most of the time he was absent). The nurse, who actually managed the ward, then introduced me as the new staff psychologist who would be working on the unit as a full-time employee.
There were a myriad of giggles, innuendoes, inaudible comments, asides, and questions that made little apparent sense. Then one woman left her chair, walked to the middle of the room, as we were all in a circle, and began dancing directly in front of me. Her actions became more and more provocative, and then she began to remove some of her clothes. This all happened so quickly that most were stunned by her brazen behavior. Now if this sounds sexy to the reader, I assure you it wasn’t—at least not to me.
I wanted to treat the entire incident therapeutically and in the way I had been trained, so I tried to address the emotions and feelings that might be present among the patients, now that there was another male on the ward. Without addressing the dancer still in front of me, I offered a reflection on what I thought might be the emotions of the group. At that time the nurse yelled at the patient and told her to sit down. The patient laughed and returned to her seat.
After the meeting I wanted to analyze the behavior of the group, as I had been trained to do after group therapy, which I thought was identical yet on a smaller scale. The staff brushed it aside. They had no interest in psychodynamics and directly went to the business of determining passes, patient requests to see the doctor, and medication changes. It was then that I realized that their primary interest was in ward management issues and not in understanding patient behavior.
WHAT DID I DO WITH THOSE UNDERPANTS?
This is somewhat similar to an experience I had while serving as a staff psychologist on an intermediate care ward. We had a psychiatrist consulting with us at the time and basically saw individual patients for psychotherapy. Our ward director—also a psychiatrist—didn’t want to bother with these talk therapies, only ordered medication, and would sit in his office during the afternoon, watching the baseball games until it was time to go home.
One day this consulting psychiatrist reported to me an incident that occurred to him one day in his training. He was studying to be a psychoanalyst, which essentially meant that he was undergoing psychoanalysis himself, while still treating his own patients. One day he told me that a female patient in the hospital had taken off her underpants during his interview.
Psychiatrist: “Dr. Craig, what did you think I did with the underpants?”
Me: “You took them to the nursing station, gave them to the nurse, and told her that Ms. X took them off during the interview.” That’s what I would have done (but not when I was a novice in training).
Psychiatrist: “No. That would have been the ego response. “(By that he meant the rational response unencumbered with any emotional issues he brought to the interview.) “No, I threw them in the garbage can. That incident occupied weeks of my subsequent analysis with my psychoanalysis.”
“EXPOSURE THERAPY”
Later in my career, I was supervising doctoral students and both chairing and serving as a member on dissertation committees. One of our students (female) was doing her internship in an all-male prison setting. She was conducting individual psychotherapy with a sexual abuser. During the sessions he began to expose himself and she began taking notes about these exposures, including what they were talking about before and after the exposure. She told me that she simply let him do what he wanted to do so as to not interrupt the behavior, because she wanted to analyze it. (In other words, she never told him to put it back in his pants.)
She then conducted a literature review on males who expose themselves, did a comprehensive analysis of this patient’s history, including his sexual predation, and analyzed the psychological meaning of his exposure during the sessions. She then discussed how these manifestations and behaviors coincided or varied with what has been reported in the literature. It was one of the better dissertations that I had the pleasure of reading.
SEXUAL AROUSAL
During my internship, besides clinical interviewing, another strong component was our training in group therapy. This module was an offshoot of individual psychotherapy, and began in the VA hospitals because there was a shortage of psychiatrists to conduct this therapy.
A digression. Clinical psychology, as a discipline, began as a combination of philosophy and physiology. At the time, philosophers were theorizing on what was the basic unit of mental life, while physiologists were experimenting on what was the basic unit of physical life by studying what were called “just noticeable differences” (JNDs), limens, and thresholds. For example, researchers would ask volunteers when they could notice an increase or decrease in luminosity. When did something become lighter or heavier? When did a sound become more or less audible?
When these two branches merged into what would be called psychology, these new professionals were only teaching. Meanwhile, the Department of Education in France asked Alfred Binet to develop a series of tasks that would separate the educable mentally retarded from other students, so as to develop special educational efforts for these students. Lewis Terman, at Stanford University, at Palo Alto, California went to France to study with Binet, returned to America and refined these tasks and published them as what became the first intelligence test—the Stanford-Binet Intelligence Test.
