Ericksonian hypnotherapy

Dr. Milton Erickson was one of the giants of psychotherapy, as evidenced by the fact that the largest convocation  of psychotherapists in the world, the Evolution of Psychotherapy conferences (held every four years), are organized by the Milton Erickson Foundation. He has been called the father of modern hypnosis. He not only developed a powerful alternative to traditional hypnosis, but introduced a new model of solution-focused brief psychotherapy.

I explained traditional hypnosis in a previous post. Ericksonian hypnotherapy was something new. Whereas traditional hypnotic inductions are characterized by commands and direct suggestions, implying that the therapist wields some kind of power over the “subject,” Ericksonian inductions use indirect suggestion, metaphors, and storytelling to induce trance states, circumventing client resistance to complying with the imperative voice. (You should, you will, etc.) Trance-inducing suggestions like “Your eyelids are getting very heavy and you want to close your eyes” were replaced by indirect suggestions such as “As you relax, you may find that you want to close your eyes.” Instead of hypnotic prescriptions for a person in trance, an Ericksonian hypnotherapist might say such things as “… and as you practice self-hypnosis, you may find that it’s easier for you to ________ .” Erickson also developed non-verbal methods for inducing trances.

Erickson’s life story is remarkable. Long story short, he was stricken with polio at age 17. Told that he would never walk, he taught himself to walk again. Told that he was too disabled to work, he went to medical school  and became a psychiatrist, and later a psychologist. He trained himself to be acutely aware of changes in peoples’ posture, respiration, vocalizations, skin tone (blanching or flushing) and pupillary dilation. He learned to “read people” and their immediate responses to his therapeutic interventions, adjusting his techniques to the unique individual and situation.

Erickson recognized that trances occur naturally every day in all of our lives. (There are many kinds of trance states, including confusion, daydreaming, rumination and jealousy.) He learned to induce them in non-traditional ways and to utilize the power of the subconscious mind to focus on solutions to the presenting problem that brought the person to therapy. He could induce a trance with a handshake or a story. Sometimes he used a confusion technique, framing his words with a deliberate complexity that caused confusion. This put the listener off-guard and receptive to suggestions aimed at the subconscious. The immediate results of some of his interventions would appear miraculous to someone unaware of the techniques being employed.

A well-told story can put listeners in a trance. Erickson was a master storyteller, as well as a master at crafting strategic metaphors that were aimed at the subconscious mind, pointing toward solutions. His verbal presentations – whether in conversation or telling a story – were often layered, talking about one thing on the surface, but using metaphors designed to become embedded at the subconscious level. Sometimes he’d prescribe specific activities related to the metaphors he employed, to amplify the embedding.

An example of this is a case history I remember reading, about a client who was an alcoholic. Erickson first asked questions until he felt he had a good understanding of the client’s life situation and his history of problem drinking. Then he gave a rambling discourse about cacti. “There are many varieties of cacti, but they all have one thing in common. They hardly ever need rain, because they have an amazing capacity to retain all the moisture they need. It’s like they’re never thirsty.” Having planted a strategic metaphor about thirst and resiliency, he then directed his client to take a hike on a specific nearby hiking trail (Erickson lived in Phoenix) the next day and study all of the different kinds of cacti. As I recall the case history, the client got and stayed sober after this strategic intervention. There are many such documented stories of Erickson’s successful brief therapies.

In his later life Erickson suffered from post-polio syndrome and lived with daily, severe pain, which he controlled using self-hypnosis. He knew first-hand how to harness the amazing powers of the subconscious mind, and taught many others how to do this. He frequently taught his clients self-hypnosis, for pain control as well a for anxiety and other psychopathologies. He was the founding president of the American Society for Clinical Hypnosis, and had a major influence on brief therapy, strategic therapy, family systems therapy, and Neuro-Linguistic Programming (NLP).

Albert Ellis

In my post “The Gloria Sessions” I wrote about a three-part video series titled “Three Approaches to Psychotherapy”  in which a brave young single mother named Gloria had brief therapy sessions with three of the twentieth century’s giants of psychotherapy. The three therapists were Dr. Carl Rogers (client centered therapy), Dr. Fritz Perls (gestalt therapy), and Dr. Albert Ellis (rational therapy). Little did I know  when I saw the series in grad school that I would actually meet two of these luminaries. I’ve already described my encounter with Carl Rogers. I’ll conclude this post with an account of my brief exchange with Albert Ellis.

