By Susan Kolod, Ph.D.
In the musical, Guys and Dolls, Adelaide reads a psychoanalytically tinged medical textbook and concludes, “In other words, just from waiting around for that plain little band of gold, a person can develop a cold.” This is the basic tenet of somatic medicine: intense negative emotion can cause physical illness.
Black Americans have greater prevalence and earlier onset of disability and chronic illness, as well as significantly lower life expectancy, than any other ethnic group in the US (Williams, 2012). This has traditionally been explained as resulting from unhealthy diet, lack of exercise, and stress of economic disadvantage. New research supports a direct link between racism, especially when experienced in childhood, and life-threatening illness.
Somatic Medicine
Jean-Martin Charcot and Sigmund Freud were among the first to observe how repressed traumatic memories affect the body, leading to physical illness. Freud called this the “puzzling leap from the mental to the physical.”
During World War I, Freud’s ideas about emotional origins of physical symptoms were applied to shell-shock and other “war neuroses,” now called post-traumatic stress disorder. When soldiers displayed symptoms of paralysis, muscular contracture, or loss of sight, speech, and hearing which had no organic bases, Freud recommended looking for repressed trauma.
The “Weathering Hypothesis”
Arline Geronimus, a research professor at University of Michigan’s Population Studies Center, posits a “weathering hypothesis” of elevated rates of illness among Black Americans as a physiological response to structural barriers and daily slights, stereotypes, and other threats to one’s identity that comprise the Black experience in America.
If so, a strategy that may work for white people does not significantly improve health issues faced by Black Americans. As the latter attain higher levels of education and access to professions that were once closed to people of color, they often face new and more subtle types of discrimination. Affluence offers no protection against enforced segregation in a racist society.
A recent study (Simons et al, 2018) published in Developmental Psychology compares the weathering hypothesis to the traditional socioeconomic standing (SES)/risk factor hypothesis regarding health inequities in Black Americans. The latter assumes the remedy for poor health in Black Americans is improving socioeconomic standing and accounting for factors such as diet, exercise, and smoking.
The recent study looked at elevated systemic inflammation, a strong predictor and suspected cause of chronic illness and mortality in all ethnic populations, as a possible factor. Using data from the Family and Community Health Study, collected over a 20-year period from over 400 Black Americans, they investigated the extent to which exposure to discrimination and enforced segregation at various points in the life course predicted inflammation at age 28.
They found the effects of discrimination and enforced segregation, particularly when experienced in childhood, were significantly greater than that of traditional health risk factors such as diet, exercise, smoking, and low SES. While addressing SES/risk factors is important, the study suggests it is insufficient, as the impact of exposure to racism during childhood is a powerful predictor of serious, chronic, life-threatening illness in adulthood.
Psychotherapy can help reduce the stress of racism
This vignette, related by my colleague, Dr. Anton Hart, illustrates how talking about racist interactions can detoxify and alleviate the potential for trauma. Processing the racist event with a therapist, rather than “moving on” from it, makes it less likely that the trauma will be stored in the body, leading to physical symptoms.
A 20-something African American woman came late to her session, in a tearful, sweaty state. She had been shopping prior to her session and realized the long wait would make her late for her session. She had put her items back and was walking out of the store when she was stopped by a security guard.
After first protesting being stopped, she realized things might get worse if she failed to cooperate. They searched her backpack and, without apology, allowed her to go on her way.
“He actually put his hands on my body as if he was entitled to!”
The patient wanted to quickly move on from this upsetting incident but I gently urged her to stay with it.
“They already barged in on your session by stopping you, scaring you and on top of that, making you late,” I said, “So, I think, we might have to talk about what happened in order to get them out of here.”
What bothered her most was when the security guard detained her. He kept saying he did not believe she had anywhere more important to go; that as a “black girl,” an intimidating detainment experience was something she obviously had time to spare for.
I said, “Of course not; black people idle ‘cept when we is stealin’,” which we both laughed at, a kind of laugh that quickly migrates into a feeling of tearfulness after a moment.
