Dilemmas in the Psychotherapy of Sexually Impulsive Patients

When I first met Ms. A, a 25-year-old woman, she was sobbing uncontrollably in the waiting room at the Baylor Psychiatry Clinic and was about 20 minutes late for our appointment. She had called the clinic earlier on her cell phone, reportedly lost and panicky, and had pleaded with clinic staff not to hang up until her arrival. In the interview room, Ms. A calmed down quickly and apologized for her tardiness and behavior. She appeared very assertive and remained dramatic even after she had regained her composure. I was immediately struck by her physical beauty, impeccable grooming, and stylish clothing. Her chief complaint was “my medication isn’t working,” and she stated that she had had depression and anxiety since age 10. She recounted numerous recent stressors, most notably her marriage a few months earlier. Her life had changed in many ways, including that she no longer needed to work or attend school, and she alluded to this transition as fairy-tale material, a dream come true. Despite this development, she endorsed multiple symptoms of depression and felt confused and purposeless. She ruminated about how horrible she was, sometimes for hours before falling asleep each night, and engaged in excessive apologizing. She complained of constant worry and expressed concern that her moods were up and down and out of control. She also described several episodes of what she called “paranoia” that involved people looking at her or following her—experiences that sounded credible rather than delusional.

Ms. A had been in psychotherapy for the presumed treatment of depressive symptoms with a well-respected psychiatrist and family friend from the ages of 13 to 16. During this time, she had not received any medication. She had had no subsequent psychiatric care until age 24, at which time she sought help for depression and anxiety, was given a prescription for an antidepressant, and saw a psychiatrist every 3 months or so for medication management.

Her pertinent medical history included very painful menstrual periods since menarche and monthly treatment-resistant vaginal infections since she became sexually active with her husband. She also reported a past history of polysubstance abuse, reportedly in full remission for 2 years.

Her developmental history was significant in that she was the third of three children born to first-generation immigrants. Ms. A’s mother was reportedly told that she could not get pregnant again after Ms. A’s birth. Ms. A described her mother as depressed, overly protective and manipulative, and chronically ill with multiple health problems. Her mother was also the daughter of two victims of severe trauma, and her maternal grandmother reportedly “went crazy” after her grandfather’s death. Ms. A’s father worked until late at night, and Ms. A described her childhood as spent primarily with her mother. She described herself as a rebellious, argumentative adolescent who frequently fought with her mother, who would laugh openly at her the angrier Ms. A became and who would punish her by not speaking to her for days. During her school years, she felt that she did not belong and had few female friends but always wanted them. She attributed this to their being jealous but hesitated to link it to her beauty. She added, however, that despite everyone always telling her that she was beautiful, she didn’t know if she believed it or not.

When asked what her goals were in coming to the clinic, she stated that she wanted to get her medication adjusted and was interested in therapy. When asked what she would like to work on in therapy, she stated that her main concerns were her inability to show her husband how much she loved him and to “calm… down.” I diagnosed her with dysthymia, anxiety disorder not otherwise specified, and polysubstance abuse in full remission based on her history. I made a mental note of her histrionic traits, restarted her antidepressant, and scheduled our first therapy session for the following week.

Ms. A started our first therapy session by joking about a recent dream. In the dream, her husband and his sister were having sex in a room with a large plate-glass window. Her husband was fondling his sister’s nipples. Ms. A was outside watching them through the window. Her husband rose up partially from the missionary position in obvious enjoyment. He turned and looked at her and smiled. She did not attempt to work with the dream in therapy and seemed uninterested in its meaning. For the next 7 months or so of therapy, Ms. A would come in, sit down, and start talking, not stopping until the session was finished. As her dream suggested, she focused primarily on her feelings of isolation and being an outsider. She also felt that she did not know who she was anymore or what she wanted. She could not separate her own needs and desires from her husband’s. She grappled with the things rich people do, which she often viewed as shocking or wrong, and the demands of her new role as a wife in a well-known and socially visible family. She spoke “at” me rather than “to” me in a rapid and dramatic (but not pressured) manner and would often talk through my occasional comments or interrupt me before I had finished. If I did finish, she would ignore, disregard, or minimize my comment almost immediately. I felt angry, frustrated, and inadequate. I might as well not have even been in the room. The sessions felt completely beyond my control, and I anticipated them with dread. I was gradually becoming aware of a characterological style that made me wonder about borderline or histrionic traits, especially because her depressive and anxiety symptoms appeared context-dependent.