Ellis is best known as the creator of Rational Emotive Behavior Therapy (REBT), and is widely considered one of the most influential psychotherapists since Freud. I first came across his work as a teenager, when I read his 1958 book Sex Without Guilt, which made the case that guilt about responsible sexual behavior is irrational. This was my first introduction to rational thinking, which made a lot of sense to me. However, parts of the book were (in retrospect) just his claptrap notions, like his theory of homosexuality – which was still considered a mental illness back then. He corrected his errors in later editions of the book.

Ellis was a foundational pioneer of what is now known as cognitive behavioral therapy (CBT), and I consider his A New Guide to Rational Living to be his single most important book. (He wrote or co-authored more than eighty books and many academic papers.) When I watched him in “Three Approaches to Psychotherapy,” I didn’t like his therapeutic style. He was the opposite of sensitive, gentle, avuncular Carl Rogers; he was a fast-talking, abrasive New Yorker, who seemed impatient in his dealings with Gloria. But I couldn’t argue with his logic, and Gloria seemed to get something from the session.

Although behavioral therapies weren’t popular in my humanistic Masters program, I started learning and practicing rational thinking in the eighties, and began teaching it in my clinical practice. Being a rational thinker has spared me a lot of unnecessary pain, and I’ve been known to say that if I had a Gospel to preach as a therapist, it was the Gospel of Rational Thinking. REBT focuses on the rational analysis of irrational and self-defeating beliefs and behaviors. Ellis continued to write and lecture and do therapy until shortly before his death in 2007, at the age of 93. He has been charitably described as having a “provocative personality.” I was in the audience for several of his presentations at Evolution of Psychotherapy conferences over the years, and witnessed his provocative style first-hand.

For one thing, his presentations were laced with profanity, and his response to any objections about his language was usually  along the lines of “F _ _ _ you!” If you didn’t like the words he chose, that was your problem. He was still the abrasive stereotypical New Yorker I’d first seen on videotape in grad school; but I’d come to appreciate his personality and his delivery, as well as his contributions to psychotherapy. He made the point in his public speaking that it’s what you say that  matters, not so much how you say it. In his own way he echoed Fritz Perls’ idea, “I am not in this world to live up to your expectations and you are not in this world to live up to mine.”

At an Evolution of Psychotherapy conference I happened to find myself on the same elevator as Dr. Ellis and his small entourage. Seizing on the opportunity, I asked him, “Dr. Ellis, didn’t you write a book titled Sex Without Guilt?” “Yes I did. Did you read it?”  “Yes I did.” “Did it help you?” “I’ve read several of your books and I think I’m a better man for it.” Dr. Ellis grinned at me and said, “I’ll bet you’re a sexier  man for having read Sex Without Guilt, too!”

I don’t know about that, but I do know that Ellis’ influence made me a better therapist. He enhanced my ability to reach some clients, helping them to understand that they didn’t need to feel guilty about being a sexual person, with sexual feelings and needs.

High anxiety

A certain amount of anxiety is normal and inevitable in every life. It ranges from free-floating anxiety – unattached to specific issues or situations – and performance or situational anxiety, to deep existential anxiety. It can cause the same physiological responses as fear. With fear, you know what frightens you: a charging bear in the woods, an earthquake, a cancer diagnosis. Anxiety, on the other hand, may result from cumulative stressors in your various life roles. It’s a cliché that we live in the Age of Anxiety, due to the complexity of modern life. The average person’s stressors are many and varied.

In Western society we have a history of regarding the body as separate from the mind, but this dualism can be misleading. Much modern science supports the notion of a bodymind – a unity of embodiment and consciousness. The physiology of anxiety is a hard-wired stress response. I’ve written previously about the fight-or-flight response that we experience when we perceive ourselves to be in danger. In situations where we find ourselves in physical danger, the instant physiological response – rapid breath and heartbeat, increased blood pressure and blood sugar, tense muscles, etc. – can prepare us to fight or flee, as the situation requires. But sometimes this automatic physiological response can cause us to “choke,” to feel paralyzed or out of control. And if the perceived threat isn’t something you can fight or flee from, your bodymind’s response can be feelings of high anxiety. Triggers for anxiety (or fear) don’t even have to be actual threats. Sometimes they occur simply because we feel threatened or inadequate, even if we’re not truly at risk.