Dr. Hart observes that psychotherapy can address and alleviate the trauma of racism particularly when the therapist is prepared to recognize the significance of such trauma.
What can be done to counteract the effects of “weathering”?
- Obviously, everything possible should be done to protect children from exposure to racism and other discrimination – by the family, the school, and by the society in which they live.
- If a stress-related illness is suspected in a child, medical and mental health interventions should be sought immediately.
- Medical and mental health professionals should educate themselves about implicit and explicit bias and the “weathering hypothesis.”
- Adult environments characterized by high levels of nurturance and support could reduce levels of inflammation. Trusting relationships with teachers, doctors, and mental health professionals who understand the impact of racism on chronic health conditions is key.
- The government should curb housing practices and education policy that perpetuate segregation.
Racism is a public health issue. There are actions that could be taken that would mitigate and protect people and need to be addressed.
It’s all about anxiety.
By Susan Kolod, Ph.D.
Patients often ask, “Why am I so anal”? Or, “Why is my partner, friend, parent, boss so anal?” Where does this term come from and what exactly does it mean?
The psychological usage of this term was coined by Sigmund Freud, born 163 years ago on May 6th 1856. Turns out many of Freud’s ideas remain firmly ingrained in our “collective unconscious” without awareness of their psychoanalytic origins. His theory of the “anal-retentive personality” is one of them.
Freud’s Theory of Anality
In Freud’s “Three Essays on a Theory of Sexuality,” he outlines three psycho-sexual stages of early childhood development: oral (birth to 1 year), anal (1 to 3 years), and phallic (3 to 6 years). The anal stage coincides with the era of toilet training, a time when, children realize for the first time they can control their bowel movements, as well as themselves and their environment. For the first time, a child can decide whether or not they want to comply with their parents’ wishes. “No” is a popular word among 2 and 3-year-olds. So far, few would argue with Freud’s observations.
The controversial part of this theory is that difficulties and struggles over toilet training can lead to an “anal-retentive personality” with characteristics such as excessive orderliness, extreme meticulousness, reserve and suspiciousness.
While anal-retentive personality is not included in the Diagnostic Statistical Manual, it has some commonalities with Obsessive Compulsive Personality Disorder: excess cleanliness expressed through repetitive hand-washing, extreme orderliness and need for control. Whatever one calls them, the aim of these behaviors is to reduce anxiety.
What is Anality?
Typically, someone asking, “Why am I so anal?” is usually referring to an extreme need to control their surroundings by attention to detail. This can be irritating to those around them because such behavior extends beyond what is felt to be reasonable, helpful or productive.
For example, Jason, a young associate in a law firm complained the senior partner supervising him on a brief demanded he investigate every possible theory involved with an aspect of the case, even those theories deemed far-fetched or unlikely. This required spending his entire weekend researching decisions that, in his opinion, had no bearing on the case and were a complete waste of time. He described the partner as “being so anal.” By this, he means that he experiences her as extremely anxious and controlling.
Similarly, people can become frustrated by their own need to control and focus intensely on non-essential details but feel unable to control this need or impulse.
Bob wanted to buy a new refrigerator. He checked on-line for the best models, finding one in his price range that was highly rated but with a couple of negative reviews. He spent several days researching the features that had been reviewed negatively as well as researching other models. Each highly rated model had a few negative reviews. After a while, Bob realized he was afraid he would make the wrong decision but his research just made him more anxious and was not helping him decide.
In each of these examples, the “anal” behavior is an attempt to ward off anxiety by creating the illusion of order. The anxiety comes from a sense of impending chaos and the anal behavior is an attempt to control or ward off chaos.
What to Do About Anality
Anality is in the eye of the beholder. Jason, for example, may feel his boss is being anal but she views her behavior as meticulous—a positive quality—and regards Jason’s resistance as an indication of sloppiness and laziness.
In Bob’s case, he himself is annoyed at his anal tendencies and would like to simply make a decision and get on with life. He would be happy if someone else could decide for him.
