In this newsletter, we discuss three clinical issues that arise in our practice: impotence, self-harm, and eating disorders. We have written the information on impotence and self-harm. Dr. Carolyn Nesbitt, a psychologist colleague with a part-time private practice in Richmond, BC, contributes a piece on eating disorders. Carolyn’s appearance here reflects our interest in collaboration and the creation of networks among health-care providers in our community. At the end of the newspaper, please find an invitation to join us on April 14, 2005 for a talk on “Building Relationships That Work”.

Once again, we thank all of you who have been making referrals to us. It is a pleasure for us to see our practice thrive after only one year in Richmond, and we consider it a privilege to provide service to our clients. If you would like to have more of our brochures or business cards in your office, please call 604-279-8992.
Marianne and David

Impotence: Beyond Viagra
Clients who are struggling with sexual problems often ask us, “What do you think about my using Viagra?” This deceptively simple question raises a number of complex issues. We have no doubt that Viagra provides a positive answer to men’s sexual difficulties in some cases. However, even for successful Viagra users, the drug does not work 20 to 35 percent of the time. More striking still, the estimated dropout rate for Viagra within a year is between 40 to 80 percent of users (McCarthy, 2004). This may be related to unrealistic expectations, and the belief that medication can be a stand-alone intervention. As with so many simplistic solutions to human emotional problems, the promise of cure far exceeds the reality.

We would like to offer three perspectives that physicians might want to discuss with patients before prescribing Viagra, and that patients themselves could consider when asking for such medication.

#1: Normal Changes in Sexual Performance
By mid-life or even sooner, all men experience the loss of the instant, completely reliable, rock-hard erections of youth. This unavoidable feature of aging is a serious problem for those men who respond to it with shame and a sense of inadequacy. For them, each sexual encounter becomes a trial in which they are an observer, just waiting for the first sign of getting soft. This observer/judge state of mind almost guarantees continued difficulty in getting and maintaining an erection, and a self-feeding cycle of failure is set in motion. In our view, lasting treatment consists of helping patients to understand that less than youthful performance is normal and a call for creativity. For example, if a man can discuss his concerns with his partner, she may be able to help him relax with her while staying close and enjoying their overall physical and emotional intimacy. She may be interested in teaching him alternatives to the “penis-in-vagina” method of providing sexual pleasure. He might also find that her subsequent arousal is an aphrodisiac for him, especially if he is now focussed on her pleasure rather than what his penis is doing. The solution to “normal impotence” consists in helping partners to work together to create patience, mutual support, and alternate means of sharing sexual pleasure. As one therapist eloquently said, “Despite all the obvious distinctions between men and women, our hearts share the same fears and yearnings. Learning how to hold each other’s hearts tenderly is the art of lovemaking.”

#2: The Too-Busy-For-Sex Couple
We observe that in some long-term marriages, partners have neglected their sexual relationship for years. For all kinds of very understandable reasons, they have put their sex life on hold. Their focus has been on making a living, building a degree of financial security, and getting the kids to soccer, through school and launched into adult life. This necessary busy-ness has taken away from the time and energy that is required to maintain a strong emotional/physical bond. Then the day comes when one or both wish that sex could once again be a regular part of their lives. Unfortunately, when they try to resurrect sexual intimacy, they may find that the man is impotent. For these couples, turning to Viagra as the sole solution may be disappointing, since their real need is the re-vitalization of their sense of connection and intimacy. This is crucial to creating sexual desire and passion. Some women whose husbands are using Viagra report that it is difficult for them to feel that their husband wants THEM. It seems to them that their husband’s erection is merely a medication-induced phenomenon, and they feel “pressured” into manufacturing a passionate response that can only be truly developed by attending to what has been missing in the relationship.

