Arch Sex Behav (2014) 43:1031–1034 DOI 10.1007/s10508-014-0321-3
LETTER TO THE EDITOR
Polyamory: A Call for Increased Mental Health Professional Awareness Nicole Graham
Published online: 22 July 2014 Ó Springer Science+Business Media New York 2014
Polyamory, meaning ‘‘many’’ and ‘‘love,’’ is defined as the philosophy or state of being in love or romantically involved with more than one person at the same time (‘‘Polyamory,’’ n.d.). The term was coined by Morning Glory Ravenheart Zell in 1990; it is often abbreviated as‘‘poly’’by those who practice it (Easton & Hardy, 2009). A polyamorous author expanded the definition to include the practice of theory of having emotionally intimate relationships with more than one person simultaneously, with sex as a permissible expression of the caring feelings, openly and honestly keeping one’s primary partner or partners (or dating partners) informed of the existence of other intimate involvements (Benson, 2008). Others have summarized polyamorous relationships as being characterized by individuals who pursue multiple concurrent romantic relationships with the permission of their partners (McCoy, Stinson, Ross, & Hjelmstad, 2014). While many have provided insight into what polyamory is, it might be best to highlight what polyamory is not for starters. Polyamory is not to be confused with polygamy, the practice or custom of having more than one wife or husband at the same time (‘‘Polygamy,’’ n.d.). Unlike polygamy, polyamory is not illegal and is not grounded in any particular religion. Polyamory is also not a sanctioned form of group sex or even about being promiscuous,as‘‘poly’’individualsmayormaynothavesexualencounters withall oftheirpartners (Easton & Hardy,2009). Polyamory is also not a fad; rather, individuals in polyamorous relationships seem to experience the same longevity (Rubin & Adams, 1986), level of marriage satisfaction, and self-esteem (Buunk, 1980) as those in monogamous couples. Additionally, polyamory is not synonymous
N. Graham (&) Adult Intensive Outpatient Program, Department of Psychiatry, Yale New Haven Hospital, 425 George St., New Haven, CT 06511, USA e-mail: [email protected]
with infidelity; rather, poly individuals are committed to being open about each of the relationships in their lives (McCoy et al., 2014). Lastly, polyamory is also not practiced in one uniform way (McCoy et al., 2014; Weitzman, 2006). Weitzman (1999) noted that there are three common relationship dynamics often seen in the polyamorous community: 1.
2.
3.
An individual has one main or primary partner and one or more other intimate relationships and the different partners do not have any significant relationship with each other. An individual has more than one partner with whom they are in equally intimate relationships and the different partners do not have any significant relationships with each other. The‘‘poly family’’—three or more individuals have intimate relationships with each other that may or may not include sex. If children are involved, this may include sharing of the parental roles.
Scant polyamory research has been published; however, the available data indicate that it is not as rare as once was thought. Weitzman (2006) noted that openly polyamorous families in the United States number more than half a million. A study with 3,574 married couples demonstrated that 15–28 % had an understanding that allowed non-monogamy under some circumstances; this same study showed that the percentages were even higher among cohabitating couples, lesbian couples, and gay male couples (Rubin & Adams, 1986). Additional studies in the lesbian, bisexual, and gay communities also demonstrate the growing number of individuals in polyamorous relationships. Page (2004) tallied 33 % of the lesbian couples in their sample were polyamorous. West (1996) documented that 20–28 % of their lesbian responders were polyamorous and, in a gay male sample by Blumstein and Schwartz (1983) a noteworthy 65 % were polyamorous. These studies, albeit sparse, indicate that polyamory, while still not embraced universally by the general public, has become part of many Americans’ lives.