If you feel you are being anal, here are some things to think about:
- Is something going on in your life that is making you anxious? Your “anality” might be a way of controlling that anxiety.
- Ask someone close to you if your behavior seems out of control or excessive.
- Try to delegate tasks to other people and then let them determine the extent of attention to detail.
- Consider, what are the consequences of a result that is good enough but not perfect?
Everyone can become anal at one time or another. When you or someone else is being anal, keep in mind it is an indication that one’s anxiety is out of control. Anal behavior is an attempt to control that anxiety. It may not be connected to toilet training but it is an attempt to control a “mess.”
There are 4 reasons people typically lie to their therapist
Why would someone lie to their therapist? That’s totally counterproductive, right? You’re paying for it, so what would be the point? However, according to a study published in 2016 in Counseling Psychology Quarterly, of 547 adult psychotherapy clients, 93 percent reported lying to their therapist at some point. This in part, has to do with the nature of truth, which is never just black and white. In fact, in therapy, “truth” is something that emerges over time, when there is a trusting relationship between therapist and patient.
So why do people lie to their therapist?
The most common reason patients lie to their therapist are the same reasons people lie to those close to them—shame and fear of judgement. The lies could be about substance use, sexual or romantic encounters they feel bad about, even unusual thoughts they are having.
Dan, a man in his mid-30s, was often attracted to men who were inaccessible. With such partners, there were a few exciting encounters that didn’t lead to a real relationship and left him feeling empty and lost. When he became involved with a straight man from a religious family, his therapist expressed these concerns to Dan who experienced this as judgmental. Without even realizing he was doing so, Dan stopped reporting his encounters with this man to his therapist. Eventually, it came out that he had been omitting this topic from their sessions and they were able to address his feelings of being judged.
No truth without trust
In therapy, you reveal painful and sensitive feelings and memories. The “basic rule” of therapy is to “say whatever comes to mind.” This is a lot more difficult than it sounds, especially if you have a history of betrayal and difficulty trusting people.
It is imperative that trust is established early on. You should feel that the therapist respects you and is open to criticism. Often the relationship with the therapist becomes emotionally charged. At times, you may feel that you love or even hate your therapist. These intense feelings are difficult to state openly.
The therapist should be easy to talk to and able to listen to you without judgement. If you notice that you feel mistrustful of your therapist, bring it up! Over time, if that feeling persists, it might be time to find a new therapist. It is only through a trusting relationship with a therapist that the truth will emerge.
Lying to yourself
Oftentimes, a patient may intend to be truthful but is not ready to accept the truth about themselves or someone close to them. We all come into therapy with a story or “narrative” about ourselves. As therapy progresses, the narrative starts to change and we begin to see new things about ourselves and others that we may not have been able or willing to see.
April came into therapy because she had been depressed for several months and didn’t know why. She soon revealed a tumultuous relationship with her husband. She complained that he went out every night and came home late without any adequate explanation. One day she found a used condom in a wastepaper basket. When she confronted her husband with it, he told her he was trying a new brand to see if it fit. April accepted this explanation without question. She told the therapist that her husband was completely trustworthy. When the therapist looked skeptical, April reassured her.
To the therapist, it was obvious that April’s husband was cheating on her and she was not ready to admit this to herself—in other words, she was lying to herself.
Not connecting the dots
Some patients may be less than truthful with their therapist not because they intend to mislead or deceive, but because they have not processed past traumas and are disconnected from the ways in which these traumas are affecting their behavior. I call this “not connecting the dots.”
For example, Misha was unable to commit to a relationship because he could never trust anyone enough to let down his guard. He did not disclose to the therapist that his mother suffered from alcoholism and was unreliable and emotionally unavailable, not because he wanted to be deceitful but because he simply didn’t see any connection. This is not lying, per se, but an inability to connect the dots. Misha is aware that he has difficulty trusting anyone and is also aware that his mother suffered from alcoholism but keeps these facts carefully separated from each other.
Can therapy be effective if you are lying?