Mild-to-moderate anxiety can sometimes be helpful, if it motivates us to effectively address its causes. You can reduce your anxiety about an upcoming exam if you study hard for it. However, avoidance also works, if only in the short-term, to reduce performance anxiety. But whether anxiety is a spur or a hindrance, it’s never a pleasant  experience.  One manifestation of high anxiety or fear is phobia – an irrational fear – which often leads to avoidant behavior. The power of phobia is contextual. A phobia about crossing bridges may not be a big problem if you live in the desert Southwest, but may cause significant problems if you live in the Florida Keys. Another common symptom of anxiety is panic attacks, which can also lead to avoidant behavior.

Anxiety rises to the level of pathology when it impedes or disables us. Some people are crippled by their anxiety. I believe that there’s a physiological basis for clinical anxiety, and that people with anxiety disorders shouldn’t be blamed for their disabling symptoms. But I also believe that, to some degree, anxiety is something that we unconsciously do, not just something that happens to us. Irrational thinking is a significant factor that contributes to both normal and pathological anxiety, and cognitive behavioral therapy is an effective treatment for many anxious people. Anti-anxiety drugs like Valium and Xanax can be helpful in the short-term, but long-term reliance on pharmaceuticals (or recreational drugs) to control anxiety only leads to chemical dependency.

To a certain degree we create our anxiety by the way we think. I’ve written about how, when facing a challenge or an upcoming performance, we can either mentally rehearse for failure or for success. And we can make pessimistic assumptions about things we don’t really know, and fear things that don’t really present a threat. Our physiological response to a perceived threat can be identical to our response to an actual threat.

Cognitive behavioral treatment of anxiety disorders involves teaching clients about both the physical and mental aspects of anxiety, and teaching them to distinguish their rational thoughts from their irrational thoughts. The treatment may involve the technique of exposure, where the client is exposed to the thing she typically avoids, or does the thing he usually avoids doing. Treatment often involves “homework” assignments – things to be worked on between therapy sessions – that will help the client to develop new skills and establish new mental habits. The development of insight need not precede relief from anxiety symptoms. Positive behavior change often enables a client’s development of insight into how, and to what extent, he was “doing anxiety.”

Involuntary commitment

Throughout the years I worked in the Alabama and South Carolina mental health systems, one of my responsibilities was to serve as a Designated Examiner (DE) in the Probate Court. Both states reviewed my clinical qualifications and certified me to examine people and give testimony in the Probate Court as to whether they met the legal criteria to be involuntarily committed to a psychiatric hospital. This commitment process was established nationwide to safeguard the rights of mentally ill persons, insuring that they couldn’t be “railroaded” into involuntary treatment, without due process. With only a few exceptions that I’ve witnessed over the years, the system worked.

You’ve probably heard the term “certifiably mentally ill.” Well, I was a certified certifier.  In most (all?) states a person that someone has petitioned the court to assess for possible involuntary commitment has to be independently interviewed by two DEs, one of whom has to be an MD. The two criteria were that the person had a diagnosable mental illness (based on the judgment of the DEs) and that he presented a credible threat of harm to self or others. Both DEs had to agree that the criteria had been met, in order for the person they’d examined to be deprived of their liberty. That person couldn’t be hospitalized indefinitely, but had to be re-certified at specified intervals.

The commitment process went like this: someone – usually a family member or medical professional or  law enforcement officer – had to petition the court for a hearing. Both DEs independently interviewed the individual, wrote reports on their findings, and made a recommendation for or against involuntary commitment. If both DEs agreed that that the person met the criteria for commitment, a Probate Court hearing was held. The hearing was recorded so that there would be a transcript, and if the person didn’t have his own attorney present, they were represented by a court-appointed attorney. Sometimes the person agreed that he needed hospitalization and the hearing was just a formality; but if he disagreed, the lawyer made sure that his point-of-view was represented in testimony.