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While polyamory is not a psychiatric condition itself, members of the community are not immune to the diseases and disorders that could necessitate a mental health referral. Yet to date, education about polyamory has not made it into standard mental health curricula (Weitzman, Davidson, & Phillips, 2009). Research exploring the efficacy and confidence of providers in addressing sexual issues or disorders indicates that a lack of exposure to and comfort with variations in sexuality is correlated with poor treatment efficacy; this has been demonstrated with medical students (Mu¨ldner-Nieckowski, Klasa, Soban´ski, Rutkowski, & Dembin´ska, 2012) and with practicing psychologists (Miller & Byers, 2012). A study by Knapp (1975) had alarming results that indicated that a third of therapists in the sample thought people in open relationships had some type of personality disorder or neurotic tendency and that almost 20 % of this same sample would try to unduly influence a return to a monogamous lifestyle. It is apparent that a lack of awareness of and appreciation for non-traditional relationship patterns can have deleterious effects, including but not limited to a lack of objectivity, inadvertent criticism and potential pathologization of individuals, damaged therapeutic alliances, resultant treatment non-adherence, and potentially poorer patient outcomes.
Case Report The patient is a 21-year-old female student with a history of depression and anxiety who presented with recurrent suicidal thoughts and recent engagement in self-cutting behaviors in the context of increasing academic demands, treatment non-adherence, relative social isolation, and a recent move from out of state. She reported worsening depression marked by thoughts of self-harm and recent self-cutting behaviors with an onset of 2 months prior following her decision to discontinue treatment secondary to ‘‘she [her psychiatrist] blamed all my issues on polyamory.’’The patient reported cutting over her left clavicle as recent as 2 weeks prior and fleeting thoughts of‘‘giving up’’due to the stress related to her recent move, the increased academic rigor of her new school, and her inability to make friends at school despite efforts to do so. She reported that her only local social supports were members of the polyamorous community. Her psychiatric history included depressive episodes marked by discrete episodes of low mood, suicidal thoughts, self-injury, and neurovegetative symptoms (i.e., low energy, poor concentration, reduced appetite, daytime fatigue, and feelings of being slowed down) starting in her teenage years with the most recent episode beginning 2 months prior and a history of anxiety marked by a needle phobia, apprehension and discomfort with novel situations, and, at times, people and classic panic attacks. She denied any history of manic symptoms, psychosis, other anxiety disorders, eating disorders, any attention or hyperactivity issues, substance use disorders or disruptive behavioral disorders.
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Her psychiatric treatment history included counseling at age 6 due to her teachers thinking she was‘‘disturbed’’based on ‘‘morbid drawings,’’ a history of pharmacologic management by her internist back home, and recent referral to a psychiatrist who the patient felt had unfairly judged her‘‘poly lifestyle.’’ The patient reported that this provider had recommended she stop her multiple relationships because they were‘‘likely the source of her problems’’and the cause of her current depression. The patient’s current medications included Citalopram 20 mg daily and Alprazolam 0.25 mg every 8 h as needed for panic that the patient reported taking 3–4 times per week. There was no history of inpatient psychiatric treatment or substance abuse treatment. There was no history of past suicide attempts, but the patient did report a history of suicidal thoughts without a specific plan or intent and a history of cutting her wrists and clavicle starting in her teenage years with her most recent episode 2 weeks ago. Past psychotropic medication trials included Fluoxetine and Escitalopram, both of which worked well but were stopped secondary to‘‘They decreased my orgasm.’’ Her medical history was significant for asthma and seasonal allergies. There was no history of head injuries, seizures, or loss of consciousness. There were not any known drug allergies. The patient’s family history was significant for a mother with depression, anxiety, and addictions to pain pills and alcohol and a father she described as‘‘a psychopath in denial’’ with compulsive hoarding and at least two suicidal gestures versus attempts via intentional insulin overdose. Her social history was significant for current college enrollment with a recent transfer while in good standing, residing in an apartment with her pets, being raised in a household of four, including a mother, father, and older brother none of which she is particularly close with, and identifying as agnostic. The patient hadhadfewclosefriendshipsinherlife;themajorityofthemwere platonic male friends. She reported her current social supports as including members of the local polyamorous community. Her sexual history was significant for identifying as bisexual and