Memoir Reflections: Night Falls Fast, Understanding Suicide, by Kay Redfield Jamison

Anna H.

For Scott Wiessman, 6/27/09

Mental Health Practice

In the book Night Falls Fast are Kay Redfield Jamison’s personal attempts, shared with the world, to understand the nature of, reasonings behind, and struggles leading up to a person’s choice to end his or her own life, and the subsequent devastation, horror, and confusion experienced those left to behind. In exploring her own ruminations, fear, and sadness about the prevalence of suicide—Jamison herself has bipolar disorder, and has been suicidal several times throughout her life, nearly completing once— and our western society’s intense discomfort with it as a world-wide mental health crisis, Night Falls Fast is aimed at filling in our lack of understanding about and empathy for those who suffer from and sometimes succumb to the lead contributors to suicidal acts: depression, manic-depressive [bipolar] disorder, schizophrenia, and substance abuse. In reading the book, however, it was my experience that Jamison seemed to get lost in gory details and terrible stories of bright lives consumed, focusing instead on the same sensationalism and voyeurism which she condemns in the general public treatment of this terrible phenomenon. Jamison, in setting out to dispel the stigma of suicide, insomuch as she can persuade her readers to recognize the struggles with mental illness most often behind it, falls frequently into the same culturally-bound showcasing treatment of suicide-as-spectacle that she criticizes. In this paper, therefore, I will examine the ways in which Jamison— despite her goals of addressing the dearth of knowledge about why and how people come to a decision of suicide and its underlying causes in such a way as to remove its stigma, that it may be more swiftly and easily addressed for public health— nonetheless struggles in her writing to escape the ways in which suicide is often treated in America: as morbidly fascinating, but largely incomprehensible.

Jamison’s book is not strictly a memoir in that, while she does include small personal narratives as a woman with an intimate history of suicidal ideation and attempt, she largely treats it as a collection of discourses, studies, and essays, all trying to make sense of how and why so many have and continue to take their own lives, and what do we who are left, or who survived, do to try to curtail its prevalence. Her own experiences with major bouts of depression, as the result of having bipolar disorder, seem to have a major impact in the way in which she writes the book, both in the loving and admiring prose with which she describes the multiplicity of brilliant and inspiring historical figures, known and unknown to the general reader, who eventually took their own lives, and in the brutally vivid details she embeds in our minds of their decent into a personal hell only escapable through suicide. I have no doubt that she identifies with her subjects, and in doing so takes her readers on the same terrible journey that she and they felt for the first two thirds of the book.

This book actually came highly recommended for me prior to taking 698 Practice in Mental Health by a friend who himself has struggled for years with bipolar disorder, as a window into the downward spiral of hopelessness one experiences in feeling suicidal, written by someone who had “been there” herself. I had sought out and spoken with Jim about depression and suicidal thoughts, in response to my own most recent experience of both— the third such in my lifetime— looking for someone who would understand how dark my vision had become, and in the course of dinner he brought up identifying with Jamison’s depictions and writings. I purchased the book, but could not bring myself to read it until it became absolutely necessary to choose a mental health memoir for class and I found Night Falls Fast already in my possession; ultimately, given my personal mental states over the course of 2009, I wish I had chosen a different book to use for this assignment, but I did finish it, albeit with reluctance, after much discomfort and some with secondary trauma. Unlike Jim, I would never recommend this book to a person currently battling the personal demons of depression, hopelessness, or suicidal thoughts: rather than feeling like I could empathize and relate from a healthy distance, Jamison’s style of storytelling is so terribly detailed, and her depictions so graphic, that I found myself frequently only able to read a handful of pages at a time before becoming profoundly disturbed. There is no wall that one can construct to protect themselves from these stories of real-life, unbearable suffering and often violent, grisly endings sought when they have felt the pain described in the pages before them. I struggled mightily with this book, and ultimately finished it, but was unsatisfied by the treatment it gave to both its subject, and its prognosis for the future.

Jamison, perhaps in exorcizing her own feelings at coming so close to becoming another casualty of her book, repeats over and over stories of young lives lost and great minds destroying themselves, multiplicities of statistics which numb the heart at their prevalence and methods of terrible sought-after release which felt physically harmful to read over and over again. Given the pain I felt in reading the repetition of stories with wrenching, early endings, the amount of loss experienced and the enumeration about ways people have sought their own demise, I can only hope their purpose serves to drive home the point of suicide’s terrible reality, and the need to intervene in seemingly senseless self-destruction. I fear, however, that it may serve the opposite end of further cutting off communications, either through desensitization, making these tales like a macabre depiction from a crime novel, or overwhelming the reader to the point where they do not know how they might deal with such pain in their own lives, and therefore shut down the possibility of open communication. I can imagine how powerful these depictions would be for someone who had not had firsthand knowledge of these feelings, that now they might really begin to recognize the crushing weight of these feelings, and how such an otherwise awful end might seem like relief, but for anyone recovering or still battling with depression themselves, reliving it within these pages is traumatizing and can threaten to suck you back in. In the book’s first two thirds’ unrelenting reiteration of violence and despairing, Jamison seems to be searching for answers to why people must suffer so, on behalf of those left behind, those who have survived their own attempts, and those who still consider suicide to be an option worth considering; there does not, sadly, seem to be a good enough answer to justify the inclusion of so much pain which assaults the reader. However, repeating again and again the same pattern of promising lives full of accomplishments already, devoured by mental health problems incomprehensible to those who have not felt their oppression, and ended for lack of hope that life will ever get better, Jamison’s ruminations, though disturbing as intrusive thoughts or flashbacks, do serve a significant purpose: suicide is de-romanticized in the extreme and laid bare and raw for the horror that it is, that the concerned reader might address it in his or her life and community with urgency and a somewhat better understanding.