As stated above, the truth is often not black and white. There are always things in our lives from which we disconnect, and some are more important than others. There may be things that are too shame-inducing, embarrassing, or anxiety-provoking to reveal to even to yourself—let alone to your therapist.
If you are aware that there is something you’re not disclosing, it is preferable to tell the therapist that there are certain things you are unable to reveal at this time. You and the therapist can try to understand why something is so painful or difficult to talk about. Eventually, you might find that you are able to reveal the information.
But some issues take time. As with April, she and her therapist worked together over the course of several years before the truth emerged.
If you find that there are more and more things you are hiding or lying about, it is important to address the issue with your therapist. In some cases, you may want to evaluate whether or not a therapist is a good fit.
By Sue Kolod Ph.D.,
As the holidays approach, many people look forward to spending time with family. The warmth and familiarity are undeniable, but with that comes the threat of arguments and renewal of bad feelings. How can we avoid the bad parts and simply enjoy this most wonderful time of the year?
We psychologists have a theory called “regression”, which in very general terms, means reverting to childhood roles and behavior. This can especially happen during stressful times, like the holidays, and all of a sudden a middle-aged adult is acting like a 14-year-old.
Why does this happen?
To our parents, we will always be a child no matter what our age. Even if you are a mature person, parents may still worry that you are not eating well, not wearing warm enough clothes in the winter, not hanging out with the right people, or not fulfilling your dreams. As your parent’s child, you may automatically respond to this with the same frustration and defensiveness you experienced when you were a child trying to establish your independence.
This type of regression is often self-reinforcing. In other words, your parent says or does something that reminds you of your childhood struggle for independence, inducing stress. You then respond as you did as a child, and your parent, in turn, treats you like you’re still a bratty teenager.
Take Melanie, a successful lawyer in her mid-40’s. As a teenager, she was irresponsible, always arrived late, and had problems with drugs and alcohol. Since then, she’s pulled her life together. However, when she goes home for the holidays, her parents still remember their flakey, irresponsible teenage daughter who caused them so much worry. When Melanie is reminded of this by their actions or words, naturally she is irritated, upset that her family seems to ignore how much she has changed. She is hyper-sensitive to jokes about her lateness, or stories of past bad behaviors, which put her on the defensive with her family and set her up for fights with them.
Doug is a photographer in his mid-thirties. Although his parents and siblings have always known that he is talented, for years he was never able to make much money. Now he is finally able to support himself and is gaining a reputation in his field. When he goes home for the holidays, his parents fall back into the habit of concern and worry about his financial situation. He experiences their concern as a lack of faith in him and a refusal to see what everyone else in his life can see: that he is becoming a success. When this dynamic gets going, he becomes sullen, reinforcing his parents’ concern that he hasn’t grown up.
How to Prevent Regressing
If you feel family members are treating you like a child, particularly the child you used to be but are no longer, try not to react in a defensive, knee-jerk manner. Stay calm, step back, and reflect on how they are making you feel. Then decide to react in a manner that will not reinforce their image of you as a dependent child. Here are some things to try instead:
- When family members tease you about your past behaviors you have outgrown or overcome, don’t be offended. If you get angry or defensive, that may provoke more teasing. If you don’t respond, they will probably stop.
- Don’t be afraid to remind the family of your successes. They love to hear about it!
- Keep in mind that if your parents express worry or concern about your future, it doesn’t mean they think you are still a child or will fail. Worrying about your child, even your adult children is a common reaction in parents. It’s really about them, not you.
- Sibling rivalry is present throughout the life cycle. You may feel your brother gets all the attention or your sister is more loved. When this occurs at family gatherings, it can be very painful. However, what you don’t realize is that your envied brother or sister probably has his or her own reasons to envy you. Try to keep that in mind.
- If you have children yourself, notice the ways in which you may induce regressive behavior in them by treating them in ways that remind them of times when they were more dependent than they now are.