polyamorous. The patient reported having learned about sex during middle childhood from same age peers and reported having engaged in touching and consensual sexual play with peers. She did not reportanysignificant religiousinfluencesin herknowledge or attitude towards sex. The patient reported sexual attraction to both men and women. She reported a total of 10 sexual partners, including 7 men and 3 women. She reported three past relationships, one of which was with a woman. Her first sexual experience was at age 14 with her then girlfriend; her first penetrative intercourse was at age 17 with her then boyfriend. She reported a current weekly sexual output of four with one to two being with a partner and the rest in masturbation. She reported engaging in safe sex practices and reported recent negative STI testing. The patient reported being in a‘‘poly’’relationship with her boyfriend back home for the past 3 years, having met a local male partner via an internet polyamory website and actively
Arch Sex Behav (2014) 43:1031–1034
looking for a polyamorous female partner. With her primary relationship long distance, the patient reported feeling somewhat socially isolated due to her inability to make friends at school; she reported that engagement in several polyamorous activities was her ‘‘only social outlet.’’ After feeling judged by the therapist, the patient reported pulling away from the polyamorous community slightly, spending more and more time alone and noting a decline in her mood and zest for life. While the patient acknowledged that treatment nonadherence likely contributed to her decline, she felt that avoiding the polyamory community and those few friends was detrimental to her overall mental well-being. On mental status examination, the patient appeared her stated age, exhibited adequate grooming, and did not have any visible skin lacerations. She was dressed in loose fitting clothing with multiple ear and facial piercings, two necklaces, and numerous bracelets donning her wrists. The patient was alert with good eye contact and free of abnormal body movements. Her speech was spontaneous and normal in rate, rhythm, volume, and tone. Her mood was ‘‘better than before’’ and her affect was mildly constricted. She denied any current thoughts, plans, or intent for self or other harm. Her thought process was linear and goal directed; the content was devoid of delusions (false beliefs) and she reported no perceptual disturbances (to include no hallucinations). She denied current suicidal or homicidal thoughts, plans or intent. Insight and judgment were adequate. Cognition and memory were grossly intact. After the initial assessment, the patient expressed willingness to restart psychotropic medication and was titrated up on an antidepressant alone; she refused, however, to have her prior provider contacted as ‘‘there is nothing she can add.’’ She additionally agreed to a course of supportive psychotherapy and was surprisingly candid about her sexual history and relationship preferences. Early on, she discussed her decision to withdraw from the polyamory community, as a result of her encounter with the therapist; while upset, she wondered if this provider was right. The patient recounted how putting distance between herself and the‘‘poly’’community had made her feel more isolated and alone. While still able to abstain from suicidal gestures or attempts, she recalled several episodes of suicidal ideation with urges for self-harm. In therapy, the patient was able to advocate for herself and how the polyamory community allowed her to feel connected and‘‘included.’’ Following a re-introduction to the ‘‘poly’’ community, the patient was able to find a third partner, who she described as ‘‘She’s someone I can be myself with.’’The patient reported that this third partner, in addition to her two male partners, were great supports for her during the depressions and whenever she felt like engaging in self-harm. On further prompting, the patient elaborated in saying that her partners were most helpful in allowing her to use‘‘creative ways’’to abstain from self-harm. She described how such sexual freedom allowed her to turn her mental turmoil into pleasure through fantasy, role play, and erotic talk. During
1033
one session, she detailed how she and the local male partner had used theatrical props and role played cutting behaviors during foreplay. She also reported how it was typical for her and her long-term, long-distance boyfriend to incorporate her urges into their erotic conversations. The patient reported finding these experiences as ‘‘good replacements’’ for her self-injury during distress, as well as during times for pleasure. The patient was seen in our clinic for another 6 months until the conclusion of the spring semester, at which point she returned home for the summer and was referred to a local provider. For the duration of the treatment in this clinic, the patient was adherent with her medication and appointments; she was even able to abstain from engaging in cutting behaviors with infrequent suicidal ideation. She attributed her improvement to reengagement with the polyamory community (including her new female partner), treatment adherence (medication and therapy), and this ‘‘creative’’ transference of distress that she felt ‘‘enhanced her experiences.’’