After about 7 months into therapy, Ms. A came in one day and stated, “I haven’t been honest with you…. I haven’t told you about a big part of my life because I’m scared you won’t like me.” She then proceeded to tell me about her sex life, which included sadomasochistic sex with her husband as well as their “swinging” lifestyle. This was somewhat awkward because I did not know what “swinging” meant and said so. This obviously pleased Ms. A, who smiled and laughed a little, stating that now she could teach me something. She proceeded to define swinging as similar to dating but for couples rather than individuals. I simply listened as she described a meeting that she and her husband had with a couple for dinner and drinks. After dinner, they went to a hotel room together, where they talked some more, including about what they liked sexually, and then had sex. Ms. A stated that the sexual activity consisted of male-female or female-female kissing and touching, followed by intercourse with one’s spouse while the other couple watched. She stated that they would always talk about everything afterward and that she really liked this part of the experience. In terms of the sadomasochistic sex, this was something that she and her husband did alone together. She vaguely described him as the aggressor, downplaying it as all in fun—nothing serious—but did not supply any details at this time. Somewhat defensively, she stated that her husband believed that if it felt good, do it, and that what two or more consenting adults did privately was their own business and that they should not be judged negatively for it or considered freaks. She added that she agreed with him and that she loved sex, had always wanted lots of sex, and couldn’t get enough. She also talked about “wanting to know women” and about how she had never had any close female friends and craved this intimacy. Ms. A openly questioned her sexuality and the conventional societal definitions of heterosexuality versus homosexuality. She defined sexuality as more of a spectrum.

During this session, I felt like I was caught up in an embarrassingly riveting made-for-television movie. The content was titillating, and Ms. A was obviously aware of this and enjoyed the delivery. Her dramatic tone made it very easy to visualize the foursome. I also remember picturing the shock on my supervisor’s face as I told her about this session. I did not feel particularly concerned for Ms. A’s safety at the time. She had essentially described the swinging as talking, petting, and sexual intercourse only with her husband and had minimized the danger involved in the sadism and masochism. It felt like she had customized the script on my behalf—emphasizing the talking, openness, and honesty and downplaying the risks. Perhaps because of this, I did not feel repulsed by her actions or judge her negatively for them. It did not cross my mind that this was perverse or deviant but instead seemed more playful or exploratory. I found myself rationalizing the behaviors right along with her. In general, I agreed that, for the most part, what consenting adults did in private was indeed their business, as long as they were not hurting themselves or others. I also agreed that sexuality is not always black and white. Despite this, I felt uncomfortable and awkward. This intensified when she stated that several couples they had met while swinging were medical doctors and nurses. This bothered me more than her telling me about her participation in the swinging. It felt too personally intrusive, too close to the realm of possibility. It made me feel further isolated and somehow judged negatively by the patient, as if I were the outsider, not one of the group. Just as important, however, I felt relief. A “secret” had been revealed in the therapy that I found very frustrating. I now had renewed enthusiasm about the therapy and, with it, some small sense of control and guarded optimism that the therapy would now progress. I was concerned that this disclosure occurred 7 months into therapy and felt somewhat staged, but given her expressed desire for intimacy with women, this seemed to make sense at the time in terms of her fear that we would lose our connection.