- Offer to help cook, do the dishes, or run errands. If you’re feeling stressed or picked on, go for a walk, watch a movie or start talking to those family and friends who aren’t behaving this way towards you.
Remember: regression is a two-way street. Your parents are regressing too. So when your parents or family start to treat you like a child, the worst reaction is to start acting like one, too.
Happy holidays!
Susan Kolod, Ph.D. is Chair of the Committee on Public Information and editor of the blog, Psychoanalysis Unplugged at the American Psychoanalytic Association. She is supervising and training analyst, faculty, and co-editor of the blog Contemporary Psychoanalysis in Action at the William Alanson White Institute. Dr. Kolod has a private practice in Manhattan and Brooklyn.
Maintaining therapeutic boundaries are vital to your mental health
By Susan Kolod, Ph.D.
“There’s a force more powerful than free will: our unconscious. Underneath the suits, behind closed doors, we’re all ruled by the same desires. And those desires can be raw, and dark, and deeply shameful.”
These opening lines, spoken by Naomi Watts playing the unhinged psychotherapist Jean Holloway in the Netflix series Gypsy, have great truth. But, from the mouth of Dr. Holloway, they are a rationalization for her disturbing boundary violations of her relationships with her patients. For example, Dr. Holloway initiated a sexual relationship with the ex-girlfriend of a patient, sought out and befriended the daughter of a patient, and allowed a patient to live in a secret apartment she kept in Manhattan.
The show raises interesting questions about how much involvement therapists should have in their patients’ lives. There are times when some contact outside the session is inevitable, such as when a therapist and patient live in a small town.
However, it is a fundamental rule in psychotherapy that the therapist maintains appropriate boundaries between herself and her patient. In fact, psychotherapy simply will not work and can be potentially harmful without these boundary limitations, sometimes referred to as the frame. They are:
- No physical contact with a patient.
- No relationship with a patient outside of the consulting room.
- The therapist should not treat close relatives or friends of the patient.
- No practical advice to a patient.
- Maintain objectivity and neutrality toward the patient and avoid excessive worrying/thinking about the patient.
- Seek supervision if you are tempted to, and before you do, violate any of these rules.
Although not every violation will lead to disaster, and some flexibility may be harmless or even appropriate in certain circumstances, the failure to take seriously the potential for disaster from any boundary violation is a grave error. Trouble happens most often when the therapist is tempted to think she is above these rules, not subject to temptation, or can handle this particular situation. That is when consultation with a supervisor may be most helpful.
The therapeutic relationship is not a friendship because the therapist and patient have no relationship outside the consulting room. That doesn’t mean that the therapist has no feelings towards the patient. In fact, many patients evoke extremely strong emotional reactions in their therapist: reactions of love, lust, curiosity, envy, competition, and even distaste or hatred at times. The feelings evoked in the therapist by the patient are calledcountertransference, and the feelings that the patient has for the therapist are referred to as transference.
Transference and Countertransference:
First identified by Sigmund Freud, transference is one’s reaction to another person based on feelings and patterns of relating that were established in early childhood, often towards a caretaker, usually a mother and father. Transference reactions are not limited to the therapy relationship. In fact, we unconsciously transfer feelings derived from our earliest relationships onto many of our adult relationships.
In psychoanalytic therapy, transference is something to be examined, explored, and understood. The therapist also examines and explores her countertransference feelings as a way of understanding the effects a patient is having on her. This examination of the countertransference gives the therapist insight into the patient and protects her from inadvertently acting in ways that may interfere with her functioning in a non-judgmental and objective manner. Problems ensue when the therapist is unaware of her countertransference.
Psychoanalytically-trained therapists have themselves undergone psychoanalysisprecisely so that they can become aware of their own unconscious patterns of thought and behavior established early in life. As a professional, when Dr. Holloway realized how her patients were affecting her, she should have sought consultation and possibly gone back into analysis.
What is an enactment?:
Edgar Levenson, a preeminent psychoanalyst, notes that therapy truly begins when the therapist recognizes that the kinds of interactions the patient describes as having with other people have begun to occur in the consulting room between the patient and therapist. These situations are referred to as enactments.