Once the voice recorder was turned on, the court was declared to be in session and both DEs were sworn in. After they read their reports and recommendations, the attorney could consult with her client and ask follow-up questions, or have the client speak for himself. After hearing all the testimony, the Probate Judge could either dismiss the petition or order the person to be involuntarily committed. If both DEs had recommended commitment, the judge almost always went along with their recommendations.

The deprivation of liberty is no small matter, and the Probate Court hearing is an important safeguard, to insure that the commitment laws aren’t abused. Many people with severe, chronic mental illnesses have gone through the process multiple times and accept that they’re going to spend some time in the hospital. A few physically resist and have to be sedated. Yet others resist treatment in  a variety of ways, once they get on their assigned ward.

I spent the last nine years of my career as a treatment team psychologist on a locked ward at South Carolina’s largest psychiatric hospital, and had to deal with every kind of resistance imaginable. Some patients reasoned incorrectly that their refusal to speak or answer questions in treatment team would somehow shorten their stay. I remember an instance when I recognized an intelligent young man ( I’ll call him John) who’d been assigned to the treatment team I served on during a previous commitment, years earlier. At his treatment team initial assessment he was surly, but at least minimally cooperative. I asked if he remembered me, and he said he did. “You’re the one who told me that it’s impossible not to communicate.” I’m pretty sure I smiled at him, recalling our first encounter.

It had been John’s first commitment, and he must have reasoned that giving the treatment team the Silent Treatment (or elective mutism, as we call it) would lead to an early discharge. We’d tried to get him to open up, but he’d refused to answer a single question. So I said something like this: “John, it’s impossible not to communicate, and even though you’re not speaking, you’re communicating right now. What you’re communicating is, ‘You can’t make me talk,’ and you’re absolutely right. We can’t. We know you don’t want to be here, but we can’t discharge you until we know what’s going on with you, and that you’re safe.

“Let me tell you one thing that everybody on this team has in common with you. None of us wants you to stay here even one day longer than you have to. We plan for discharge from Day One. The best thing you can do to shorten your stay is to let us know what you think is going on. Work with us and I promise we’ll get you back home as fast as we can.” My intervention worked and John started answering our questions.

Sometimes people are so angry about their commitment that they get violent, so all employees who have contact with patients are trained to work with other staff to take down combative patients without anyone coming to harm. However most patients on locked wards understand that violent acts would be evidence of the “harm to others” criterion of commitment, and try to control their tempers.

 

 

The role/goal model

There are many models of human behavior in the field of psychology, among them the psychoanalytic, behavioral, gestalt, and dialectical models. Most have their utility, but none of them is “the best,” or explains everything. A model is just a description or a map and, as I quoted in a prior post, “the map is not the territory.” I haven’t written about what follows in any formal or comprehensive way yet, but I’ve come up with the bare bones of my own model. I think it’s original, and helpful in explaining certain unconventional or extreme behaviors – as well as many common ones. I call it the role/goal model. It has to do with motivation and it’s rooted in social psychology.

We all play multiple roles in our lives, some of the more conventional being spouse, parent, employee (or boss), host, and caregiver. Other roles have to do with one’s profession or skill set, and yet others are unconventional and highly specialized. Behaviors appropriate to one role in a person’s life – for instance sexual expression within a marriage – are inappropriate in other roles. If a drill sergeant behaved at home like he did at work, it would be domestic abuse.

Many behaviors are motivated by the desire to feel good about ourselves for fulfilling the expectations of a given role, whether that role is father, wife, breadwinner, merchant, healer, or evangelist. You may not feel like getting up when the alarm goes off at six, but in service to your role as family provider, you get up on time and prepare to go to work, day after day. The goal of such persistent behavior is the feeling of satisfaction you get from providing for your family’s material needs. You know that if you don’t get up and go to work most workdays, you won’t get a check on payday. You’ll fail to meet the goal of the breadwinner role, your family will suffer, and you’ll feel terrible about yourself.