Over time, Ms. A continued to reveal more detailed and explicit accounts of her sexual behavior. She and her husband often attended private swinging parties and frequented swinging clubs most weekends. Her description of these events featured rooms full of naked people drinking, talking, and involved in various sexual acts, some behind closed doors and many not. Threesomes and foursomes with spectators and participants changing roles were common. Ms. A actively sought out the largest, most overtly aggressive men at these events and would engage in intercourse, oral and/or anal sex with them, most often while her husband watched. The female-female sexual behavior also progressed to oral sex, with Ms. A always the “giver” (because she refused to be a recipient). This contrasted with her sex life with her husband, which never included oral sex. She continued to present this material in a dramatic manner that seemed designed to maximize its shock value. Ms. A recounted these events with a remarkably theatrical flair, including dramatic (dare I say “pregnant”?) pauses for effect when she appeared to be gauging my reaction. I did my best to respond in a consistent and nonjudgmental manner, but I worried increasingly about her safety. When I brought up this concern, she would rapidly reassure me that she always used condoms and that her husband was always there.

The sessions became even more graphic. She described “sex-a-thons” that involved going to conventional bars with her husband to pick up large, athletic men and bring them home. She and the chosen man would then have loud, aggressive sex for hours at a time, as she described it, while her husband listened downstairs. She also boasted repeatedly about her talent for pleasuring women in ways that amazed both the women themselves and their husbands. Often, she said, husbands or male partners would ask her afterward to teach them her technique. As I listened with fascination, I realized that the sessions had begun to feel like peep shows. I found myself actively disliking Ms. A for the first time and judging her somewhat contemptuously for participating in these sordid events. I also felt a degree of self-loathing for my role as a captive audience that had been dragged into these “show-and-tell” sessions. Nevertheless, I attempted to maintain the superficial demeanor of a concerned and interested neutral therapist. As her participation in this sexual lifestyle intensified, I worried that my nonjudgmental manner was actually encouraging her behavior. The sessions felt even more out of control, in delivery and now in content.

Ms. A came in one day and casually mentioned that her husband had arranged a date for the two of them. She nonchalantly joked that her husband was like a pimp and chuckled about her analogy. When asked more about this, she casually stated that this was nothing new; her mother had done the same thing. She then described how her mother used to dress her up “like a doll” in a “princess dress” and take her to see her father at work at a bar. She would then be placed on a bar stool (she was too small to climb up herself) and was expected to smile, chat, and generally entertain the “regulars.” When her father wasn’t busy, she would be available to spend a couple minutes with him. Most frequently, however, she remembered these nights as consisting of older men of varying degrees of intoxication fawning over her, buying her pretty drinks, and telling her that she was a beautiful little girl. This went on throughout her childhood, starting from around the time she was 3 years old, at least once a week until closing time. As an adolescent, her mother would set up dates for her with friends’ sons or young men she had met and deemed appropriate. Ms. A would then inform her mother of their specific plans, and, unbeknown to the date, her mother would watch from nearby. At this point, my face must have revealed some degree of amazement or concern because she paused and then added that she told her mother everything, even about the swinging. When I asked how her mother had responded, she said that her mother had told her about a lesbian encounter that she had “almost” had but “didn’t go through with.” It seemed a source of pride to both mother and daughter that Ms. A had actually gone through with these experiences. I asked her how she felt telling her mother about such things. She snickered, stating that her mother had been dressing her in sexually provocative clothing since she was a young child. I then made a comment about how difficult it must be to be someone else’s plaything, and she shrugged, stating that she was used to it by now. In this regard, it is important to stress that Ms. A always expressed thorough enjoyment of the swinging, despite her husband having been the one to initiate these experiences.