For example, in sessions, Sarah often focused on her unhappy interactions with friends and family. She complained they were frustrated and fed up with her and didn’t want to listen to her problems. At a certain point, she began demanding of her therapist in a distraught tone, “What should I do? Just tell me what to do!” The therapist, against his better judgment, felt compelled to give Sarah advice, something which he refrained from doing with his other patients. Sarah never followed the advice and the therapist began to note how frustrated and fed up he felt towards her.
Sam, a handsome and engaging young man, sought therapy because he had been unable to establish a loving relationship. He reported on his whirlwind courtships with one woman after another, which inevitably led to his finding a flaw in the woman and then losing interest. The therapist looked forward to sessions with this patient, in part, because he was so pleasing and complimentary. When she noticed that she was having romantic fantasies about him, she realized she was becoming involved in an enactment of his seductions and knew where it would lead.
The ability to discern and examine the presence of an enactment requires that the therapist maintain the frame and keep clear boundaries with the patient. With Sarah, the therapist realized he and Sarah were enacting the very problem they had been discussing. Once the therapist noticed this, he was able to step back from the advice-giving and explore with Sarah the foundations of her frustrating pattern of demanding and then rejecting advice.
In the case of Sam, the therapist realized that she and Sam were enacting his pattern of seductions. She could then focus on exploring the reasons for this behavior and how it interfered with his development of loving relationships with women.
The therapy relationship can and should evoke strong feelings in both therapist and patient that are vital to effective treatment. But those feelings can only be used therapeutically if they are explored and understood, but not acted on. The rules of the frame, which prevent boundary violations, are critical to therapeutic success. And that is why your therapist cannot, and should not, be your friend.
The joy of self-love can be powerful and sustaining.
Narcissism is bad, right? Google search is flooded with questions: “What is narcissism?” “How can you tell if your partner is a narcissist?” “Am I a narcissist?”
So my patient Adele was surprised and intrigued when I told her that we needed to work on developing some healthy narcissism. “Is there any such thing as healthy narcissism?” she asked in disbelief, “I thought narcissism was negative.”
The diagnosis of Narcissistic Personality Disorder is indeed very negative and includes characteristics such as arrogance, preoccupation with oneself, a need for constant admiration and, most importantly, a lack of empathy for others. But narcissism itself is not positive or negative–there is a continuum from healthy to pathological.
What does healthy narcissism look like?
Adele is a beautiful, highly intelligent and creative person who does not recognize or appreciate these qualities in herself. She mentioned in passing, that she never looks in the mirror. You may remember that in the Greek myth, Narcissus falls in love with his reflection. Adele is never in love with her reflection and this creates problems for her. When completing a difficult project at work, she experiences no pleasure or satisfaction, just a grim sense of “on to the next problem.” When people comment on her style and grace she is disconcerted. In her romantic life she is surprised and taken aback when someone attractive shows an interest in her.
Healthy narcissism is related to self-esteem and self worth but is not exactly the same. It’s taking pleasure in one’s beauty, in the workings of one’s mind, in the accomplishment of a tough job well done. It is ecstatic joy in oneself. Although the joy of healthy narcissism can be a fleeting sensation, it is powerful and sustaining.
Healthy narcissism is exemplified in the song from West Side Story, I Feel Pretty.
I feel pretty,
Oh, so pretty,
I feel pretty and witty and bright!
And I pity
Any girl who isn’t me tonight.
I feel charming,
Oh, so charming
It’s alarming how charming I feel!
And so pretty
That I hardly can believe I’m real.
The Narcissistic Phase of Childhood Development
Complete preoccupation with oneself is normal and expectable in children at a certain age. The Narcissistic Phase of development begins at around the age of two—the same time children begin to talk. During this time children start to use words like “I”, “mine” and “no”. During this phase, children frequently behave as if the world revolves around them and have little concern for the needs and desires of others.
