No Face Pic = No Chat

I cruise the hook-up apps just like most gay men that have smart phones. A comment I see in profiles a lot is something along the lines of “no face pic = no chat.” It is a sentiment that I can understand. In fact it is a sentiment I kind of share. I like to visualize what a guy that I am chatting with looks like. I think it makes it more like real time. It’s also nice to think the person I am chatting with is not dealing with shame. I am too out to try to be closeted when in public with someone.

However, I also recognize that despite the progress we have made in society there are still many proud people who do not feel comfortable being quite so public. In fact I have often thought about obscuring my identity on social media as well because of my professional position. It can be disturbing for clients to know too much about my personal life—it can be distracting from the work we are doing or they can find out something they don’t like but is irrelevant to the professional work we are doing. I know that some clients have seen me naked or seen pictures of me naked—just as I have stumbled onto naked pictures of my clients on occasion—and this is something that ideally I would not like to have as part of our relationship, but being open is a decision I personally have made.

One of the comments I have seen deriding the absence of a face pic referenced the age of Don’t Ask, Don’t Tell being over. I have a client who is an officer in the military reserves. We talked about what it might mean for him to add to his Facebook profile that he is in a relationship with another guy after Don’t Ask, Don’t Tell was overturned. He acknowledged that he thought it was great that he could not be kicked out for being found out anymore, but expressed sincere concern that he would not receive another promotion in his career if his superiors found out that he is gay. One’s career in the military is not secure just because of a change in policy, it will take a while before there is a change in attitude up the ranks.

There are also many conservative professions in which having that much exposure could be occupationally damaging. Here in Houston, the economy is dominated by oil & gas, the medical industry, and shipping. All three of these industries are notoriously conservative.  Some of the energy companies have excellent non-discrimination policies. However, I think that by now we also know that not all of management abides by the spirit of non-discrimination policies. Similarly, we think of the medical field as well educated (and equate this with liberalism), but the medical industry (like the mental health industry) have a long history of keeping one’s private life private. The majority of the gay doctors I have talked to do not put their face on their profiles because they have to deal with both a broad political spectrum of patients and a politically conservative work environment. I don’t think there is any confusion about how liberal or conservative the shipping industry is.

The counter argument I hear a lot in my defending the faceless is that only other gay people are looking at the apps, so what would be the concern? This has been the argument about why it is safe to go to the gay bar for years—only other gay people will see you there. Today, neither of those arguments is quite true. I see straight people at my bar almost every time I go, and I go to one of the least straight-friendly bars in the city. But the apps are even more vulnerable to exposure outside of the community. How many gay guys are showing profiles to gal pals non-gay friends because the guy is particularly hot or the profile is particularly amusing? Okay, now what if the friend shown the app is a co-worker of the person whose profile was just shown? Sure, the friend is probably open-minded, but nonetheless the person on the app was just outed at work without control of that information—and without consideration of the possible consequences.

Everyone needs to decide what they want in a potential partner or trick on the apps, but I do wish that people would respect that not everyone is free of consequences of being out. The majority of states—including Texas—do not have non-discrimination clauses and many employers are still willing to punish, terminate, or limit gay employees. And besides, the next time you ignore the faceless guy on the apps, you just might be missing out on that doctor you mother wanted you to marry.

Excited and Angry

Two things of note happened in my life recently related my identity as a gay man, and as a mental health professional. President Obama publicly announced his support for same-sex marriage and in the same week a former client committed suicide because his family could not accept his sexual orientation. This is a rough juxtaposition for me.

Part of me wants to celebrate President Obama’s announcement. I want to share in the joy of this gesture. I see it as a symbolic action in that as President he has little official power to effect change in state marriage laws. I see that it has importance nonetheless, in that it will inevitably affect public opinion and has the potential to set same-sex marriage rights as an official party policy. I recognize that progress will only be made incrementally and often symbolic gestures can turn a real world, practical tide, which is what I hope happens in this case.

However, I am reminded on a weekly basis in my office, by the people that sit on my couch that as a people, GLBTs are far from being accepted. Many of us living our insulated lives—frequently among our liberal friends—are unaware of the daily oppression that has gone on or continues to go on.  Most of us have not been directly affected by the oppression. I have been an out gay man for just over 25 years; in that time I have been threatened with physical harm or even death a half dozen times—sometimes anonymously, sometimes from a person standing right in front of me—and I have had my apartment door vandalized  in grad school (see picture).