Discussion In this case, the patient reported feeling judged and misunderstood by her prior mental health provider; she felt that her therapist was dismissive of the importance of her chosen relationships and inappropriately attributed the majority of her depressive symptoms to the polyamory lifestyle. In addition to feeling misunderstood, the patient reported not feeling comfortable discussing the more intimate details of her relationships and ultimately stopped coming to treatment. The therapeutic alliance, the relationship between a psychologist or psychotherapist and a patient (‘‘Therapeutic alliance,’’ 2013), is paramount in successful psychotherapy. A strong alliance is thought to include the communication, expression of caring, and the agreement on the goals and methods with which to achieve those goals. Research suggests that a positive alliance is associated with a more positive therapeutic outcome; likewise, a negative therapeutic alliance can result in a less desirable outcome (Goldfried, 2013). If a provider is not aware of, comfortable with, and sensitive in their handling of variations of sexual and relationship practices, it can be almost impossible to achieve common goals and a sound alliance. Thus, for optimal therapeutic outcomes, mental health professions need tobetrainedinandbecometolerantoftheseincreasinglycommon relationship patterns. Failure to do so could result in a poor therapeutic alliance, treatment non-adherence, failure to appreciate the role such relationships play in the patient’s stability or wellbeing, and subsequent poor patient outcomes. Polyamory, more than one intimate relationship at a time, is becomingamorecommon relationship pattern within theUnited States. Unfortunately, most standard mental health curricula do not cover polyamory in any depth. A lack of appreciation for polyamory and other non-traditional relationship patterns could
123
1034
result in a damaged therapeutic alliance; such damage has been shown to negatively impact patient outcomes. The case presented highlights the deleterious impact such ignorance can have on patient care. Therefore, all mental health professionals need to become familiar with polyamory and other non-traditional relationship practices in order to provide the best possible treatment to our patients.
References Benson, P. J. (2008). Polyamory handbook. Bloomington, IN: Author House. Blumstein, P., & Schwartz, P. (1983). American couples: Money, work, sex. New York: William Morrow and Company. Buunk, B. (1980). Extramarital sex in the Netherlands. Alternative Lifestyles, 3, 11–39. doi:10.1007/BF01083027. Easton, D., & Hardy, J. W. (2009). The ethical slut: A practical guide to polyamory, open relationships and other adventures. New York: Celestial Arts. Goldfried, M. R. (2013). What should we expect from psychotherapy? Clinical Psychology Review, 33, 862–869. doi:10.1016/j.cpr.2012. 09.006. Knapp, J. J. (1975). Some non-monogamous marriage styles and related attitudes and practices of marriage counselors. Family Coordinator, 24, 505–514. McCoy, M. A., Stinson, M. A., Ross, D. B., & Hjelmstad, L. R. (2014). Who’s in our clients’ bed? A case illustration of sex therapy with a polyamorous couple. Journal of Sex & Marital Therapy, doi: 10. 1080/0092623X.2013.864366. Miller, S. A., & Byers, E. S. (2012). Practicing psychologists’ sexual intervention self-efficacy and willingness to treat sexual issues.