The eminent child psychologist, Margaret Mahler described this phase as a “love affair with the world.” Picture a two-year old running down the street with a broad smile on her face, Mom frantically chasing after. If development proceeds, as it should, the child learns, through close contact with parents, friends and teachers that those people also have needs and desires. Egocentrism diminishes and the child develops concern for others.
Healthy narcissism or a “love affair with the world” is something that adults can retain, although it no longer depends on being the center of the universe. It is that joyous, euphoric feeling of taking pleasure in oneself and one’s impact on the world.
Why is healthy narcissism important?
Healthy narcissism is important for a variety of reasons: If you can experience ecstatic joy in yourself it can help you through difficult times. For example, if a person can derive narcissistic pleasure from a difficult job well done, it can sustain that person through times of frustration and failure, thus preventing the likelihood of burnout. Likewise, taking joy in one’s beauty and positive impact on others can provide resilience during times of disappointment and heartbreak.
For a variety of reasons, some people don’t retain or develop healthy self-love. Here are some examples:
An extremely self-centered parent may demand all of the attention from the child, not leaving room for the child to revel in herself. When Carina was a child, she believed that her mother knew everything and was perfect. As Carina got older, she learned that to get attention and approval, she needed to bolster her mother’s belief in her own omniscience and perfection. If Carina asserted her needs, she got the cold shoulder—or even worse. This was not an environment in which Carina’s healthy narcissism could flourish.
Some children never develop healthy narcissism because they fear that others will envythem. If a child learns that they will be punished or treated in a hostile manner if they excel, that child will hide or diminish the impact of their excellence, even hiding it from themselves.
Does it feel wrong to accentuate and revel in your good qualities? Think about what it brings to mind: fear of envy or the “evil eye”? Worries of being conceited? If so, reframe your healthy narcissism as gratitude for what you have been given. Being thankful for your natural talents may be a way to appreciate them without feeling too egotistical. Remember that the ability to take joy in yourself is a quality that can sustain you through the rough times in life.
Susan Kolod, Ph.D., is a supervising and training analyst, faculty and co-editor of the blog Contemporary Psychoanalysis in Action at the William Alanson White Institute. She is Chair of the Committee on Public Information of the American Psychoanalytic Association. Dr. Kolod has written numerous chapters and articles about the impact of hormones on the psyche. She has chapters in 2 new books: Alike/Different: Psychoanalytic Perspectives on Identity and Difference (Routledge) and Unknowable, Unspeakable and Unsprung: Navigating the Thrill and Danger of Living amidst Truth, Fantasy and Privacy(Routledge).
It depends what kind of sexual problem you are having
By Susan Kolod, Ph.D.
Flibanserin or “Addyi” is the first drug approved by the FDA to treat Hypoactive Sexual Desire Disorder (HSDD) in women. The drug will become available on October 17th. There has been much discussion in the media over whether the drug is pro or anti-feminist. But the really important question is, “does it make you horny?”
How Does Flibanserin Work?
Flibanersin treats desire, unlike Viagra, which improves performance. Flibanserin is not “female Viagra”–Viagra is taken before sex and it pretty much assures an erection. Flibanserin must be taken every day and is being marketed as a drug to increase desire. So how does Flibanserin actually increase sexual desire?
To find out, I spoke to the expert on rat sexuality, James Pfaus, Ph.D., and learned how Flibanserin affects female rats with the hope this might shed some light on how it affects women.
Pfaus, Professor, Concordia University and President Elect, International Academy of Sex Research, gave me a crash course on the sexual behavior of female rats. Female rats love sex and make their desires known very clearly. They pursue sex actively with partners they find attractive and avoid sex with rats they don’t find attractive. They love to have their clitorises stimulated with a paint brush. No slut-shaming among rats.
In Pfaus’ lab, rats whose ovaries had been removed were administered a low dose of estradiol and then Flibanserin. The low dose of estradiol created a sex hormone scenario similar to women going through menopause. Usually, a female rat whose ovaries have been removed and is given a low dose of estradiol will not initiate or “solicit” sex. After a
two day trial, Flibanserin restored these rats to their normal rate of solicitations. Impressive results!