In those 25 years I have also seen sodomy legalized, DADT overturned, and same-sex marriage begin to be legalized. I have seen numerous openly gay or lesbian politicians be elected. I have seen numerous states pass non-discrimination laws. I have seen a President specifically address a GLBT audience, appoint openly gay and lesbians to sub-cabinet positions and ambassadorships, and invite GBLT individuals to state dinners. The amount of progress I have seen is sometimes enough to make my head spin.

We have made tremendous progress in the last 25 years. But there is a sentiment that (suddenly?) everyone can be out and open with reprisal. I see this sentiment on the online hook-up apps all of the time because the person himself feels safe without consideration for what consequences may result from another’s different consequences (demands that people have a face picture in their profiles without any consideration as to the workplace or family consequences involved in being exposed). There is a sense that since we live in a liberal city which elected an openly lesbian mayor we are safe. All of the threats and attacks that I experienced also occurred in exceptionally liberal cities.

The day that President Obama made his announcement there were protests all over the country planned in response to the vote the previous day in North Carolina to ban same-sex marriage. The majority of the protests were immediately converted into celebrations. I agree that having a sitting President express support for our equality is a momentous occasion as well. But I also was a little frustrated that it diffused our anger. It is our anger that fuels us toward continued progress, not celebration. Stopping to celebrate our progress is essential in maintaining hope and I fully support it. However, I also fear that we will become complacent with the crumbs of acceptance.

I am reminded of how far we still have to go about every week by my clients. I also am aware of the (indirect) effect of the barrage of stories of oppression—bullying and ministers, as of late—has on the psyche; it is not healthy to be continually reminded that people hate us. How many times a week are you exposed to homophobia by reading the news? I hope that we still get angry, but do not stay angry, but I also hope we do not stay joyous yet. I hope that we are able to appreciate the progress with one eye, while simultaneously recognizing the immense progress still to made with the other.

Therapy Does Not Equal Rent a Friend

“I don’t need therapy, I have friends”

This is a sentiment that is frequently expressed.  However, this is not the reality that I generally see among my clients. While it is true that I often perceive that my clients could strengthen their social support networks, they do not come to therapy to share their mundane problems—that is what social support systems are for. Rather, they come to me with enduring or intense problems that they feel for which their support systems are inadequate.

A concern that I often hear from clients is that they do not want to overburden their support systems. I think most of do not like friends that are constantly complaining—most of us also do not like to be the friend that is constantly complaining. We do not want to be perceived as an embodiment of our problem, but to be seen for the multidimensionality that we are. As a consequence, we often withhold some of the pain we are experiencing from our friends in order to appear to be “bigger” or more than the pain. We want out friendships to be a balance of support and entertainment-companionship.

When a problem is enduring and personal it is difficult to constantly have ‘the problem” as the context in which one interacts with friends. Friends are often well meaning in asking about a problem, but rather unprepared to deal with the full brunt of the problem. They also do not understand that by asking about a problem, while they intend to be supportive and are genuinely interested and concerned, they actually help keep the problem in the forefront of the person’s mind. Sometimes we want our friends to offer us support as a “time out” from the problem.

Friends also lack the ability to be objective. Friends have insight that a therapist never will, however, they also have their own filters as well. Friends are also are rarely free of their own agenda. When a therapist develops an agenda for a client it is grounded in an understanding of the client’s best interest. While I genuinely care about the happiness of my clients, at the end of the day my life will largely be unaffected by the outcome of a client’s decisions. Friends are frequently affected by friend’s decisions, and are aware of this. Therapists are able to be outside, independent observer in a way that friends can never be. Friends also recognize that by being too challenging of their friends they can endanger the friendship. As a therapist I get more liberties to challenge people about their problems and call “bullshit” when I see it.