#3: An Unhappy Marriage
Many couples that we see in therapy present a long-standing history of resentment and bitterness. In these cases, it is very likely that their mutual anger and frustration is the source of their sexual performance problems. Of course, the man may also have a purely physical problem that requires treatment. But, once again, couples are likely to be disappointed if they try to gloss over relationship problems with a pill.
We believe that each of these perspectives underlines the crucial importance of attending to relationship issues in effecting a lasting solution to the common experience of reduced potency.

References:
Dr. Barry McCarthy’s Case Study in Psychotherapy Networker, May/June 2004.
McCarthy, Barry and Emily. Rekindling Desire: A Step-By-Step Program to Help Low-Sex and No-Sex Marriages, 2003.

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Bodily Harm: Treatment for Self-Injurers
“A message for self injurers… You are not alone. You are likely to feel hopeless and desperate, like your problem is yours alone, something nobody else shares or understands. You may feel like you walk around every day with an embarrassing secret too painful to discuss with anybody, one that will never go away. We want to show you that there is a different path, a more joyous life, that you can pursue.”
This is a quote from the book Bodily Harm: The Breakthrough Healing Program for Self-Injurers, by Karen Conterio and Wendy Lader. This book, published in 1998, is highly readable, and our clients report that it has been helpful to them in many ways.
In our counselling practice, we’ve recently met several people (usually women) who fall in the category of self-injurers. This seems to represent a growing trend of using violence against oneself as a way of handling emotional distress. Self-injury, like eating disorders, is a serious mental and physical health problem that many people do not fully understand.

What is self-injury? It is the deliberate mutilation of the body as a way of managing emotions that seem too painful for words to express. Cutting and burning the skin are the most common forms of self-injury, but there are numerous other forms including hitting oneself, extracting hair, biting or burning oneself, and scratching to excess. Self-injury encompasses a range of behaviours, some of them not so distant from the stress-busting strategies of normal, healthy people. Many of us bite our nails, pick at acne lesions, scratch mosquito bites until they bleed, or go on starvation diets to fit into a pair of pants for a special occasion.

While some self-injurers come from relatively healthy homes, the vast majority come from families with serious problems. Some have been physically, sexually, or emotionally abused, or had parents who ignored their basic needs. Most grew up in rigid households where expressions of emotion were not accepted, or where their every move was scrutinized and criticized by a hovering and intrusive parent. On the other end of the spectrum, some grew up in homes where there was little or no parental guidance or emotional involvement.

The most typical self-injurer is a white, middle-class woman who began cutting herself in adolescence. She has low self-esteem and may suffer from bouts of depression. Because she did not internalize positive nurturing skills from her parents, she has failed to develop adaptive, internal abilities to soothe herself or control distress. She comes to rely on action to gain relief from any uncomfortable feelings or thoughts. Ironically, her goal is to put an end to the pain and suffering she feels in her head, even if it means her body has to bear the brunt of the attack.

Strange as it may sound, self-injury represents a frantic attempt by someone with low coping skills to “mother herself.” She feels alone and terrified, with no hope that a soothing presence will come “make it all better.” The act of self-injury is a harsh but available substitute for the care that she truly desires. It brings a temporary sense of relief.

Self-injury is a distinctly different activity from a suicide attempt, but the boundaries often seem murky, and many self-injurers do indeed have suicidal thoughts or have committed acts aimed at ending their lives. It is rare that a self-injurer will carry her actions to the end, causing death. Paradoxically, self-injury is usually a life-sustaining act, a mechanism to cope with stress and to relieve inexpressible feelings. Most self-injurers say it is a mechanism to stave off suicide; it is a “life preserver” rather than an exit strategy.

Self-injury is more prevalent than many people realize, and there is reason to believe it is grossly under-reported and misdiagnosed. Some studies of college students have shown that over 10% admit to having harmed themselves deliberately.

Self-injury is not a new phenomenon. It is documented in biblical times and in virtually every culture in every era. However, it seems to have increased tremendously in the last 10-15 years. The movie “Thirteen” dramatically portrayed a 13-year-old American girl who was cutting herself. Family physicians, psychologists, and psychiatrists have been seeing more and more of this phenomenon in recent years, even among high-functioning adults. Many more people are suffering in silence, frightened to admit to something considered so repulsive and disturbing.