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Arch Sex Behav (2014) 43:1031–1034 Archives of Sexual Behavior, 41, 1041–1050. doi:10.1007/s10508011-9877-3. Mu¨ldner-Nieckowski, Ł., Klasa, K., Soban´ski, J. A., Rutkowski, K., & Dembin´ska, E.(2012). Medical students’ sexuality—Development and fulfillment of sexual needs. Psychiatria Polska, 46, 35–49. Page, E. H. (2004). Mental health services experiences of bisexual women and bisexual men: An empirical study. Journal of Bisexuality, 4, 137–160. doi:10.1300/J159v04n01_11. Polyamory. [Def #1] (n.d.). In Oxford dictionaries online. Retrieved from http://www.oxforddictionaries.com. Polygamy. [Def #1] (n.d.). In Oxford dictionaries online. Retrieved from http://www.oxforddictionaries.com. Rubin, A. M., & Adams, J. R. (1986). Outcomes of sexually open marriages. Journal of Sex Research, 22, 311–319. doi:10.1080/00224 498609551311. Therapeutic alliance. [Def #1] (n.d.). In Oxford dictionaries online. Retrieved from http://www.oxforddictionaries.com. Weitzman, G. D. (1999). What psychology professionals should know about polyamory: The lifestyles and mental health concerns of polyamorous individuals. Paper presented at the Eighth Annual Diversity Conference, Albany, NY. Retrieved from http://poly savvy.com/columns/guest-shouldknow/. Weitzman, G. D. (2006). Therapy with clients who are bisexual and polyamorous. Journal of Bisexuality, 6, 137–164. doi:10.1177/136 3460706069963. Weitzman, G. D., Davidson, J., & Phillips, R. A. (2009). What psychology professionals should know about polyamory. Baltimore, MD: National Coalition for Sexual Freedom. Retrieved from http://www.pinktherapy.com/portals/0/CourseResources/ACDKink/ What%20Psychologists%20Should%20Know%20about%20Poly% 20Relationships.pdf. West, C. (1996). Lesbian polyfidelity. San Francisco, CA: Bootlegger.
LETTER TO THE EDITOR
Polyamory: A Call for Increased Mental Health Professional Awareness Nicole Graham
Published online: 22 July 2014 Ó Springer Science+Business Media New York 2014
Polyamory, meaning ‘‘many’’ and ‘‘love,’’ is defined as the philosophy or state of being in love or romantically involved with more than one person at the same time (‘‘Polyamory,’’ n.d.). The term was coined by Morning Glory Ravenheart Zell in 1990; it is often abbreviated as‘‘poly’’by those who practice it (Easton & Hardy, 2009). A polyamorous author expanded the definition to include the practice of theory of having emotionally intimate relationships with more than one person simultaneously, with sex as a permissible expression of the caring feelings, openly and honestly keeping one’s primary partner or partners (or dating partners) informed of the existence of other intimate involvements (Benson, 2008). Others have summarized polyamorous relationships as being characterized by individuals who pursue multiple concurrent romantic relationships with the permission of their partners (McCoy, Stinson, Ross, & Hjelmstad, 2014). While many have provided insight into what polyamory is, it might be best to highlight what polyamory is not for starters. Polyamory is not to be confused with polygamy, the practice or custom of having more than one wife or husband at the same time (‘‘Polygamy,’’ n.d.). Unlike polygamy, polyamory is not illegal and is not grounded in any particular religion. Polyamory is also not a sanctioned form of group sex or even about being promiscuous,as‘‘poly’’individualsmayormaynothavesexualencounters withall oftheirpartners (Easton & Hardy,2009). Polyamory is also not a fad; rather, individuals in polyamorous relationships seem to experience the same longevity (Rubin & Adams, 1986), level of marriage satisfaction, and self-esteem (Buunk, 1980) as those in monogamous couples. Additionally, polyamory is not synonymous
N. Graham (&) Adult Intensive Outpatient Program, Department of Psychiatry, Yale New Haven Hospital, 425 George St., New Haven, CT 06511, USA e-mail: [email protected]
with infidelity; rather, poly individuals are committed to being open about each of the relationships in their lives (McCoy et al., 2014). Lastly, polyamory is also not practiced in one uniform way (McCoy et al., 2014; Weitzman, 2006). Weitzman (1999) noted that there are three common relationship dynamics often seen in the polyamorous community: 1.
2.
3.
An individual has one main or primary partner and one or more other intimate relationships and the different partners do not have any significant relationship with each other. An individual has more than one partner with whom they are in equally intimate relationships and the different partners do not have any significant relationships with each other. The‘‘poly family’’—three or more individuals have intimate relationships with each other that may or may not include sex. If children are involved, this may include sharing of the parental roles.
