(Author's note: My other blog is in a Q&A format, where a reader submitted the following ten questions.)
I've been thinking, Dr. Smith, and have some random questions for you. I hope to see some or all of these questions answered because they are burning a hole in my head, suppress them as I might try. - Just Asking.
Dear Just Asking,
Each of your questions would qualify for one of my trademark essays: long, convoluted, and in need of a good editor. Today, I'll shoot for a different standard: short, unreliable, and barely coherent. I'll skip my usual review of the literature and instead pepper my answers with mixed metaphors. Why? It seems like the right thing to do since I'm depriving you of citations.
1. There is information that certain countries have more or less mental illness (and other diseases) than others so my question is: Are certain mental illnesses more prevalent in certain parts of the U.S. vs. other parts of the country?
American trends in mental illness more closely follow socioeconomic status than geography (and the reverse is true: socioeconomic status follows mental health). Treatment options are limited for the poor. Since the Community Mental Health Act of 1963, jails have become the de facto mental health institutions for the seriously mentally ill who have no resources. Having worked in a prison, I can attest that treatment resources are stretched as thin as a drum. Of course, relatively few people end up in prison. More often, people with mental illness and minimal resources somehow manage to get by. They suffer a reduced quality of life that frequently includes poverty.
2. Why does a heterosexual fantasize about a three-some (2 men/1 woman or 2 women/1 man) and/or a homosexual sexual liaison? Does this mean there are some latent homosexual tendencies or desires in said heterosexual?
It is fortunate that I'm avoiding the professional journals today. Articles in this realm tend to have titles like Moonbeams On Sappho: A Post-Deconstructionist Exploration of Whitmanesque Archetypes, and they slide rapidly downhill from there. Only in an American university can a person become an expert on sex while never having participated.
So. Here's my clinical take on homoerotic and orgy fantasies: they're normal, don't worry about them. Sexual orientation is hardwired, but that doesn't preclude a bit of leeway. Finding something attractive in people of the same gender is perfectly normal for a heterosexual.
3. Is sexual fantasy and masturbation healthy? Is it more or less healthy if one is married vs. being single, assuming you are not fantasizing about your spouse or significant other?
Sure, it's healthy. Your average teenage boy would say it's inevitable. The evolutionary-minded say it even has a purpose. There is evidence that male masturbation serves to rotate the stock so that there is always a fresh batch of gametes at the ready.
As for fantasizing about people other than your partner, I make the distinction between thoughts and actions. Thinking about a sexy coworker is worlds apart from actual intercourse. But that's my personal ethical slant. Other people, like Jimmy Carter, prefer a stricter approach. Regardless, the only true danger in fantasy is that it can go too far and serve as a way to avoid real-life responsibilities. If a person is fantasizing to the exclusion of intimate connection with his or her partner, then clearly there is a problem.
4. If one has suffered from depression, anxiety, etc. in the past, is that person obligated to tell a future significant other about said past? In other words, how important is full disclosure especially if you don't anticipate a future problem?
I am not a believer in full and reckless disclosure. Partners and spouses don't need to know every little thing about each other. Will you and your special someone truly benefit by disclosing some forgotten, unfortunate episode that has no chance of recurring or rebounding? Probably not.
But in this particular case, I'm wondering why a person wouldn't want a partner or spouse to know about past struggles. Educating them on your past need not involve every gory detail, but offering a general synopsis should bring you closer to that person. If discussing past difficulties proves to be harmful, then perhaps the relationship has bigger problems.
5. Do you think people with a prior mental illness, be it depression, anxiety, PTSD, etc., should be allowed to adopt children? What about people with personality disorders, bipolar disorder, etc.?
Adoptive parents are low on the list of society's ills. On the other hand, I could take you on a magical tour of unstable, untreated bio-parents at my neighborhood Walmart.
The salient issue is treatment. Whether a parent has diabetes or depression, there is a duty to properly manage the problem. Parents who intentionally neglect their mental or emotional difficulties are as useless as a tin roof on a bull. Their children, and society at large, pay the price for their self-neglect.
So in answer to your question: properly treated problems should not preclude adoption. I believe that the ability to overcome hardship makes one a better parent.