I struggle with Jamison’s conflicting viewpoints, as she writes this book both as one who has fought continuously against depression in her own life—and thus far, won—and an upper class psychiatrist who uses the terminology of mental illness to describe not only schizophrenia and manic-depression, but also substance abuse and major depression. Hers is not a strengths-based model of study, and perhaps due to that, she focuses greatly on the pathology of suicide, particularly as it relates to genetics and is compounded by drug and alcohol abuse, leading up to the terrible details that go into the deaths of so many of her discussed examples. In effect, due to her major focus being the horrors of depression as it leads up to suicide, Jamison seems to largely ignore the positives of biopsychosocial input, tempered with protective factors, personal strengths, and multiplicity of treatment options— now more than ever used together to help prevent depression from growing so unmanageable— and she approaches the majority of her book with little hope and less optimism. Coping with bipolar disorder, Jamison gives her whole-hearted support to lithium, the classic mood-stabilizing drug; I have concerns, however, with her terming it the “antisuicide medication”, as it is a dangerous tendency, among Americans in particular, to assume or expect that one can oversimplify treatment of something with as complex a set of contributing factors as suicide. Despite her warning to readers that it may not work for everyone, terming anything with a cure-all designation is dangerous in a book so desperately lacking in hope for its readers, and I fear too many would latch on to one such buoy as their only possible salvation from suicidal ideation and eventual completion. My greatest criticism of Night Falls Fast, however, is that despite her seeming understanding of the dangers inherent in a culture-bound search for a magic bullet to “cure” these mental health issues and the expectations for a true “antisuicide medication”, as she discusses in the “As a Society” chapter on the how the media ought not to treat suicide, Jamison herself persists in using language and storytelling techniques which undermine her otherwise sound understanding of how to address suicide. Jamison quotes the CDC’s recommended guidelines to the media regarding suicide treatment as a paradigm for how suicide ought not to be portrayed: by presenting simplistic explanations for suicide, engaging in repetitive, ongoing or excessive reporting of suicide in the news, providing sensational coverage of suicide, reporting “how-to” descriptions of suicide [acts], presenting suicide as a tool for accomplishing certain ends, glorifying suicide or persons who commit suicide, or focusing on the suicide completer’s positive characteristics, (Jamison, 280-282). While she does not ignore all of these guidelines, despite including them in her book, Jamison herself still falls into these same habits during the first two thirds of Night Falls Fast, recounting multiple times the specific details of horrible deaths with morbid fascination, including as examples wonderful and famous minds in literature and art, and getting caught by her own condemnation.

What Jamison does do well is give factual evidence of the terrible impact that depression and its too-often-successor suicide do to individuals, regardless of gender or ethnicity, and their survivors. Using comprehensive statistical information and examples from all eras, nationalities, races and gender groups, Jamison poignantly illustrates that depression and suicide are great equalizers: they spare no population. That she is a well-educated white woman does show through in her more elaborate case examples and stories, in that most are about white men and women of prominence or potential (though with a few notable exceptions). Jamison does try to point out explicitly the troublingly ignored populations of homeless mentally ill, many of whom suffer from bipolar disorder or schizophrenia and for whom suicide is perhaps a more common option that with the general public, but recognizing that the greatest impact will be made on her audience with examples from more prominent—and therefore, theoretically better off— spheres of life, she spends the majority of her ink tracing more well known or well off figures from history who have succumb to suicide. Despite her best efforts to show the devastatingly vast scope of life suicide touches, non-white, non-educated populations remain largely unrepresented in this book, reflecting our cultural concern which only becomes actively alarmed when those who somehow should not be so desperate are taking their own lives.

The last third of the book is far less overwhelming, as it offers some light at the end of the tunnel in the form of treatment discussions and the usefulness of medication and public health awareness work, both of which are promising steps. It includes a discussion of most effective treatment methods—“Modest Magical Qualities”, with a discussion of both medicinal and therapeutic interventions—a discourse on the positive efforts public health workers have been making towards suicide awareness and prevention, and a sober conclusion discussing the impact of suicide on surviving family, spouses, and friends. Given the book’s publication in 1999, I think it would behoove Jamison to update for her audience, to add in the hopeful advancements of psychopharmacology in the past 10 years beyond what she discusses regarding the older generations of mood stabilizer, MAOIs, and tri-cyclic antidepressants, including the now common usage of most SSRIs and the new class of antidepressant medication, SNRIs. Similarly, while Jamison creates a depiction at once poignant and resilient of the family and friends left to rebuild themselves after the suicide of a loved one, she gives very little of herself, either as a survivor who managed to cope with the suicide of her dear friend (though we know not how), or how her own family coped with the darkness she lived in on and off throughout her life. Neither does she offer anywhere near as detailed accounts from the lives of others as she does for the deaths of those whose stories she does tell: this imbalance of perspective deprives us from taking away anything therapeutic, and keeps us perpetually sapped of emotional vitality all the way through to the book’s end.