Sometimes clients come to me because they do not feel safe talking to their friends about their problems. If the problem is about a friend and one is not sure how to address it or is uncertain about the problem in some way, then talking to the friend about the problem is not likely to feel comfortable. There are also things that we would rather not have our friends know about us. While I am not a big fan of secrecy, it is a reality of many people’s lives—as is privacy. Sometimes there are things that we would like to better understand before we are ready to share with friends—or even know how to share with friends. One of the reasons people come to therapists is because we are trained to deal with the heavy shit—questioning the existence of god/good/evil, feeling life is meaningless, questioning one’s gender/sexual orientation, figuring out what roles one actually wants in society—these are not questions that most friends are prepared to deal with and can only give pat advice.

Friends also are not trained in theories of personality, human development, symptom identification and treatment, and processes of human change. Therapists are. Listening to problems and being supportive is an incredibly important role of friendship. But listening to problems and being supportive is not facilitating change or personal growth, actually it often facilitates the status quo. Therapy often provide and educational or normalizing role that friendship cannot—either the friends do not have the knowledge or they will be trusted as unbiased.

I cannot overemphasize the importance of a social support system. In fact it helps feel keep us stable and from sinking into poor mental health. But friends cannot offer the same professional guidance and exploration (not advice) that therapists provide.

Labels (Part 2)

I recently wrote about why I think labels can be useful, even though there is a mantra against labeling people. The double edged sword of labeling people is that they promote expectations, but this can be both problematic and beneficial. Names for relationship status is another area where I hear an avoidance of labels. I hear less encouragement of avoiding labels of relationships, but no less frequency of it; “it’s complicated” is one the ways that people frequently avoid labeling a relationship these days.

I have friends that are dating, and apparently in a monogamous relationship, only they are afraid to label their relationship as “dating” or refer to each other as “boyfriends.” They are sexually exclusive with each other and have romantic feelings for each other but do not dare label their relationship as “boyfriends.” I do not know what they think is the risk of labeling what is going on between them, but it feels risky to them.

It seems that they think that by not labeling it a relationship—they are roommates—they do not risk being emotionally hurt. However, I think they actually create greater risk by not labeling their relationship. Labeling a relationship does mark certain expectations, or can clarify expectations. But in this case, the absence of the label does not mean the absence of the expectations. If either of them were to have sex or go on a date with someone else they would very hurt—as much hurt as if they had labeled the relationship. Only without the label, the expectation is not made explicit.

Both of these guys are sexy guys and this is where the label would be useful for others. If they labeled themselves as being in a relationship it would give the rest of us a better sense of how to treat them—namely as a couple. Until I figured out that they were dating (unbeknownst to themselves) I would hit on each of them, now I know to back off. I still do not know when I am expected to invite them both to things or just one of them—with couples I default to inviting both, but with roommates I am more inclined to invite one or the other to something, based on what the event is.

Of course the flip side is that labels sometimes do not help in clarifying some things and can even cause more confusion because we have limited expectations for labels. Relationships come in many forms. But they can at least inform us as to what questions to ask. If someone is in a relationship I can inquire about the nature and boundaries of the relationship, but without a label we are more likely to step on toes without realizing it. Even when I encounter an open relationship I attempt to clarify the parameters of the openness of their relationship. So the label cannot tell one all of the nuances of the relationship, but it provides a framework in which to work.

There may be a shortage of terminology to describe the full range of relationship types—the term “monogamy” does not well apply to a triad relationship in which the three members are exclusive to each other, but neither does the term “open” apply well. Similarly, an open relationship in which the members of the relationship only play with outsiders separately is different than a couple that only plays with others together, but “open” is still the only term we have for either relationship style. However, “open” provides a framework for either style.

Expectations are essential to relationships—they are part of what defines them in fact. The label is not what defines the relationship—the expectations exist (perhaps unspoken) without the label—but the label helps others know how to best interact with the members of the relationship. Unfortunately, the feelings and expectations are there regardless of the label. The label also provides clearer guidance as to how to act for the members within the relationship—including what inquiries to make about how to act.

Labels (Part 1)

Many educated people often talk of the wisdom of avoiding labeling people and or interpersonal dynamics. To a certain degree I can agree. I agree that sometimes labels reduce us to objects within a category, rather than the individuals that we are. However the opposition to labels also misses the utility of labels. Labels allow us to form cognitive shortcuts and form expectations.