Psychologists could now do three things: teach, research, or give IQ tests. The field began to develop exponentially, and psychologists developed achievement tests, aptitude tests, projective tests and the like. Notice that, at the time, these were all individually based tests. But it gave psychologists yet another activity—testing.
At about the same time, the theories of Sigmund Freud had become very popular in psychiatry. There was a hierarchy, so to speak, in the field, consisting of psychoanalysts, psychiatrists in analysis training to become psychoanalysts, psychiatrists who had not been analyzed, and fellows in psychiatry—the lowest on this totem pole. Psychologists were invited to become a member of the psychiatric team to do psychological testing.
Psychologists had developed tests that got at the psychological processes that were of interest to psychoanalysis. What were they interested in? Unconscious processes, arrested psychological development, transferences, object relationships, and conflicts. Psychologists developed projective tests, such as the Rorschach inkblot test, the Thematic Apperception Test, and figure drawings, to tap these areas of interest. But they could not do psychotherapy, which was only the purview of psychiatrists.
That all changed in World War II. With hundreds of thousands returning GIs, the government set up a string of VA hospitals to care for these GIs, and many required psychiatric treatment. There were not enough psychiatrists to treat these psychiatric casualties, so psychologists in VA hospitals were “allowed” to do group therapy.
In explaining this history to my students, I would often ask them “What do you think happened when psychologists in VA hospitals began to do group therapy?” But they never gave me the answer I was looking for. The correct answer is that they liked it. Some even liked it better that psychological testing. And then what happened? They thought they could do it better than psychiatrists, so they began to write books on how to do it. Of course, the books they wrote were from a psychoanalytical perspective, because that was the only way, at the time, to understand psychological functioning.
In the 1950s, Carl Rogers at the University of Chicago developed an alternate way of thinking about human psychological function, and a theory of therapy to ameliorate problematic cases. He called it client-centered or non-directive psychotherapy. This form of therapy became very popular because Rogers’ students needed to do dissertations in order to graduate and so they were spewing out a plethora of studies, most of which validated many of the tenets of Rogers’ thinking. This gave psychologists yet another activity to perform as professional services.
This was the background when I became an intern and assigned as a co-therapist who met twice weekly with a group of female mental patients. Our group met during the entire year of my internship and I met with my supervisor, who actually conducted the group, and processed that session. Of course, the patients came and went, as they were admitted and discharged. It was a great learning experience, and, as a staff psychologist, I continued to do therapy groups, both with inpatients and with outpatients, at our community-based outpatient clinic. I also conducted group therapy regularly later, when I was the director of the drug abuse treatment center at a VA Medical Center, I found it to be a very useful intervention.
My supervisor had been a staff psychologist at the medical center. He was well experienced and had a down-to-earth approach. He was also easy for both me and the patients to relate to. One of the better training episodes occurred one day with a female patient who was very histrionic and displaying this behavior in group. After the session, I asked the supervisor what was wrong with her. Now I expected some fancy diagnosis, some reasoned exposition of her psychodynamics, some erudite explanation of her behavior. His response shook me. “She’s a bum,” he said. That was exactly the way I thought of her and it reminded me an old adage. The simplest explanation is often the preferred explanation.
Now back to sex. There were two women in this group that were problems for different reasons. One was an extremely dependent woman, perhaps the most dependent person I had ever met. She needed explanations for everything, reported continued helplessness and inadequacies, and totally lacked any sense of independence of behavior or thought. She was about 30 years old and white. The second person was a 55-year-old white female who sexualized everything. No matter what anyone brought up, she had a sexual explanation or sexual comment pertaining to the topic of discussion.
I was getting married in the middle of my internship. When I returned to the hospital, my supervisor was taking a two-week vacation, and this would be my first opportunity to conduct the group alone, and I was looking for to it. Again it turned into yet another learning experience for me:
Dependent Patient: “Mr. Craig, are you still married?”
Me: “Yes.”
Dependent Patient: “Does she wash your clothes?”
Me: “Yes.”
Dependent Patient: “Does she do the dishes?”
Me: “Yes.”
Dependent Patient: “Does she cook for you?”
Now I realized where this was headed. I was still somewhat inexperienced in handling issues, and not ready to deal with their real issue (sexual stimulation and desires of a dependent woman towards a young male) and so I tried to cut this off:
Me: “She takes care of all my needs.”
Sexualized Patient: “Yeah, how’s her cookies?”