As Ms. A continued to relay her sexual experiences, a degree of ambiguity gradually surfaced. During one session over a year into the therapy, she stated that her husband had complained that she always “zoned out” before a party or before going to a club. He was annoyed because it appeared that she didn’t want to go out. Ms. A then described a period of several hours’ duration that typically occurred preceding swinging events. She would essentially dissociate at these times, becoming nonresponsive to others, focusing internally, and attempting to self-soothe. She stated that she needed to do this to “prepare” for the evening and that once she was at the event, she was able to smile, socialize, and have sex. She spontaneously connected this to a memory from her childhood. Throughout her childhood and adolescence, Ms. A was “strongly encouraged” by her mother to model. As a young child, she was a runway model for a department store chain. She vividly recounted an experience when she was 3 years old: it was before a fashion show, and she was backstage with her mother. She was crying and screaming that she did not want to do it. She had tears running down her face, and her makeup and hair were getting ruined. Her mother became very angry, yelling and swearing at her to “do it.” She struggled with her mother, still crying that she didn’t want to do it. Her mother pushed her onto the runway, yelling in a more hushed tone, and suddenly she was out on the runway, and everyone was staring at her. She paused, remembering the dress as pink and black with ruffles, and then stopped. I asked what happened next. She sarcastically responded, “What do you think happened? I stopped crying and did it.” She then casually added that it was the same with swinging, that she needs to prepare for the performance, but once “on,” she can “do it.”

Ms. A often relayed snippets of her childhood that were as dramatic and “shocking” in both delivery and content as those regarding her sexual exploits. Oftentimes these memories were as uncomfortably tantalizing as listening to her describe her sexual exploits. Frequently, they seemed intertwined. Whereas I often revisited my internal struggle over my attempt to remain nonjudgmental regarding her swinging, I had no hesitancy whatsoever voicing my judgment regarding her childhood experiences with her mother. I could not help but think of my own daughter when listening to Ms. A at these times and knew in my gut that my patient’s childhood experiences were unequivocally wrong. When Ms. A relayed such childhood memories, I responded empathetically and supportively, emphasizing how horrible such things must have been for her and validating her view of her mother as a very controlling, selfish, and, at times, downright sadistic woman. At first, Ms. A resisted this intervention, stating that she loved her mother and knew she had done “the best she could.” I did not dispute this but kept emphasizing how horrible the scenarios were that she described and how hard it must have been to develop one’s own self when one’s primary caregiver had such a dominant personality. This approach seemed to calm her, and she seemed to consider what I was saying for the first time. In terms of content, she gradually shifted to talking less about her sexual exploits and more about her childhood. She became more open about her insecurities regarding being female, including her discomfort with her body and its femininity.

In terms of the transference, the room felt warmer. The countertransference thawed a bit, too. I began to like Ms. A. I worried about her over the weekends and wanted to keep her safe and protected. To a large extent, I felt like I was mothering an adolescent. She continued to discuss material that was just as fantastic and sexually explicit as ever, but her motive seemed to be less to titillate or “shock” and more to share. She appeared to hear me when I expressed my dismay or concern. Finally, her behavior started to change, and her general impulsivity (angry outbursts, reckless driving, and alcohol use) began to diminish.

Ms. A had a difficult time with my canceling appointments, regardless of the advance notice. Despite my consistently outlining coverage in my absence and/or giving her a cell phone number to call, she developed a pattern of canceling her last one or two appointments before my scheduled absences. During several sessions before one such scheduled absence, we delineated a plan for a weekend during which her parents, her husband, and I would all be gone. Ms. A had stated repeatedly that she knew that she would just want to “go out…act crazy…do something impulsive.” She described herself as “horny” and did not think she could resist the urge to have sex. In spite of these statements, I sensed an ambivalence to act. Her tone was less passionate, her words lacked certainty, and she seemed to be looking for a way out. It felt like she was taunting me in an adolescent manner, as if daring me to discipline her. We discussed alternative behaviors that she enjoyed, such as reading and playing with her pets. I asked about masturbation with some trepidation, and she snickered, stating that she had already thought of that and had plenty of “toys” to keep her occupied, adding, “but it just isn’t the same.” I emphasized that it was a lot safer and positively reinforced how well she was doing caring for herself, thinking and talking rather than doing. I also asked her to picture me telling her to be safe and to tell herself “don’t do it” if she thought she was going to do something impulsive and potentially self-harmful. She laughed and said she would. She then canceled the last session before this weekend, stating in her voice mail message that she knew I would think she was canceling because I was going away but really she had other things she needed to do and no other time to do them. At our first session after the weekend, she laughed when she described what she had done that weekend—stayed home alone, played with the pet, and read. She stated that she had come close to going out and being “wild” several times but was overtly proud that she hadn’t. I was proud of her and derived pleasure out of being her “good mommy.”