Treatment for self-injurers
The good news is that many self-injurers can stop their behaviour. Like many ingrained patterns of unhealthy coping, self-injury is a learned behaviour that can be unlearned. Self-injury is a behaviour that people rely on to relieve or distract themselves from difficult feelings. Once they learn to express themselves in other ways – verbally or in writing – the impulse subsides. The troublesome feelings may not completely go away, but the coping mechanism becomes a healthy one.
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Eating Disorders - A Matter of Life or Death
Dr. Carolyn Nesbitt
Dr. Carolyn Nesbitt is a Registered Psychologist in private practice in Steveston. She also works at BC Children’s Hospital and is a Clinical Associate of the Clinical Psychology Centre at Simon Fraser University. She sees adults, teens, couples and families for a variety of disorders, such as anorexia, bulimia, depression, anxiety and relationship issues. She has treated compulsive overeating, obesity and night eating syndrome. Carolyn’s office number is 604-376-9801.

I have been witnessing a troubling trend in my practice, and a new study has just confirmed my observations. In addition to the well-known health risks associated with eating disorders, these disorders, especially anorexia nervosa, are associated with an increased risk of attempted suicide in young women (Pompili & Tatarelli, 2005).

The girls and women (and an increasing number of boys) who come to me with eating disorders, are depressed about their situation. They feel that their particular pain is not understood. What might have started as a simple diet has turned into an obsession. The thinking goes something like this: “I am so fat! How could I have eaten that whole plate of food? How many calories were there? How much fat? How long do I have to exercise before I burn it off? I will skip my next meal and go for a long run. I am so hungry right now just thinking about it. If I eat, then I can just throw up and that will take care of it. I hate my body. I hate myself. How could I have eaten all that?”

This cycle of reasoning becomes obsessive and inescapable, and spills over into many parts of the person’s life, having a universal negative impact. A teenage girl, for example, can’t concentrate well on schoolwork when she is planning a binge or purge. In addition, if the girl is severely restricting her food intake, her ability to think clearly is negatively affected by low blood sugars, dehydration, etc.

This negative cycle of thinking also gets in the way of healthy communication in relationships, leaving her feeling alone and misunderstood. Above all, she experiences intense shame and self-loathing.

In the attitudes towards food and exercise, the atmosphere at high school is very different now than it was twenty-five years ago. Girls throw their lunches out en masse. They mock each other openly about throwing up, a way of establishing a kind of camaraderie in the midst of their confusion and shame about their behavior. In addition, the current tight fashions allow for endless discussion and judgement about every inch of the body.

This trend does not necessarily end with adolescence. Often women, who may seem so strong in the workplace and/or effective in raising healthy children, crumble when it comes to their own aging bodies. The emphasis on youthful beauty standards affects these women to a great degree, eroding self-esteem despite the woman’s accomplishments. Adult women may talk about diets or denigrate their own bodies to each other, but they usually hide the extent of their self-loathing. Binges and purges take place in secret. No one would be able to tell how intensely the eating-disordered person is suffering.

People with eating disorders often express intense shame about their behaviour, and share thoughts of taking their lives. Psychological intervention can help them establish a broader set of criteria for judging their worth, and a more gentle approach to self -evaluation.

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“Building Relationships That Work”

Where: Thompson Community Centre
5151 Granville Avenue, Richmond
(Entrance to free parking is ½ a block north of Granville, on Lynas Lane.)

When: Thursday, April 14th, 7:30 – 9:00 p.m.

Life partners, lovers, friends, relatives, co-workers… we are all in relationships, and we all want them to be successful!

Come and learn some practical ways to enhance any relationship.

Marianne and David draw on their experience in counselling couples, as well as their experience in their own relationship, as the base for this talk and discussion. For more information please call, 604-279-8992.