As a student of social work, I was very pleased to read Jamison’s endorsement of combining psychopharmacology with therapy (psychiatry, in her case) as both her personal salvation and the best means of combating suicidal action. I truly wish that she had spent more time using herself as an example of those who can and do recover; despite having personally lost a number of friends and acquaintances to suicide, in addition to almost succeeding in taking her own life, Jamison is an emblem of hope for those who fear they cannot make it, yet she does not use her status as a model for others. We do not get to hear what worked for her, beyond sticking with her lithium and psychiatry regimen, we do not get to experience her headway made out of the depths of despair and into normal, even stellar functioning. Other than her dedication to her husband and brother, we know nothing about her support systems, which are not at all addressed elsewhere in the book’s tally of losses either. It is a significant failing on Jamison’s part that she leaves us without her own example of recovery from depression, or at least a discussion of its remission, as hope, to counteract the overwhelming burden left by the other stories in this book. We are left feeling unmoored and helpless after an onslaught of depressive stories, and instead of stressing those people and actions which did reach her through the darkness, we are left with only the smallest glimmers and told merely to keep holding on.

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Jamison, Kay Redfield. (1999). Night Falls Fast, Understanding Suicide, Vintage Books: New York

Getting Through Grief with Yourself: Relearning Self-pleasure After the Loss of a Partner

Anna H.
For Sallie Foley, 5/3/09
SSW 700- Treatment of Sexual Dysfunction


Despite the copious amounts written in books and journals addressing the theories of, and approaches to, understanding and treating depression, grief and loss, and sexual (dys)functioning as isolated topics, very little can easily be found that looks at the intersection between these very common aspect of life. The loss of a romantic partner-- be it due to a breakup, separation and divorce, or death-- is a near-universally experienced part of human relationships. Stroebe, Schut & Stroebe report that particularly among older populations, as many as 45% of women and 15 % of men older than 65 become widowed (Stroebe, Schut & Stroebe 2007). Sadly, losses of this nature, though relatively common, are most often accompanied by a significant period of grief or bereavement, encompassing a multitude of emotions ranging from severe loneliness, to anger, relief, confusion or depression. Included among these are the very real, but not often acknowledged, needs for physical comfort and expression of one’s sexuality; despite this reality, however, modern healthcare and culture does little to acknowledge that sexuality remains a part of those people struggling with depression due to grief and loss, particularly if they are widows, widowers, or the elderly. Although self-pleasuring may or may not have been part of a client’s sexual routine before or during their time with their partner, learning-- or relearning-- ways to derive feelings of pleasure in both sensual and sexual experiences, safely, in the privacy of one’s own home, with the help of a sex therapist, can empower grieving clients to provide themselves with another means of solace.

In this paper I will discuss the ways in which therapists can help bereaved clients begin to reintegrate sexuality into their lives on their own, after the loss of a their partner, by affirming their need for comfort and pleasure and teaching them sensuality-focused means of self-pleasuring, even in the midst of grief. I will begin first with an overview of what Worden calls the “mourning process”, looking at how people proceed through what occurs after loss (Worden, 2009). I will continue on from there to discuss the integration of sexuality into grief, bearing in mind that the assumption of this paper is that clients are not dealing with a low sexual desire disorder per say, only sexual desire mitigated by grief. Due to the dearth of study on specific treatment for learning to use self-pleasuring as an outlet for sexuality and a source of comfort during the mourning process, I will finish with a discussion of sex therapy approaches used in treating low sexual desire, low arousal, and overcoming orgasm difficulty. Through these, I hope to suggest a course of sex therapy tasks meant, in conjunction with continued therapy for bereavement and support, to make one comfortable with masturbation and more attuned to their body’s sexual response.

This paper focuses specifically on self-pleasure and masturbation practices as a safe and non-threatening sexual activity that can continue to be enjoyed even after becoming single, though there are many others which can be explored to whatever extent the client has interest. All that must be emphasized with a cautionary note is that a client’s emotional and physical safety stay of paramount importance in whatever sexual expression is chosen. Clients dealing with grief and loss are likely suffering through some degree of depression, and clinicians must be particularly aware of their clients’ moods, affect, and engagement in high risk behavior as a result.