Scant polyamory research has been published; however, the available data indicate that it is not as rare as once was thought. Weitzman (2006) noted that openly polyamorous families in the United States number more than half a million. A study with 3,574 married couples demonstrated that 15–28 % had an understanding that allowed non-monogamy under some circumstances; this same study showed that the percentages were even higher among cohabitating couples, lesbian couples, and gay male couples (Rubin & Adams, 1986). Additional studies in the lesbian, bisexual, and gay communities also demonstrate the growing number of individuals in polyamorous relationships. Page (2004) tallied 33 % of the lesbian couples in their sample were polyamorous. West (1996) documented that 20–28 % of their lesbian responders were polyamorous and, in a gay male sample by Blumstein and Schwartz (1983) a noteworthy 65 % were polyamorous. These studies, albeit sparse, indicate that polyamory, while still not embraced universally by the general public, has become part of many Americans’ lives.
123
1032
While polyamory is not a psychiatric condition itself, members of the community are not immune to the diseases and disorders that could necessitate a mental health referral. Yet to date, education about polyamory has not made it into standard mental health curricula (Weitzman, Davidson, & Phillips, 2009). Research exploring the efficacy and confidence of providers in addressing sexual issues or disorders indicates that a lack of exposure to and comfort with variations in sexuality is correlated with poor treatment efficacy; this has been demonstrated with medical students (Mu¨ldner-Nieckowski, Klasa, Soban´ski, Rutkowski, & Dembin´ska, 2012) and with practicing psychologists (Miller & Byers, 2012). A study by Knapp (1975) had alarming results that indicated that a third of therapists in the sample thought people in open relationships had some type of personality disorder or neurotic tendency and that almost 20 % of this same sample would try to unduly influence a return to a monogamous lifestyle. It is apparent that a lack of awareness of and appreciation for non-traditional relationship patterns can have deleterious effects, including but not limited to a lack of objectivity, inadvertent criticism and potential pathologization of individuals, damaged therapeutic alliances, resultant treatment non-adherence, and potentially poorer patient outcomes.
Case Report The patient is a 21-year-old female student with a history of depression and anxiety who presented with recurrent suicidal thoughts and recent engagement in self-cutting behaviors in the context of increasing academic demands, treatment non-adherence, relative social isolation, and a recent move from out of state. She reported worsening depression marked by thoughts of self-harm and recent self-cutting behaviors with an onset of 2 months prior following her decision to discontinue treatment secondary to ‘‘she [her psychiatrist] blamed all my issues on polyamory.’’The patient reported cutting over her left clavicle as recent as 2 weeks prior and fleeting thoughts of‘‘giving up’’due to the stress related to her recent move, the increased academic rigor of her new school, and her inability to make friends at school despite efforts to do so. She reported that her only local social supports were members of the polyamorous community. Her psychiatric history included depressive episodes marked by discrete episodes of low mood, suicidal thoughts, self-injury, and neurovegetative symptoms (i.e., low energy, poor concentration, reduced appetite, daytime fatigue, and feelings of being slowed down) starting in her teenage years with the most recent episode beginning 2 months prior and a history of anxiety marked by a needle phobia, apprehension and discomfort with novel situations, and, at times, people and classic panic attacks. She denied any history of manic symptoms, psychosis, other anxiety disorders, eating disorders, any attention or hyperactivity issues, substance use disorders or disruptive behavioral disorders.