She was laughing all the while, and the other women in the group were giggling. I reported this incident to my supervisor upon his return because I wanted to gain from his perspective how this should have been handled more therapeutically. He laughed too.
THE DOCTOR AND SEX
One day, on the intermediate care ward, we were told that we would be getting a doctor who would take care of the physical needs of the patients. This would relieve our psychiatrist from this responsibility, who could then concentrate on their psychiatric care. And this doctor was licensed.
Unfortunately, he was an octogenarian with intractable ideas of practicing medicine. He also seemed somewhat obsessed with sex. He would tell me how woman would come for an examination and ask him to check their breasts. He would do this but he said the women actually enjoyed this and found it arousing. (I doubt that.) He was married and had grandchildren. He was foreign-born but had been practicing here for decades, and wanted to take it easy but still be involved in patient care. He thought working in the state mental hospital would maintain his involvement in medicine and would be far easier than the pace of private practice.
Our ward, by that time, had become coed, and I don’t think he liked that idea. So he began prescribing high doses of Mellaril—a major tranquilizer—to all our male patients. He was doing this because this drug made it difficult to maintain an erection or ejaculate. Now can you imagine a male patient who has already lost his mind going to a psychiatric unit where he loses his masculinity? The rest of our staff was somewhat liberal in many areas, but we were united against this man prescribing medication solely for the purpose of controlling sexuality on the ward. If this medication had some unfortunate side effects involving sexuality, so be it, as long as the primary purpose in giving it was to treat the psychiatric disorder. But he wasn’t using it that way. So we, as a group, confronted this matter with the ward psychiatrist, who said he would talk to the new doctor. And he did. The octogenarian was not happy neither with our complaints nor with the instruction to curtail the use of Mellaril, but he complied.
LOOK AT THAT!
Not only were the patients affected by having another male staff member on the ward, but staff apparently had some issues as well, which I had not expected. There was a female physician assigned to the ward just a few weeks before I arrived there. A new patient was admitted, and she was dressing provocatively as well. She was somewhat hefty in build and very buxom. She would wear tight-fitting clothes with an abundance of cleavage and strut around the ward as if she owned the place. During this community meeting, the female physician was seated next to me and was amused by the women’s reaction to my presence. After a while, she turned to me and asked me to look at Beverly—this newly admitted woman with breasts barely covered. She began making suggestive comments about her and about my feelings. She seemed to want to make me feel embarrassed, although I was not. She said “Look at that.” I looked and smiled, but said nothing.
Later, at the staff meeting immediately after the “dancing” community meeting, she continued her “barbs about the boobs,” obviously testing me. Again, later, when some test results came in revealing that one of the patients had a sexually transmitted disease, a male physician said to me “at least she got a disease while having fun.” The psychiatric aides began to tell me about their “fantasies” about the psychiatrist and his nurse, both of whom were unmarried. They alleged these two were having an affair. I asked them why they were telling me this. One said they just wanted me to know about it. Another said they told me so I would know the nurse is “hands off.” I told them I was engaged and they said, “what difference does that make?”
Again, the permeating theme of my first day on the job was sex. In the case of patient behavior, I dealt with it somewhat directly. In the case of the staff, it was “dealt with” more subtly. I thought the best thing to do was to do or say nothing and keep my mouth shut. I did report it to my supervisor, who laughed about it and agreed with my interpretation of both the staff and patient reactions and agreed there was little to be gained by “analyzing” the staff’s behavior with them, so I never did.
JUST A MINUTE, PLEASE
The following incident occurred on another intermediate/chronic all-male ward and was witnessed by a psychologist colleague of mine. He reported to work one morning and a large group of patients were standing and mumbling at the back window. He walked over to see what the commotion was and just then, the ward physician reported for work. Seeing the same commotion, he too walked to the back of the dayroom and peered out onto the garden. There was a male patient completely naked and masturbating.
This psychiatrist become quite irritated and agitated and said, “Come in here this second!” The patient, while never losing a beat (nor a stroke) said “Just a minute, please.”
Now you may find that the most amusing part of this scenario but what I found most interesting was what happened next. The psychologist had a friend who was a photographer and filmmaker and he told him about this incident. The photographer entered a contest with the theme “The Meaning of Life,” which had to be portrayed in 60 seconds of less. He hired an actor, recreated this scene and titled his film “Just A Second, Please.” He won third place.