Outpatient therapy is sometimes known as the referral of last resort. Generally, people go to their doctors first to explain distressing symptoms and after some routine questions and tests about a patient's behavior that are unexplained by medicine, doctors refer to mental health. This is my bread and butter as a psychotherapist.
One of my favorite examples is Dorothy. That's not her real name of course, but it will make sense in a moment. When Dorothy first came to my office, she was like most other mid-thirties, upper middle class housewives that find themselves in a therapist's office with no history of mood or anxiety disorders. Skeptical, yet concerned they're crazy. These are assumptions of course, but all I had in the brief moments of scanning her intake forms minutes before she stood nervously in my office doorway. Dorothy was beautifully over dressed for a therapy appointment. I'd make a point to tell her comfort is key. She appeared as the stereotype of a high school beauty queen turned soccer mom.
"So tell me what brings you here, Dorothy." The rote opening line in my daily work with new patients.
Dorothy smiled and stammered her words, uncomfortably shifting in the arm chair adjacent from mine. "Well... its a long strange story. It's just uncomfortable and so weird. I don't know."
I smiled and shuffled in my seat to match her behavior, the routine of building rapport. "Take all the time you need. It's safe here. Just between us, my license depends on it." We both forced a chuckle.
Silence. I let it go to the point of discomfort and continued to make eye contact for nearly a minute. It's her turn.
"Uhm. I'm having trouble with sex." I nodded and affirmed, still listening and waiting. "You see, I'm married and have been for a long time but... our sex life had stopped. I just couldn't get in the mood."
"Couldn't? Past tense?" I replied.
Dorothy smiled and shuffled, I noted that this body language meant that she's got something uncomfortable yet important to say.
She gave another chuckle as her eyes wandered the room. "Yes, so it was really nonexistent and I just couldn't ever get in the mood, like at all. It was really bad and caused a lot of problems with my husband."
"So, what I'm hearing is that for a long period of time you wanted no sex at all to the point where it stopped. But it sounds like it's not like that right now?" Reframing... right out of the motivational interviewing text book. "So what changed?"
"Well, we found something by accident. It all happened on Halloween last year. We went to costume party. I dressed as Dorothy from the Wizard of Oz and my husband was the lion. So when we got home, I was extremely... horny... and we had really passionate sex, like really passionate and this was after a year of none at all."
"Well that's not odd at all. Role play is very common and stimulates sex lives really well. As a matter of fact, it's a recommended intervention pretty often. I've assigned it as homework more than I can count." I said with confidence, thinking this will be a breeze. The smile and shuffle followed and I knew I missed the mark.
"Right! I thought it got us back on track, but it didn't... at all. The next day and week we were right back where we were. We tried to figure it out. We tried to be detectives about it and I eventually put the costume back on and... we'll then I was..."
"Horny again?" Always use their words. Therapy 101.
Dorothy smiled and nodded. "Yeah, so that was about 8 months ago. And... well, I can only have sex and only have an orgasm, even when I'm alone, if I dress up like Dorothy from the Wizard of Oz." She put her palms over her eyes in embarrassment. This was obviously causing distress. I didn't respond, just observed how she'd react to the silence. She uncovered her eyes and squinted at me as if I'd think she was insane and needed to be hospitalized.
I attempted to normalize the behavior. "Again, role play can stimulate. But it sounds like you want to find a way to have sex as yourself and not someone else?"
Dorothy let out a sigh of relief, "Yes! That's exactly it! I feel like something is really wrong with me" her voice quivered as I pushed the tissue box on the small table dividing our chairs toward her.
I formulated my plan: normalize, psycho educate, teach basic emotional scaling, analyze current behavior, replace with more adaptive behavior. "Dorothy, I think we can work together to come up with a plan. We've already identified the goal. Let's see if we can do this together."
Dorothy smiled while wiping her tears and I could see the body language expressing hope. A good sign. We spent the rest of the session walking through the thoughts, emotions and subsequent behaviors, detailing the sex down to every position and scaling the "horny-ness" she felt. I gave her a stimulus reducing exercise for homework. Go home, dress like Dorothy, get fucked and scale the emotion. Then do it again, but reduce the costume slowly. Start with taking off the shoes, then the braids, then change the dress to something similar but not the Dorothy dress, etc. The purpose as she scaled was to find the minimum point of stimulation and slowly reduce the needed role play.
***
At the following session, Dorothy was late. That either meant she failed to do the homework or it worked to the point that the distress level didn't warrant a subsequent visit.
She finally arrived. No smile, but with a sullen look on her face. She didn't speak.