 Many of the labels that we use in fact are problematic specifically in the ways in which they act as cognitive shortcuts and framing expectations.  But the use of the label is not so much the problem as the rigidity to which we stick to the expectations or associations of that label. Take the labels “gay or “straight,” for example. Both of these labels are laden with expectations and associations, which often on whole are true for the majority (if not all) of the people that would fit the label. A liberal interpretation of the label would allow for a man labeled as “straight” to enjoy shopping or watching Glee more than watching sports and for a gay man to enjoy working on his car or hunting more than Project Runway or RuPaul’s Drag Race, as well for the more stereotypical reverse.

 

However, knowing that a man is “gay” or “straight” also informs me of the likelihood that he will know certain people or places that are frequented by other people labeled “gay.” Most “straight” people in Houston are not familiar with the Ripcord or BRB, but most “gay” people are. Perhaps most importantly, I know how safe or appropriate it is to hit on someone who has labeled himself “gay” or “straight.”

 

Of course, again there is the problem that while most people can in fact be neatly sorted into categories, others are poor fits for any of the existing categories that we have.  I have a client who would less identify as “gay” or “straight,” as he does “submissive;” the striving force of his sexual arousal is grounded in the dominant nature of a partner, rather than the partner’s gender. This client shies away from identifying as “bisexual” because “bisexual’ tends to be interpreted as attracted to both males and females, but this terms side-steps the notion that a partner’s gender is irrelevant, but rather it is the nature of the person—regardless of gender—that attracts him. I know other people who are honestly attracted to males and females and for whom gender is actually part of the attraction—“bisexual’ applies aptly for these clients.

 

Labels also give us a sense of belonging. Race or ethnicity is another area in which there is resistance to labeling. Race and ethnicity are, like sexual orientation, false categories that are socially constructed and do not reflect the diversity of people. However, through such labeling one has a sense of belonging, of having a kin-group.  According to Abraham Maslow, Belongingness is one of our basic needs and is foundational to our forming a positive sense of self. Acceptance, a form of belongingness, is essential to healthy self-esteem. Humans are naturally (it seems) suspicious of out-group members and more willing to support in-group members, and so labeling ourselves helps provide us with sources of support as well

 

So labels simultaneously allow us some expectations and associations (which we ought to confirm for each individual occurrence of a label in order to avoid too rigid of interpretation of the label), and fail to capture the full range and nuanced differences among people.  They also help give us a sense of how to behave and toward and around others. Similarly, they help us can give us a sense of community and promote mental health. Rejecting labels altogether because they do not work perfectly seems equally unwise as interpreting labels too rigidly.

Choosing a 100% Chance of Being Miserable

There are a couple of things which clients have said to me over the years that really stuck. The first one is from my very first client in training as a graduate student; the other was in the early days of my private practice. Both statements continue to resonate for me because they symbolize a recurring issue that I see in counseling, namely a refusal to leave a bad relationship after recognizing it is a bad relationship.

My first client was a volunteer from a psychology class for trainees to practice on; many of them did not think that they had problems that warranted counseling. She described to me the discomfort and difficulties she was having in her relationship, how her boyfriend would say mean things and go out with friends and “force” her to stay home, and how he had broken the windshield of her car. When I asked why she was still in a relationship that was so distressing she responded “It doesn’t hurt enough yet.”

She was able to recognize that being in the relationship “hurt,” but did not see that as a good “enough” reason to leave the relationship ”yet.” As this was my very first session with my very first client, I did not feel that I had the rapport with her to ask “how much does it have to hurt before it is okay to leave?” or challenge her on the notion that there needs to be some sort of threshold for pain at all in order to leave an emotionally abusive relationship. Note that there was no hope or expectation that this relationship was going to get better. In fact there appeared to be an expectation that the relationship would get worse. I kind of presume that she was waiting for the abuse to become physical—because breaking her windshield was not violent enough yet.

This was the basic sentiment expressed by the second client that left such an impression on me. He came to me to better deal with a relationship in which he was very unhappy. He relayed that they had been together about three years and how the relationship was unsatisfying in a variety of ways and how his boyfriend showed no signs of (or interest in) changing his behavior. The client described his boyfriend as a nice guy, but who did not want to do anything except stay home and watch TV; they had also stopped having sex. The client was clearly frustrated and did not know what to do, and then he said the words that continue to echo for me: “I wish he would just hit me.”