Sexuality is not often talked about as an aspect of bereavement that deserves to be addressed and promoted as an aspect of life which does not simply end after the loss of a partner or spouse. Sex therapists have for years promoted the idea that adult sexuality continues for as long as we live, and even major life changes such as losing a partner do not have to spell the end of one’s sexual life or the enjoyment of sensual activities. “Divorce may impact your sexuality by depriving you of a partner… and widowhood… has a unique impact on your opportunities, desire for, and capacity to be sexual, but neither need derail your sexuality or sexual identity,” (Foley, Kope, & Sugrue, 34, 2002). In the context of grief and mourning, however, in order to get the stage of a therapeutic relationship where clients are ready and want to address their sexual needs, it is important that clinicians in all fields of therapy first understand better what the experience of loss does to a person, physically, emotionally, and psychologically.

Stroebe, Schut & Stroebe outline in their review of health outcomes related to bereavement that there are extensive implications for physical as well as mental health when one has lost a loved one, including strong support for the idea that the “quality or nature of the lost relationship has much effect on outcome [for the survivor’s experience of loss]” (Stroebe, Schut & Stroebe, 1967, 2007). Therefore, the impact on surviving spouses of deceased partners, or individuals who have just been through divorce, separation, or breakup, is that one can expect to go through much during his or her time of grief over both the loss of relationship and partner. Physically, loss frequently manifests itself in a variety of behavioral and psycho-somatic changes which make up, in part, the experience of grief. These can include changes in a number of activities and aspects of daily living which are also hallmarks of depression, such as fatigue, agitation, weeping, social withdrawal, loss of appetite, sleep disturbances, and physical complaints (Stroebe, Schut & Stroebe, 2007). Further, depression as a normal result of grief can directly negatively affect how one responds to things that once gave them pleasure, sensually and sexually. Changes in general mood, attitudes towards sexuality, and physical wellbeing can be as mild as losing interest temporarily in one’s favorite past times, or can be as severe as to cause anhedonia, or the inability to take pleasure, physically or mentally, from normally pleasing events and activities. Seidman and Roose describe reduction in sexual interest as one of the most common changes in sexual response during depression, which can express itself physically as well as emotionally; for example, roughly “one third of depressed men develop loss of nocturnal penile tumescence (NPT), suggesting that depression can impair the neurophysiology of arousal or genital vasocongestion,” (Seidman and Roose, 2001). For the purposes of therapy, what this translates to is that clinicians can reassure their clients confidently with normalizing statements that, if they experience symptoms of marked decrease in arousal or sexual interest, these are common grief reactions influenced by both the loss itself, that they will likely dissipate or lessen over time, and if the client wishes to work on them clinically, they are completely welcome to do so, as sexuality is a normal and healthy part of life, even during major loss.

Emotionally and psychologically, Worden explains that there are “tasks” involved with processing and moving through the “phases” of mourning which, though a client may not follow a linear progression of milestones, are nonetheless essential to understand if clinicians want to provide support and help through loss (Worden, 2009). The first of these is “to accept the reality of the loss…that the person is gone and will not return” (Worden, 2009). This becomes a more complicated matter if the client’s partner is not deceased, but rather they are divorces, separated, or otherwise no longer in a relationship. As the literature I found devoted to the process of grieving spends little time addressing losses of these natures, I will for the purposes of this paper apply the tasks of grieving a dead partner also to the tasks of grieving a now-ended relationship. Regardless of the type of loss, many newly-single or widowed people go through a period of denial, during which they struggle against the concept that their relationship has ended and will not be the same again; it may take a person a very long time to come to terms with this. The second task, according to Worden, is to “process both the emotional and behavioral pain of grief,” (Worden 2009). While the degree of pain over a loss may vary from person to person, and certainly is can be effected by the circumstances of the relationship’s end, all people feel some level of sadness and pain when a deep and once-profound romantic bond has been broken. The third task Worden describes is for clients to begin to adjust to the world without their loved one by their sides; this includes making “external adjustments” in their new roles as single people, and possibly single parents, while continuing to live their lives, and “internal adjustments” to how they now must think of themselves (Worden 2009). Finally, the fourth task Worden discusses is that the bereaved person must find an enduring connection with their former partner “in the midst of embarking on a new life”. At the core of this task is integrating the ended relationship into their lives, as something which shaped and was of great value to them, perhaps for many years, while at the same time acknowledging and beginning to move towards a new phase of life where that relationship is no longer a dominant feature.