However, human sexuality cannot be observed so easily, nor is it so straightforward. In the drug trials, some women were given Flibanserin and others a placebo. All were asked to keep a diary of their sexual experiences. They also met with a psychologist once a week. Self-report, especially about sex, is notoriously subjective and often inaccurate.
Diary responses were analyzed for SSE’s or Satisfying Sexual Events. An SSE can be anything from masturbation to multiple orgasms with a partner to intimate touching. It is a broad and somewhat vague concept–it just measures how many times you “did it,” the “it” being something defined as sexual. So an SSE doesn’t really capture the experience of desire.
Flibanserin appears to be a lot more effective with female rats than with women. The increase in SSE’s was only .7 per month for women as compared with an increase in sexual solicitations of 3.94 per month in the rats!!
However, human SSEs and rat solicitations may be two different things.
Appetitive and Consummatory Motivation
Pfaus makes a distinction between “appetitive” and “consummatory” motivation in sexuality. Appetitive motivation is the first phase of a sexual encounter and involves the initiation and anticipation of sex. Appetitive behavior moves the animal (human and non-human) towards an attractive potential sexual partner and is more indicative of spontaneous desire. For example, female rats will press a bar to get access to a male sex partner. This is appetitive behavior.
In humans, appetitive motivation includes such behavior as flirting, planning for a date, fantasizing about a date.
Consummatory motivation, on the other hand, leads to actual physical interaction and completion of the sex act. In female rats, lordosis–arching the back and sticking out the buttocks so the male can mount her–is a consummatory behavior. In humans, foreplay, touching and actual sexual contact, and orgasm are consummatory.
It is possible that different drugs help with problems in one phase, but not another. Pfaus suspects that Flibanserin increases appetitive motivation. In other words, it might help a woman to feel sexual desire towards a partner, to anticipate sex with that partner, and to be motivated to initiate sex.
Three other drugs, still being tested by the FDA, Lybrido, Lybridos and Bremelanotide, may effect the consummatory sytem by maintaining excitement throughout the sexual encounter and facilitating orgasm.
Who Will Flibanserin Help?
Flibanserin, Pfaus suspects, will be most effective with women who are highly organized and always planning ahead. They may find it difficult to be “in the moment.”
For example, Stacey and Linda have been together for 18 years and married for the last 5. They have 2 small children. Stacey is highly organized both in terms of the household and at her job. She often feels overwhelmed by all of her responsibilities. Although she is very attracted to Linda, she is unmotivated to initiate love-making because she is always planning the next thing. This is exacerbated by feelings of resentment towards Linda who is not helping enough with the kids and the housekeeping.
While the interpersonal issues need to be addressed, Flibanserin might help Stacey to feel spontaneous desire and to be “in the moment.” The drug could be a good adjunct to couples’ therapy.
Flibanserin might be less helpful for a woman who can experience spontaneous desire but can’t sustain her excitement. Some of the other drugs to treat HSDD such as Lybrido, Lybridos or Bremelanotide, still being tested by the FDA, could be more helpful with difficulties maintaining excitement and reaching orgasm. These three drugs do not need to be taken every day—only before having sex, like Viagra.
The best outcome would be that a number of different drugs will become available as adjuncts to psychotherapy, couples therapy and sex therapy. And that women will be comprehensively informed about the risks and benefits. Women are entitled to make the best choices for themselves about what makes them horny and helps them to enjoy sex!
Susan Kolod, Ph.D., is a Supervising and Training Analyst, member of the Faculty, co-Editor of the blog, Contemporary Psychoanalysis in Action and on the Steering Committee of the Eating Disorder, Compulsions and Substance Abuse Program (EDCAS) (link is external) at the William Alanson White Institute (link is external). She has lectured and written about the impact of hormones on the psyche with a particular focus on sexuality, menopause and the menstrual cycle. She is in private practice in Brooklyn and Manhattan.