He went on to explain to me that he did not want to look like “the bad guy” in a break-up. Apparently, being miserable in a relationship is preferable to being “the bad guy” in a break-up. Furthermore, being miserable enough to want one’s partner to him/her is not itself a good enough reason to leave a bad relationship.

I think these clients emphasize the idea that we consider what might happen more than what is happening. I think there is this fear that something bad (e.g., loneliness, rejection, or loss of reputation) might follow a break-up. This really speaks to the importance of our desiring acceptance and belongingness—a willingness to endure being miserable over risking not being accepted by another. However, I would argue that being miserable in a relationship is a sign that the “acceptance” within the relationship is false and unsatisfying in its own right. After all, one does not have to be alone to feel lonely or rejected.

I do not mean to suggest that everyone should quit their relationships when things get tough. However, examining one’s relationship with regard to the amount of satisfaction-dissatisfaction in the relationship and the realistic hope that things will change (what reason are there to expect that things will—not just can—change?) is important in actually getting one’s belongingness and acceptance needs met. Within a bad relationship one can be 100% certain those needs will not be satisfactorily met. After a break-up there is at least an opportunity that one can get them met—in fact ending a bad relationship increases, not decreases, one’s odds of getting the positive attention one is afraid of not getting.

Psychotherapy vs. Psychopharmacology

Many patients seek medication for emotional discomfort, difficulty concentration, sleep disturbance, and somatic or physical manifestations of emotional discomfort. There is a tendency in our culture to treat illness with a pill—which drives this inclination, along with the continued stigma of being labeled with a mental illness—despite that so many people are on anti-depressants and anti-anxiety medications that their use is now “normal” to most people. Somehow being medicated for an emotional disturbance is not as stigmatizing as being in therapy for one. Additionally, there is a perspective that taking pills is easier (and cheaper) than seeking psychotherapy treatment. However, research on the effectiveness of psychotropic medication and psychotherapy show that many of these patients are doing themselves a disservice in this approach.

Overall, in early research the effectiveness of treatment of emotional disturbance (such as anxiety or depression) was shown to be roughly equal between psychotropic medication alone and psychotherapy alone for most common mental disorders. While there is a fair amount of research that has shown that combined therapy (medicine and talk therapy) is the most effective, more recent research has been suggesting that psychotherapy alone is as effective as combined therapy in the long run. Similarly, more recent research (focusing on long-term effectiveness, rather than immediate effectiveness) has shown that psychotherapy is more effective than medication with regard to long-term benefits. It turns out psychotherapy is advantageous compared to medicine in a number of ways.

Cumulatively, the research suggests that psychotherapy offers more long lasting benefits than medicine. Psychotherapy is actually shorter term. Even if one is in therapy for a number of years, people who begin antidepressants and anti-anxiety medication (without the additional benefit of psychotherapy) frequently end up on those medications for life—on account of the high relapse rates for medication alone. Ironically, studies have shown that across a lifetime, the cost of medication tends to exceed the cost of psychotherapy. Psychotherapy tends to be higher initial cost, but typically clients achieve a level of functioning that makes treatment unnecessary and the cost stops.

Psychotherapy additionally is safer. There are many dangerous drug interactions between psychotropic medicines and other medicines, while psychotherapy does not interact chemically with any medicines. Psychotherapy has few side effects—some initial increased emotional discomfort is common, but loss of sexual performance due to psychotherapy is extremely rare, for example. Likewise, sleeping disruption seems to be temporary and psychotherapy is not associated with unwanted weight gain—psychopharmacology cannot make those claims.

Ideal treatment for many emotional disturbances appears to be co-joint treatment with medication and therapy initially, with patients gradually reducing and terminating their medication as progress in psychotherapy provides symptom relief such that symptoms become tolerable in the absence of medication. However, there are some disorders, such as schizophrenia, ADHD, bipolar disorder, and dysthymia (chronic depression), for which psychotherapy is not as effective medicine. But even in these cases, there is also strong evidence that psychotherapy administered along with psychopharmacology is more effective than medication alone in treating these more severe mental disorders.
Of course, the downside is that psychotherapy is more work and requires actually looking at one’s pain (and sometimes the source of it), rather than covering it over. Psychotherapy functions with a goal of symptom removal, whereas medication frequently has the effect of symptom mediation. Of course, harder work also equals more meaningful reward though.