A note on differences among grief experiences with regards to stigma in society and gender. Greenblatt noted in 1978 that the experience of widowhood is far more common, and implies that such loss is potentially more difficult to bear, for women than for men:
Spousal mourning is a problem that mainly affects women because they have greater longevity, are usually younger than their husbands, and their marriage rate after bereavement is lower than that of widowers. Loss of spouse is, of course, a tragedy of major proportions. A widow is not only faced with loneliness, loss of companionship, and unmet sex needs, but also lacks the comfort, information, and support of a partner of many years. If her income is reduced, which is often the case, the widow may find herself poorer…. The widow’s place in society may become complicated; many widows, as well as their friends and relatives, view widowhood as something of a stigma.
(Greenblatt, 1978)
While it is easy to dismiss these observations as antiquated and outdated because of their age, there remains a significant amount of truth to them, although I would argue that the stigma and hardships described above apply equally to both men and women. A person accustomed to living with their partner and sharing a household does need to suddenly cope with the practical loss of supportive income, as well as the emotional support and companionship of their former mate, as Worden notes in his third task of making the internal and external adjustments necessary to continue living with this new and major life change. Further, it does seem to be the case that those who go through grief at the loss of a partner, particularly those who are already marginalized such as the LGBTQ and aging populations, end up denied recognition as continuing to be sexual beings. Bent and Magilvy are some of the few who explicitly acknowledge that grief in lesbian women who have lost life partners is further complicated not only by their marginalized status in society generally, but in regards to significant legal disadvantages such as visitation rights for partners in hospitals, being allowed to be beneficiaries of wills, and in some cases custody battles for children (Bent and Magilvy, 2006). Feelings of intense hurt, anger, and confusion with regards to the legal issues surrounding partner loss for this population can make the mourning process all the more painful. Foley, Kope and Sugrue note that “unlike a woman’s young adulthood, later in life her single “sexual self” may not be highly valued by the culture. Women often remark that they have to encourage themselves to stay sexually vibrant,” (Foley, Kope and Sugrue, 2002). Very little research can be found which specifically studies the sexual health or wellbeing, or even the role that sex continues to play, in the lives of those who are mourning partner loss. As Greenblatt seems to be suggesting, the general population, despite the high likelihood that most of its members will experience just this type of loss at least once in their lives, seems unwilling to acknowledge that those with grief still wish to experience sexual pleasure. In part, gender differences may be considered to try an account for this bias when looking at the way men and women view sex and it role or function in their lives, despite our modern views about female sexual liberation, it continues to be at least more acceptable for a man to have sexual needs than a woman. Regardless of this gendered division, it is important to affirm clients in their sense of loss and loneliness in missing sex and sexual expression or intimacy with their former partner, and to encourage them in their wish to remain sexual even now that they are single.
With the understanding that clients can process these multiple tasks of mourning simultaneously as life and emotion dictate, I suggest that a counselor or sex therapist’s role begins to shift from just grief work to also exploring and reclaiming the client’s sense of sexuality in the context of loss is when the client has begun to take on Worden’s third task. Recognizing that those feeling emotional pain and grief over the loss of a partner may include clients who were seeing someone for 6 months or coupled to for 56 years, it is important for clinicians to let clients who come to them with grief process it and progress through their own phases of mourning without an expected timeline for “getting better”, or even getting to the point of wanting to incorporate their sexuality into their healing. Clients may not initially feel the desire to feel or act sexually, and a client’s sexuality may be dormant for quite some time; some clients may never want to be sexual with another partner again. Foley, Kope and Sugrue remind clients that there is hope, after one becomes single again, of remaining sexual, even without their former partner:
Some single women who were previously partnered can honestly predict that there is little likelihood that they will find a new sexual partner. Their sexual response to this status is as varied as their circumstances. Some choose not to be sexual at all, others continue to masturbate and explore sensuality, and some even choose to have occasional sexual experiences.
(Foley, Kope, Sugrue, 2002).
Though addressed to women, these considerations apply to all people reintegrating sex after partner loss, since, after a time, many people do find their sexuality reemerging, whether or not they feel they are done grieving. It is at this point that sex therapists may best add their input in regards to sexual expression and health, to reassure them that their sexuality, as an integral part of their humanity, is not at all inappropriate or wrong, and in fact can be a wonderful way to self-sooth and satisfy their desire for pleasure.

The tasks of working on low sexual desire hinge on a client wanting to feel sexual, or experience sexual pleasure- so too with expressions of sexuality after loss. If the client has reached a place in their mourning process where they wish to have the means to fulfill themselves sexually, then clinicians should be ready to provide them with ways that they may get reacquainted with their sensuality and sexuality, and back in the groove. Providing permission for a client to discuss their desire to have sexuality back in their lives and offering the therapeutic context as a safe place in which to redevelop a sense of sexual self after their partner is an ideal first step, as it reaffirms trust in the therapeutic relationship, and shows the clinician’s willingness to address all needs presented by their client as they cope with loss. As a warm up for therapists to begin work on sexual exploration, it is a good idea to ask the client for a background on their self-care regimen. Understanding what they are, or are not doing, to take care of and enjoy their bodies gives you a good jumping off point for addressing the physical need for human contact, and eventually sexual needs, and leads directly into the first exercises aimed at getting clients back in touch with their sexual and sensual selves. Ask if they ever go to a salon, or get massages, or if they have in the past, how comfortable they were with that experience. Such activities are a good way to provide for the need we all have for human contact, which may not otherwise be satisfied if the client does not have children or close friends nearby. Worden points out that “being able to discuss emerging sexual feelings, including the need to be touched and to be held, is important. The counselor can suggest ways to meet these needs that are commensurate with the client’s personality and value system,” (Worden, 2009). Engaging such activities, if they do not already, is also a non-sexual way of easing clients into a reawakening of their sensuality, and getting them to begin enjoying the sensations of their body again.