Many times in my life I’ve heard people say things like, “He did that for no reason!” In fact, people don’t do things without a reason, and a more accurate statement would be “He did that for reasons I don’t understand.” We might have a hard time grasping what would motivate a person to torture animals, or purposefully start a forest fire, or shoot schoolchildren, or coax cult followers to drink a fatal dose of poison. I think this model helps to make such behaviors comprehensible.

The role/goal model explains conventional or extreme behaviors by identifying the role that a person perceived herself to be in at the time of the behavior, and the goal of that role-appropriate behavior.  For instance, a mother who has never acted-out violently in her life might inflict severe bodily harm on a stranger, if he was threatening her children with violence. Some roles, like mother, are conferred by circumstance; other roles are self-conferred and may be secret, or unrecognized by others. Self-conferred roles include Rescuer/Hero, Tragic Hero, Devil, Martyr, Outlaw/Rebel, Victim, Player, and “Secret Agent.” Identifying the role and the goal explains almost any behavior that isn’t due to psychotic mental processes.

By Secret Agent I don’t mean a literal spy {although “spy” is an example of a rare and highly specialized role), but someone who acts in secret, or has a perceived “secret identity.” I think that role descriptor helps to explain many aberrant behaviors, such as serial arson or serial rape. Examples: “They think I’m a Nobody, but I burn down forests.” “Women trust me because they think I’m a nice guy.” People like this get off on not only the feeling of power they experience when they commit their crimes, but on their daily feelings, when they think “Nobody knows who I really am” or “She doesn’t know that I want to rape her.”

A less extreme example is the role/goal analysis of an obnoxious, Bible-thumping street preacher who thinks he’s preaching on the street because God wants him to. What motivates him to persistently shout at strangers who don’t want to listen to him? The role/goal model posits that he’s in the evangelical role, and what could be more important than saving souls? The behavior is motivated by the attendant feeling, not the sure knowledge that souls will be saved. People in such a self-appointed role believe that their objective (i.e. saving souls from damnation) is what’s driving their behavior, when in fact their role-appropriate, goal-directed behavior is motivated by the feeling that they’re doing the most important work of all, God’s work.

The goal of the Hero is to be admired for his achievement or strength. The goal of the Tragic Hero is to get sympathy and to justify his helplessness in the face of insurmountable odds. The goal of the Victim is to gain something by being pitied. The goal of the Martyr is to be admired for her sacrifice. The goal of the Player is to get over on people. The goal of the Rebel/Outlaw is to get away with breaking the rules. The goal of the Devil is to raise Hell. The goal of the Rescuer is to feel powerful and to take credit for someone else’s survival or success. None of these roles exists objectively, but in subjective perception and the attainment of consequent, predictable emotional states. The feeling state is often the  goal of the behavior, although it will be rationalized as role-appropriate and goal-directed.

Emotional expression is modulated by both role and goal. An emotion is suppressed if it’s seen as inappropriate to the role or unhelpful in reaching the goal, i.e. never let them see you sweat if you’re in the Hero role. The emotion is exaggerated for effect if it’s seen as role-congruent and/or helpful in reaching a goal, i.e. the Boss’s display of anger, or the Victim’s tears.

 

 

 

 

Who is racist?

I was raised by parents who had risen above the racist influences in their lives. My father’s father, born and raised in the Bronx, was a bigot who used words like nigger, kike, wop and spic. My mother grew up in racially-segregated Charleston, South Carolina. But I never heard either of my parents use disparaging terms for minorities. (Negro was considered polite back then.) If I had parroted racial epithets I’d learned from my peers growing up, I’d have been strongly admonished not to do so, if not punished.

I served as a race relations education officer in the Army in the early seventies, leading three-day seminars designed to alleviate racial tensions and conflicts. I was stationed in Germany, and in the year that I led seminars I learned a lot about my own country. I’d read Eldridge Cleaver’s Soul on Ice and bought his assertion that “if you’re not part of the solution, you’re part of the problem” of societal racism. I’ve done many things since my Army days to try to be part of the solution and I know firsthand what it’s like to be in a recognizable racial minority, having lived in Jamaica for two years as a Peace Corps Volunteer. I’ve known many white  folks over the years who would instantly deny having any racist tendencies whatsoever, because they don’t understand the insidious nature of racism. I believe that there are two kinds of racism, which I’ll cover later in this post.