More than 2 years into the therapy, Ms. A stopped swinging. This correlated with her attempts to get pregnant. She originally did not talk of giving up this lifestyle entirely or permanently but, rather, temporarily to “keep healthy” while she became pregnant. On several occasions, I asked her how she planned to incorporate parenting into this lifestyle. She stated matter-of-factly that many of the swingers had kids and that some had even been present (in different parts of the house) at private parties. Although I never verbalized any disapproval regarding this, I am sure that my nonverbal distress was clearly apparent to this very sensitive patient. Over time, she talked more about the kind of parent she wanted to be and her concern regarding her husband as a parent. She maintained her confidence that she would be a good mother and ultimately decided she would not want to do both. Concurrently, she and her husband moved from an apartment to a new condominium. Ms. A would talk about her new home, the tree-lined sidewalks, the quiet street, and how a baby was all that was missing from this “perfect” life. This appeared to be a kind of substitute fantasy. She defined this time period as “calm” but always voiced distrust of it, unsure whether or when “the other shoe [would] drop.” Outwardly, she was containing her impulsivity and becoming more productive. She completed coursework and passed the certification examination to become a personal trainer and started work part-time at a women’s fitness center. She found working exclusively with women very rewarding and genuinely enjoyed the work. Inwardly, she still “craved” sex and missed the excitement and physical pleasures of the swinging. She talked about this, likening herself to an “addict,” stating that she was learning to resist her “urges” but that sometimes it was “1 hour at a time.”

Her husband was very unhappy with her decision to give up swinging, despite her unwavering and even increased desire to have sex with him. He continued to pressure her to start swinging again and stated that he no longer wanted children. She acquiesced to his demands for no children “for the sake of the marriage” but did not start swinging again. It had been almost 1 year since she last attended or participated in a swinging event. She and her husband had very little sex and maintained a civil roommate-like day-to-day existence. Despite her desire for more sex and her stated desire to save the marriage, she appeared unwilling to reenter the swinging lifestyle.

She then purchased a vibrator. She actually blushed when telling me this and quickly noted the irony, that of all of the things she had told me, this was the first thing that had embarrassed her. Unlike previous sex toys, this vibrator was purchased exclusively for herself, and she made the decision without consulting or informing anyone. She planned on using it by herself, not as a prop with her husband or others. I again emphasized how well I thought she was doing and how far she had come in terms of containing her impulsivity and keeping herself safe. I then told her that she should pat herself on the back, to which she responded, “No. You should pat yourself on the back,” and we both, literally, patted ourselves on our backs.

Such exchanges started out somewhat in jest when Ms. A’s behavior became more and more self-contained and have become more frequent as she has improved: I congratulate her for her good work. She typically responds that it was my doing. We both agree that it was our good work, and we both pat ourselves on our backs. This time, however, she finished her patting and told me that at the end of each exercise class that she teaches, she tells the women to pat themselves on the back, and at the end of her day (seven classes some days), she pats herself on the back as well. I felt very touched by this image, not just in terms of professional pride for the work we have done but on a more visceral level, like when I watch my daughter doing or saying something that seems all too familiar and then realize it is because she is, on a very concrete level, emulating me.