Sensate focus exercises are an excellent place to begin the therapeutic work of reintegrating sensuality and sexuality into a client’s life, regardless of whether they masturbated before or during their previous relationship, because they allow for a slow and non-threatening progression from imagination to action. Hertlien, Weeks, and Gambescia, emphasize the use of sensate focus exercises in the context of systemic sex therapy as part of treatment for several different sexual dysfunctions (Hertlien, Weeks, and Gambescia, 2009). In the context of reincorporating masturbation and self-pleasuring into the lives of bereaved clients seeking comfort and an outlet for their sexuality, sensate focus techniques can be a particularly useful tools to “practice skills they have learned in the office” for getting reacquainted with their bodies’ enjoyment after much emotional suffering and to
[e]xperience sensual and sexual touch within a familiar, relaxed, comfortable environment. The therapist prescribes detailed cognitive and sensual behavioral homework that incorporates sensual and eventually sexual touch. Each assignment involves small incremental steps that help to build confidence, competence, and an increased sense of efficacy in overcoming the sexual problem.
(Hertlien, Weeks, and Gambescia, 2009).

In the case of bereaved clients, the assignments taught also help to slowly restore their comfort and enjoyment of their sexuality without their partner’s involvement. Worden cautions that “there are those whose only sexual experiences have been with their deceased partner, so the counselor may need to address any anxiety concerning new sexual experiences,” (Worden, 2009). In reality, whether or not a client had had sexual experiences with someone other than their former partner, if they were in a long-term, committed relationship with that person and, for one reason or another, are no longer with them, then it makes sense that a client might feel nervous, uncomfortable, or perhaps even guilty at wanting to still be sexual without them. It is therefore an important task in therapy, in conjunction with the actual practice of sensate focus, to allow time for sadness or a renewed grief that the client now must practice their sexuality on their own, even if they are ready and want to begin moving forward.

Sensate focus is usually taught as a partnered activity, and it is therefore necessary to adapt the exercises to be done individually, and for at least some of the non-erotic focus exercises, such as receiving massage, to be done by a professional. Originally, the purpose of sensate focus was to systematically desensitize an anxious or disengaged partner to the anxieties and distractions which were preventing them from enjoying fulfilling sexual relations with their partner. However since “the blueprint of the exercise must carefully fit the situation”, clients can feel reassured that sensate focus can work for them as well, and that the plan they and their therapist come up with to gently and unhurriedly bring sexual experiences back into their lives will be only built to do what they want it to, and not push them too far or too fast (Hertlien, Weeks, and Gambescia, 2009). To achieve this, progression through the exercises must be made in very small steps, to avoid feelings of frustration or failure, be it to respond without grief or to respond at all.

Hertlien, Weeks, and Gambescia put forth nine functions of sensate focus which can be reconsidered and drawn on as they relate to grieving clients without partners. Of those that apply to clients wishing to resume their sexuality by themselves, the first is for the client to “become more aware of his or her own sensations”, meaning to pay attention, during the exercise, purely to the physical senses they experience when they, for example, run their hand over their arm, or rub lotion into their feet (Hertlien, Weeks, and Gambescia, 2009). This may be particularly difficult to do when starting out with a client who is in the process of mourning, as they have been working so hard already in managing their emotions, maintaining their daily lives, and trying to move on after their partner is no longer with them. The grieving process described above from Worden is a challenging and highly strenuous emotional and mental task, and to tell a client to focus on setting all that aside for a while may be met with relief, or anger, or utter bewilderment. Eventually, however, the hope is that in training their mind to let itself rest for these few minutes or hours, and just experience sensations that are pleasurable and comforting, the client will find the ability to both enjoy their sexuality for itself and use it as a healthy, temporary relief from all the other feelings they have. The second function which can be utilized by the single client is to “focus on one’s own needs for pleasure” (Hertlien, Weeks, and Gambescia, 2009). In this context, this translates to the client training him or herself to pay attention to what their body tells them it wants, and not feeling guilty or conflicted about satisfying those needs and wants without the help, participation, or support of their former partner.

The third and possibly most vital function that such clients can make use of in their own plan is to “expand the repertoire of intimate, sensual behaviors” that they currently have (Hertlien, Weeks, and Gambescia, 2009). This can mean anything that the client is comfortable and has interest in exploring: if they enjoy the feel of satin, perhaps they can see what it is like to sleep on satin sheets; if they never learned how to masturbate, now is the time to learn. It is important to use positive language when offering or hearing out options for clients to consider when expanding their sexual repertoire, and to encourage anything safe that might promote arousal and sexual feelings to get a client in a sexual frame of mind. Clients may wish to incorporate erotic novels, videos, or pictures into their practice, and this may be particularly useful if they wish to try and develop new sexual fantasies that do not involve their former partner. Alternatively, if for example remembering erotic moments with their deceased spouse is not too painful, and they can incorporate them in a healthy way which allows them to experience sexuality without their partner, but still keep the memory of them close at heart, clients should not be discouraged from using what feels good to them.