I grew up in a racist society, and to claim that  I was untouched by racism would be ignorant. I learned to be a race relations education officer at the Defense Race Relations Institute (DRRI). There I learned the (now obvious) point that you can’t grow up in a racist society without being influenced to some degree, no matter what your race or ethnic group. I was also taught that guilt is a lousy motivator for changing racial beliefs and attitudes. Racism isn’t an either/or thing, but exists along a continuum. To admit that you have residual, learned racist beliefs or (often unconscious) inclinations doesn’t mean that you’re a bad person or, if you’re white, that you should feel guilty for being white.

A Defense Department manual issued by the DRRI to support the race relations education program addressed military commanding officers who earnestly believed that that they were “color blind” or “didn’t have a racist bone in their body.” It suggested that they should discuss with their race relations education officer just how this miracle occurred in our racist society. When I encountered this attitude in race relations seminars, I’d ask with a straight face, “What planet did you grow up on?”

Despite my personal history of self-examination and of actively opposing racism since I was a young man, I can’t claim to be completely free if its taint, myself. It’s not simply a matter of “being ” or “not being” a racist, it’s matter of where you are on the continuum. Everyone belongs somewhere on this continuum, and where you see yourself may not be where others might see you. It’s not just white people who are unconsciously biased along racial lines. While I believe that America is less racist than when I was growing up, we still have a lot that needs to be examined and changed. I believe that there’s less unconscious bias among most millennials, and hope that they will prove to be a watershed generation in healing the scars of racism.

It seems to me that there are two distinct kinds of racists: those who fear and hate people who don’t resemble them racially, and those who harbor unconscious racial bias and stereotypical beliefs. It’s easy to understand why one of the latter would be offended if they thought they were being accused of being one of the former. I’ve known a lot of white people who, because they don’t fear or hate people simply because of the  color of their skin, honestly don’t believe that they’re at all racist. They would feel guilty if they admitted to having any racial bias at all. My parents belonged to this category.

There are a lot of good, well-intentioned white people who are blind to the institutional racism that still exists in our society. As a psychologist, I believe that unconscious bias – not just racial bias – is universal. Nobody has perfect, objective insight into their own beliefs and behavior. The more aware you become of your particular biases, the less they unconsciously affect your behavior.

My first epiphany regarding American racism came when I attended the DRRI. I learned at least as much in the mess hall and in late night discussions in the barracks – with white, black, Latino, Asian and Native American classmates – as I did in the classes we attended. At some point it was as if “the scales fell off my eyes” and I saw that people of color live in a different America than the one I live in. I can only imagine what it might feel like to be a black person who grew up in the South in the Jim Crow era, hearing the phrase “the Land of the Free” in our National Anthem. In high school I’d thought that racist jokes were harmless, but stopped telling them. (My high school was racially segregated until my junior year.) After my epiphany I stopped laughing at them, because I no longer found them funny. Polish jokes (for instance) are only funny if you buy the stereotypical premise that Poles are stupid.

My most recent racial epiphany was my grasp of the concept that race isn’t a biological phenomenon to begin with, but a social construct. All homo sapiens belong to the human race. I’ve long felt that every human being is kin, if you go back far enough. Racism results from learned myths and stereotypes; it’s not innate in our species. Rogers and Hammerstein wrote a song about racial prejudice for the Broadway production of “South Pacific”: “You’ve Got to be Carefully Taught.” (It was considered too controversial and replaced by “My Girl Back Home” in the film version.) We can only shed racial biases when we acknowledge that we have them.

Sexuality and guilt

I was raised a Christian and most of my values are congruent with Judeo-Christian values, but one concept I’ve never bought into was Original Sin. Many Christians believe that we’re born into Sin and therefore require divine Redemption. I tend to distrust organized religions, as most of them seem to me to be rigid patriarchal hierarchies that claim the authority to be the only authentic interpreters of the ancient texts on which they’re based. Most teach that any sexual activity not sanctified (usually in heterosexual marriage) by their religion or sect is innately sinful. I believe that such teachings have fostered widespread sexual repression and shame in many cultures and have damaged a lot of lives. As a psychotherapist I worked with a lot of people who’d been taught that their sexual feelings were somehow innately sinful, and who felt guilty for perfectly normal sexual thoughts, especially if they acted on them.

