It is a popular misconception that sex is the central focus in the psychotherapy of most adults. This is not true. Sex might be discussed within the context of a person’s relationships, but therapy is a place for people to talk about what gives their life meaning and sex is not usually high on the list. Relationships, family, work, personal fulfillment, losses, life choices, empowerment, shame, identity, anxiety, power, self-esteem, lifelong influences and present functioning are a few of the issues that are more meaningful to most people. Many people in our society do not consider sex a very personal topic. In Freud’s Vienna, sex was taboo, but in America 2015, it is not. Money is more taboo than sex because in our money-oriented society a great deal of people’s self esteem rests on how much money they make. This perverts people’s view of themselves and makes people feel that their net worth defines their self worth. Most patients will offer information about their sex life before they tell you how much money they make.
In her first session, shortly after “hello”, a teenage girl began to describe her most recent sexual exploits. Since trust takes time to develop people do not reveal deeply meaningful aspects of themselves quickly. It was clear that this girl was trying to hide by offering sexual information immediately. She confused sexuality and intimacy. By talking about her sexuality so quickly she was unintentionally revealing a lot about herself: her fear of intimacy, of honesty, her need for control, and I was to learn, her sadism. In later sessions, she bragged how she would look forward to having sex with men so she could later hurt them. It was clear she had not developed a meaningful sexual relationship in her life and she had not learned how to manage her sexuality in a healthy way that benefitted her. Despite her grand, lively presentation, it became clear that she was sad, frustrated, and depressed.
She talked a lot. She filled any space with words to fill the silence. She was anxious, scared of silence and self-reflection. It was obvious she did not feel cared for by anyone. In an early session, after speaking uninterrupted for a while, she suddenly looked up and asked me
“What are you doing?’
“I’m listening to you,” I said.
“What?” she said incredulously.
“I’m listening to you”, I repeated. She seemed shocked. After a pause, I asked her “Does anybody in your life listen to you?” For the first time, she stopped to seriously consider what was said. “No”, she said, “nobody listens to me.”
Many people try to master past traumas by using sex to gain control and power over others or to give up control and power. For these people, like this female patient, sex never becomes a vehicle for personal fulfillment and more meaningful relationships. The key to helping these people is to ease them away from talking about sex, which is not the source of their problem, and help them talk about their traumas and pain, which they use sex to avoid.
At the end of one session, this patient saw a paperclip on a table near her and asked if she could take it. I knew that taking the paperclip was a way of testing whether I would let myself be abused like her boyfriends, like her mother, who, much to this girl’s pain, accepted abuse for years from her father. This girl had expressed many times what little respect she had for her mother and how powerless she felt to help her. She saw her mother as pathetic because her mother tolerated abuse from men. Through her relationships, this patient tried to take revenge on her mother's behalf by humiliating men. The part of her that identified with her mother tried to sacrifice herself by taking her mother’s place though self-humiliation. She had not been able to find healthier solutions for her traumas. I did not want to encourage her behavior because it damaged her self-esteem and self-respect. She needed to talk about her pain instead of acting it out, and her behavior, like a drug, provided her with an unhealthy escape. It was also important to model a healthy relationship for her since she had never experienced or witnessed one, particularly with men.
“No”, I said, “you cannot take it.”
“But why?” she lamented, feigning sadness, looking directly at me with a well practiced childlike innocence.
“It’s only a paperclip,” she pleaded.
“Because”, I said, “I will listen to you, but I will not let you think you are abusing me. It’s unhealthy.”
People sometimes report dreams that have manifest sexual content. Here too, one must remember that the mind may be using sex to disguise more meaningful issues. A dream about sex may only be about sex superficially or may have nothing at all to do with sex, and a dream with no sexual content may have a lot to do with sex. Either way, the long-term focus in therapy is never sex. Rather, it is the meaning of the complete, complex life of the person that is sitting in front of you, of which sex is only one small part. Just as people use sex to reveal themselves, they also use it to cover up.