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Arch Sex Behav (2014) 43:1031–1034
Her psychiatric treatment history included counseling at age 6 due to her teachers thinking she was‘‘disturbed’’based on ‘‘morbid drawings,’’ a history of pharmacologic management by her internist back home, and recent referral to a psychiatrist who the patient felt had unfairly judged her‘‘poly lifestyle.’’ The patient reported that this provider had recommended she stop her multiple relationships because they were‘‘likely the source of her problems’’and the cause of her current depression. The patient’s current medications included Citalopram 20 mg daily and Alprazolam 0.25 mg every 8 h as needed for panic that the patient reported taking 3–4 times per week. There was no history of inpatient psychiatric treatment or substance abuse treatment. There was no history of past suicide attempts, but the patient did report a history of suicidal thoughts without a specific plan or intent and a history of cutting her wrists and clavicle starting in her teenage years with her most recent episode 2 weeks ago. Past psychotropic medication trials included Fluoxetine and Escitalopram, both of which worked well but were stopped secondary to‘‘They decreased my orgasm.’’ Her medical history was significant for asthma and seasonal allergies. There was no history of head injuries, seizures, or loss of consciousness. There were not any known drug allergies. The patient’s family history was significant for a mother with depression, anxiety, and addictions to pain pills and alcohol and a father she described as‘‘a psychopath in denial’’ with compulsive hoarding and at least two suicidal gestures versus attempts via intentional insulin overdose. Her social history was significant for current college enrollment with a recent transfer while in good standing, residing in an apartment with her pets, being raised in a household of four, including a mother, father, and older brother none of which she is particularly close with, and identifying as agnostic. The patient hadhadfewclosefriendshipsinherlife;themajorityofthemwere platonic male friends. She reported her current social supports as including members of the local polyamorous community. Her sexual history was significant for identifying as bisexual and polyamorous. The patient reported having learned about sex during middle childhood from same age peers and reported having engaged in touching and consensual sexual play with peers. She did not reportanysignificant religiousinfluencesin herknowledge or attitude towards sex. The patient reported sexual attraction to both men and women. She reported a total of 10 sexual partners, including 7 men and 3 women. She reported three past relationships, one of which was with a woman. Her first sexual experience was at age 14 with her then girlfriend; her first penetrative intercourse was at age 17 with her then boyfriend. She reported a current weekly sexual output of four with one to two being with a partner and the rest in masturbation. She reported engaging in safe sex practices and reported recent negative STI testing. The patient reported being in a‘‘poly’’relationship with her boyfriend back home for the past 3 years, having met a local male partner via an internet polyamory website and actively
Arch Sex Behav (2014) 43:1031–1034
looking for a polyamorous female partner. With her primary relationship long distance, the patient reported feeling somewhat socially isolated due to her inability to make friends at school; she reported that engagement in several polyamorous activities was her ‘‘only social outlet.’’ After feeling judged by the therapist, the patient reported pulling away from the polyamorous community slightly, spending more and more time alone and noting a decline in her mood and zest for life. While the patient acknowledged that treatment nonadherence likely contributed to her decline, she felt that avoiding the polyamory community and those few friends was detrimental to her overall mental well-being. On mental status examination, the patient appeared her stated age, exhibited adequate grooming, and did not have any visible skin lacerations. She was dressed in loose fitting clothing with multiple ear and facial piercings, two necklaces, and numerous bracelets donning her wrists. The patient was alert with good eye contact and free of abnormal body movements. Her speech was spontaneous and normal in rate, rhythm, volume, and tone. Her mood was ‘‘better than before’’ and her affect was mildly constricted. She denied any current thoughts, plans, or intent for self or other harm. Her thought process was linear and goal directed; the content was devoid of delusions (false beliefs) and she reported no perceptual disturbances (to include no hallucinations). She denied current suicidal or homicidal thoughts, plans or intent. Insight and judgment were adequate. Cognition and memory were grossly intact. After the initial assessment, the patient expressed willingness to restart psychotropic medication and was titrated up on an antidepressant alone; she refused, however, to have her prior provider contacted as ‘‘there is nothing she can add.’’ She additionally agreed to a course of supportive psychotherapy and was surprisingly candid about her sexual history and relationship preferences. Early on, she discussed her decision to withdraw from the polyamory community, as a result of her encounter with the therapist; while upset, she wondered if this provider was right. The patient recounted how putting distance between herself and the‘‘poly’’community had made her feel more isolated and alone. While still able to abstain from suicidal gestures or attempts, she recalled several episodes of suicidal ideation with urges for self-harm. In therapy, the patient was able to advocate for herself and how the polyamory community allowed her to feel connected and‘‘included.’’ Following a re-introduction to the ‘‘poly’’ community, the patient was able to find a third partner, who she described as ‘‘She’s someone I can be myself with.’’The patient reported that this third partner, in addition to her two male partners, were great supports for her during the depressions and whenever she felt like engaging in self-harm. On further prompting, the patient elaborated in saying that her partners were most helpful in allowing her to use‘‘creative ways’’to abstain from self-harm. She described how such sexual freedom allowed her to turn her mental turmoil into pleasure through fantasy, role play, and erotic talk. During
1033
one session, she detailed how she and the local male partner had used theatrical props and role played cutting behaviors during foreplay. She also reported how it was typical for her and her long-term, long-distance boyfriend to incorporate her urges into their erotic conversations. The patient reported finding these experiences as ‘‘good replacements’’ for her self-injury during distress, as well as during times for pleasure. The patient was seen in our clinic for another 6 months until the conclusion of the spring semester, at which point she returned home for the summer and was referred to a local provider. For the duration of the treatment in this clinic, the patient was adherent with her medication and appointments; she was even able to abstain from engaging in cutting behaviors with infrequent suicidal ideation. She attributed her improvement to reengagement with the polyamory community (including her new female partner), treatment adherence (medication and therapy), and this ‘‘creative’’ transference of distress that she felt ‘‘enhanced her experiences.’’