6. Can Borderline Personality be cured or is it a life sentence?
Borderline personality disorder is certainly treatable, and I am ever-optimistic that anyone who is sufficiently motivated can find real relief. One of the most difficult aspects of recovery is learning to tolerate, accept, and disobey overwhelming emotional impulses. It's hard to imagine how difficult it must be to tackle that hurdle. I give mad props, as the kids say, to anyone with the strength and willpower to overcome borderline tendencies.
7. Can Borderline Personality be misdiagnosed? If so, what could be at play that makes a professional, such as yourself, think that one has BP when they don't?
I don't know how often, but borderline personality disorder (BPD) is wrongly diagnosed sometimes. One reason is simply that some of the features of BPD loosely resemble other conditions such as bipolar disorder, and so a clinician who is rushed, inexperienced, or impatient can be misled. (Presently, bipolar disorder seems to be the catch-all diagnosis for everything from irritability to acne.)
A second reason, and I'm sad to say that I've seen it happen, is anger or frustration on the part of the clinician. Some clinicians blame the patient when therapy goes poorly. By branding their "difficult" patient as borderline, they perhaps feel absolved of responsibility for an unsuccessful course of treatment.
On the other side of the sword, there is also an under-diagnosis of BPD among men because the disorder has come to be associated with women. Men are more likely to be diagnosed with antisocial personality disorder (APD) when BPD is a more fitting diagnosis. Likewise, women who fit the diagnostic criteria for APD are more likely to be diagnosed as BPD. That's the gut feeling off the top of my head, anyway - perhaps other clinicians will weigh in.
Despite clear examples of misdiagnosis, I think BPD is typically diagnosed correctly. As a constellation of symptoms, recognizing this one is like shooting ducks in a barrel.
8. In a previous blog, you wrote of a patient having a crush on her therapist. Can therapists usually tell when a client is so enamored? If so, how? If so, should the therapist approach the subject with said client?
I doubt that therapists are especially adept at detecting hidden romantic interest. We're not much better than anyone else at detecting lies or omissions, so there is no reason to believe that we have special radar for secret crushes.
Yes, the clinician should bring it up if he or she senses something, lest it become the white elephant in the room. A skilled clinician should be able to find a non-threatening approach.
9. Do therapists ever have feelings - sexual or relational - for their clients? Can a therapist and client develop a relationship after a certain period of time has elapsed between the therapeutic relationship and the romantic one?
Yes, therapists certainly develop attraction to their clients. Often it is platonic, and sometimes it is romantic. The ethics code of the American Psychological Association advises that psychologists abstain from from sexual intimacy with clients "for at least two years after cessation or termination of therapy," and then only under "most unusual circumstances." I am certain that some shrinks interpret that liberally. Yippee! Only 730 days until I can boink my former patient!
The APA takes a pretty hard stance against all manner of dual relationships. Obviously we should not sleep with patients, but we should also avoid working with our friend's mother or the grocer that we see each week. Of course there are exceptions. For example, it's hard for a small-town psychologist to avoid dual relationships entirely. But for the most part, it's a prudent policy. Strong boundaries make for a more effective clinician.
10. Is it true that once a person has an episode or two of depression, that person will most likely continue to have episodes throughout life?
Statistically, the chances of a major depressive episode are elevated for someone who has already had one or more episodes. Statistically, that's especially true for women. Statistically, it's hard to stop that ball once it starts rolling down the drain. However, no person is a statistic. We have choices. We can render these statistics meaningless by availing ourselves of the wonderful, empirically-validated treatment options - especially mindfulness-based therapies that have lifelong benefits and no side effects. Statistics be damned, I say.
Well, there you go, JA. I do hope this arrived in time to prevent these questions from burning clean through. I'm sure you need another hole in your head like I need another drink.
* * * * *
Dr. Smith is a psychologist in Denver, Colorado
and the author of The User's Guide to the Human Mind: Why Our Brains Make Us Unhappy, Anxious, and Neurotic and What We Can Do about It
. You can read the introduction and find other goodies at guidetothemind.com
(This article was originally posted at ironshrink.com. Copyright (c) 2012 Shawn T. Smith.)