Foley, Kope, and Sugrue include masturbation in their chapter on overcoming low arousal as an exemplary means of finding out what one enjoys and one of the safest ways to experiment with sexuality on one’s own. “A number of writers have suggested that masturbation serves as the ideal learning opportunity for people to explore hour their bodies respond to stimulation,” (Foley, Kope, and Sugrue, 2002). Unfortunately, masturbation remains a largely taboo subject, which the client may take some coaxing to talk about, be it to admit to doing it, in which case they should be applauded for knowing and enjoying their bodies, or to admit they don’t know how, to which a therapist would do well to reply that their client is not alone, and if they want to try learning, there are a number of fun and non-threatening ways to go about it.

In a society where sexuality can focus more on giving pleasure to a partner than giving pleasure to yourself, masturbation has developed an unsavory reputation as being selfish, dirty, and practiced by those who aren’t getting any ‘real’ sex…. The fact is, masturbation is a great way to get in touch with your own sexual responses, rhythms, and desires, and can be part of anyone’s sex life, whether or not he or she has a partner. Masturbation is a natural, healthy part of sexuality and sexual practices worthy of recognition in its own right, whether or now you ever use a vibrator.
(Blank and Whitten, 2000.)

To help with masturbation practices in both men and women, many counselors recommend the use of sex toys, including vibrators, massagers, dildos, and anal plugs, both to increase stimulation for those people who have had trouble orgasming with manual stimulation, for those who simply want a change of pace, or for those miss the feeling of fullness being with a male partner can provide. Blank and Whidden have reassuring words for those of more conservative backgrounds who might be uncertain about introducing anything man-made into their sexual activities: “The only real difference between using the vibrator and using your hand(s) to masturbate [or a penis for penetrative sex] is that the vibrator moves faster and has more endurance. It won’t change the ways and places you like to be stimulated,” (Blank and Whidden, 2000). Clients should never feel ashamed or embarrassed if they are unsure or don’t know how to masturbate, with or without the help of a toy, and again it is the job of the therapist to reassure their client that their exploration of their sexuality on their own is healthy and positive.

Using these techniques, therapists and counselors can work with bereaved clients who have lost partners to replenish their sense of a sexual self and to reassure them of the importance of their continued sexuality, if and when they are ready to return to it. Recognition of their struggles and pain, acknowledgement of their loss, and support and constructive help in creating exercises to aide them in their return to life as a sexual being, as well as a bereaved person, are the first important steps that a therapist can offer in to met their client’s needs. Always keeping in mind the process of mourning in which clients are actively engages to one extent or another, and the need for clients to have time to grieve over the immense changes they have had to go through-- both in their everyday lives and in their expression of sexuality-- therapists can help facilitate clients’ learning of the use of self-pleasure as a means of self-soothing, an outlet for sexual feelings, and a tool to sustain them as healthy individuals for the rest of their lives.

 
Bibliography:
Bent, Katherine N., RN, PhD, CNS, Magilvy, J. Kathy, RN, PhD, FAAN, 2006. When A Partner Dies: Lesbian Widows. Issues in Mental Health Nursing 27: 447-459.
Blank, Joani, and Whidden, Ann, 2000. Good Vibrations: The New Complete Guide to Vibrators. CA: Down There Press.
Flatt, Bill, 1988. Factors Affecting Grief Adjustment. Journal of Religion and Health 27 (1): 8-18.
Foley, Sallie, Kope, Sally & Sugrue, Dennis. 2002. Sex Matters for Women: A Complete Guide to Taking Care of Your Sexual Self. NY: Guilford Press.
Greenblatt, Milton, MD, 1978. The Grieving Spouse. American Journal of Psychiatry 135 (1): 43-47.
Hertlein, Katherine, Weeks, Gerald, and Gambescia, Nancy. 2009. Systemic Sex Therapy. NY: Routledge.
Long, Irene, 1976. Human sexuality and aging. Social Casework 57 (4): 237-244.
Seidman, Stuart N., MD, and Roose, Steven P., MD, 2001. Sexual Dysfunction and Depression. Current Psychiatry Reports 3: 202-208.
Stroebe, Margaret, Schut, Henk, & Stroebe, Wolfgang, 2007. Health outcomes of bereavement. Lancet 370 1960-1973.
Worden, J. William, 2009. Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner, 4th Ed. NY: Springer Publishing Company.

Sex Manual Critique: Jay Wiseman's SM 101, A Realistic Introduction

Anna H.
For Sallie Foley, 3/6/09
SSW 700- Treatment of Sexual Dysfunction

Jay Wiseman’s book SM 101, A Realistic Introduction offers a down-to-earth, funny, and straight-forward discourse on how to safely and joyously practice bondage/discipline, domination/submission, and sadomasochism. My critique includes consideration of how Wiseman has set up his book, the weaknesses and strengths in his discussion of BDSM practices, techniques, safety, and psychosocial effects, as well as how I as a sex therapist could utilize the text in counseling. I wanted to critique this book specifically because BDSM, like other sexual minorities, is not often spoken of or written about positively for those interested in learning more about its practice or theory; when Wiseman’s book was published in its first edition in 1992, it was “the most comprehensive discussion of this information at the time” (pg. 4). Unlike writings on and for lesbian, gay, or bisexual practices however, BDSM continues to be largely illegitimate as a topic for serious discussion of sexual technique, psychological impact --even safety-- despite a significant established need and growing acceptance of these practices among younger generations. Jay Wiseman’s book is therefore very important as one of the first non-judgmental and non-titillating educational sex books to address the topics of BDSM as they pertain to long-time practitioners and novices alike, and is supremely useful for clinicians whose clients are interested, but fearful, of their interests in this aspect of their sexuality.