“Normal” is a statistical concept, not a moral one. Homosexuality is only “abnormal” in the statistical sense. It’s a sexual variation, not a deviation, and occurs in every known culture. Among the people I worked with on sexual issues were people who thought they might be gay and were terrified by the prospect. Because of their education by homophobic role models in a sexually-repressed society, they didn’t want to be gay; but they felt what they felt. Sexual orientation isn’t a matter of choice. I’m happily heterosexual, but it’s not because I chose to be. It’s just  part of who I am. My brother is gay, and his sexual orientation wasn’t a matter of choice for him any more than mine was for me. I don’t think God condemns anyone for who they’re sexually attracted to.

Masturbation is undeniably a normal behavior. In fact, it’s quite popular. I believe that what somebody fantasizes about when he or she masturbates is their own business and nothing to feel guilty about – as long as it doesn’t lead to irresponsible, exploitive, coercive or violent sexual behavior. (For some sex offenders, masturbation can be a mental rehearsal for things they intend to do; and part of sex offender treatment involves their learning not to indulge in fantasies of criminal or exploitive sexual behavior.) And yet many good, decent people feel terribly guilty for sexual thoughts and fantasies that they would never act out, or even want to act out. The only bad thing about masturbation, as one of my cousins told his son after his ex-wife caught the boy in the act, is getting caught doing it.

Despite outward appearances we live in a sexually-repressed culture, where erotica is a guilty pleasure, nudity is inevitably sexualized, and the display of breasts is okay in advertising and commercial TV shows, as long as no nipples are exposed. I’m concerned about the effects of the widespread availability of porn to young people online; but it might be the inevitable backlash of societal sexual repression, enabled by capitalism and modern technology. I consider “reality TV” shows that attract viewers with the lure of nudity, but blur out the breasts and genitalia, to be more obscene than outright porn – because of their hypocrisy.

In my career I had to educate many people about the normality of their sexual thoughts and behaviors because few of them had received any meaningful sex education, either from their parents or at school. Many women told me that when they had their first period, they didn’t know what was happening. Gay, bisexual and transgender people were often in despair because society had labeled them as “deviants.” Sexual fetishes such as cross-dressing may not be normal in the statistical sense, but as long as such activities involve consensual acts, and nobody is coerced or violated, they aren’t blame-worthy.

One of my “standard raps” to clients who were fearful or guilt-ridden about their sexual predispositions went something like this: “I get it. You don’t want to be gay (bi/trans, etc.), but you feel what you feel. For the time being, there’s no pressing need for you to put a prefix on your sexuality. What we know is that you’re a sexual person, just like everyone else, and that’s okay. Maybe someday you’ll be able to identify a prefix that fits; but when you do that is up to you, not other people. Only you can know what’s in your heart of hearts. What’s important now is that you’re a sexually responsible person. That means you don’t take advantage of other people sexually, don’t have sex with children or other people incapable of giving consent, don’t coerce anybody to do things they don’t want to do, and practice safe sex. Nobody can put a label on your sexuality unless you give them that power. As long as you’re sexually responsible, you don’t have to justify your sexual identity to anyone.”

For me, the next stage of therapy with a person who responded, “But I can’t be gay!” was teaching rational thinking: “I know it’s tough being gay in this society, so I can understand your resistance to considering that you might be gay. But I invite you not to catastrophize. Good things still happen to gay people, things that couldn’t have happened without their knowing who they are. Being gay isn’t awful or terrible unless you make it awful or terrible by your thinking. And it’s better than living a lie.”

It’s my belief that people shouldn’t be judged or condemned for what they think and feel, but only for what they do. And yet a lot of sexually responsible people feel guilty about sexual feelings or fantasies they’ve had. My behavioral prescription for this, as with other self-judgments, is “Learn to distinguish your rational thoughts from your irrational thoughts.” As long as nobody was exploited or hurt, such guilty thoughts are almost always irrational.