Discussion In this case, the patient reported feeling judged and misunderstood by her prior mental health provider; she felt that her therapist was dismissive of the importance of her chosen relationships and inappropriately attributed the majority of her depressive symptoms to the polyamory lifestyle. In addition to feeling misunderstood, the patient reported not feeling comfortable discussing the more intimate details of her relationships and ultimately stopped coming to treatment. The therapeutic alliance, the relationship between a psychologist or psychotherapist and a patient (‘‘Therapeutic alliance,’’ 2013), is paramount in successful psychotherapy. A strong alliance is thought to include the communication, expression of caring, and the agreement on the goals and methods with which to achieve those goals. Research suggests that a positive alliance is associated with a more positive therapeutic outcome; likewise, a negative therapeutic alliance can result in a less desirable outcome (Goldfried, 2013). If a provider is not aware of, comfortable with, and sensitive in their handling of variations of sexual and relationship practices, it can be almost impossible to achieve common goals and a sound alliance. Thus, for optimal therapeutic outcomes, mental health professions need tobetrainedinandbecometolerantoftheseincreasinglycommon relationship patterns. Failure to do so could result in a poor therapeutic alliance, treatment non-adherence, failure to appreciate the role such relationships play in the patient’s stability or wellbeing, and subsequent poor patient outcomes. Polyamory, more than one intimate relationship at a time, is becomingamorecommon relationship pattern within theUnited States. Unfortunately, most standard mental health curricula do not cover polyamory in any depth. A lack of appreciation for polyamory and other non-traditional relationship patterns could
123
1034
result in a damaged therapeutic alliance; such damage has been shown to negatively impact patient outcomes. The case presented highlights the deleterious impact such ignorance can have on patient care. Therefore, all mental health professionals need to become familiar with polyamory and other non-traditional relationship practices in order to provide the best possible treatment to our patients.
References Benson, P. J. (2008). Polyamory handbook. Bloomington, IN: Author House. Blumstein, P., & Schwartz, P. (1983). American couples: Money, work, sex. New York: William Morrow and Company. Buunk, B. (1980). Extramarital sex in the Netherlands. Alternative Lifestyles, 3, 11–39. doi:10.1007/BF01083027. Easton, D., & Hardy, J. W. (2009). The ethical slut: A practical guide to polyamory, open relationships and other adventures. New York: Celestial Arts. Goldfried, M. R. (2013). What should we expect from psychotherapy? Clinical Psychology Review, 33, 862–869. doi:10.1016/j.cpr.2012. 09.006. Knapp, J. J. (1975). Some non-monogamous marriage styles and related attitudes and practices of marriage counselors. Family Coordinator, 24, 505–514. McCoy, M. A., Stinson, M. A., Ross, D. B., & Hjelmstad, L. R. (2014). Who’s in our clients’ bed? A case illustration of sex therapy with a polyamorous couple. Journal of Sex & Marital Therapy, doi: 10. 1080/0092623X.2013.864366. Miller, S. A., & Byers, E. S. (2012). Practicing psychologists’ sexual intervention self-efficacy and willingness to treat sexual issues.
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