In his discourse, Wiseman covers several major themes that thread throughout his distinct chapters: safety, normalization, personal/real-life examples of practice, what to expect when beginning and how-to, and references and resources. Safety is probably Wiseman’s biggest point, because, as he points out early in his “Preliminaries” chapter, “SM is the riskiest form of sex” (pg. 6), and therefore safety issues are emphasized with every new technique mentioned in addition to the generalized safety chapter. Including normalization and real-life examples enables Wiseman to utilize humor, as well as personal stories and warnings, to stress that BDSM practices, when engaged in safely, sanely, and consensually among adults, are not only acceptable, but can be extremely pleasurable, gratifying, and fun: his purpose is to educate, inform, and validate the feelings of those interested in one of the still less-acceptable sexual minorities. Within this framework, Wiseman discusses in significant detail the technical ins and outs of bondage (chapters 5 and 6 specifically), flagellation (chapter 8), clamps (chapter 9), giving and receiving erotic pain (chapter 3 and 7), and a variety of other actual practices (11, 12, 18, 19, and 21), including always suggestions and explicit details on how to safely attempt them. In addition to a glossary of terms many may not have ever been exposed to before encountering this manual, Wiseman helpfully offers a section on resources and references (chapter 23) and a listing of means to find help with BDSM- and other sex-related problems (chapter 22), which not only pertains to his subject matter, but is useful for any sexually active person without resources.

Though somewhat less overtly emphasized, the psychosocial implications of “top” and “bottom” exchanges are the other key focal point of SM 101, brought up explicitly in discussions on how one might find a play partner (chapter 4), how to engage in such exchanges, and participating in BDSM relationships (13 and 14). Because the practices involved in BDSM are as much about mental states and the consensual submission of one party to another for the purposes of erotic interaction as they are about the physical restraint and/or giving/receiving of pain etc., Wiseman stresses throughout the book that taking care of all participating partners’ emotional and psychological wellbeing—before, during, and after engaging in any form of “play”—is as paramount to a successful “session” as it is to any other relationship. These foci are beneficial to both clinicians who don’t have much working knowledge of BDSM and those who do, but have trouble persuading clients that such interests are not wrong, sick or necessarily harmful, only need to be pursued conscientiously and safely. Addressing mental status and emotional impact is one of the great strengths of this book from a clinical perspective.

A note about readership and the specific audience addressed. During my initial read of SM 101, I was dismayed to find that, for a book aimed at a specific sexual minority too often closeted, Wiseman seemed to be largely excluding the LGBT community members who participate in or are curious about BDSM from his examples, explanations of technique and considerations. Upon further consideration, however, I realized that this was somewhat purposeful for several reasons. Wiseman acknowledges that this manual is for any interested in BDSM who don’t have much or any background in its practice, ethics, safety considerations etc., but one of his explicit purposes is to normalize BDSM for a larger, largely uninformed general audience—most of whom are hetero-normative in their thinking and orientation, and may hold many preconceived negative assumptions about BDSM learned from judgmental sources. To that end, Wiseman tries to make his book appealing and non-threatening to the uninformed “vanilla” (non-kinky) reader by expressly recognizing the many heterosexuals, as well as a percentage of lesbian, gay, bisexual and transsexual folks, who engage in and enjoy BDSM. Further, Wiseman acknowledges that because he himself identifies as a heterosexual male who participates in BDSM usually as a “top” or “dominant” (although he himself is open-minded enough to “switch” roles and “bottom”), his context for personal stories or play tips are going to be similarly oriented.

Beyond this initial concern, my criticism of this book is largely stylistic in nature, with one major exception. Having last been published in 1996, Wiseman’s book lacks some substantial technological, legal, and informational access updates to recognize and take into account those changes that have occurred in the past 13 years; both author and readers would be well served with a significant update to include these things. SM 101’s recognition of sodomy and other sex laws as they pertain to BDSM is a sound and very important to note inclusion within the general safety guidelines of practice. It does not, however, have any mention of the changes that have occurred since Lawrence vs. Texas (2003), which invalidated sodomy laws on the books in all 50 states-- meaning that while on the books, such can no longer be enforced. References to various websites, “world wide web” resources, as well as concrete establishments, are sure to have been reworked, relocated, removed, and/or otherwise changed substantially; these would be very useful for younger/ new generations of players—those at whom Wiseman originally intended to gear his book towards—therefore, a newly revised listing of good, current online archives and knowledge banks, both for specific resources and for club or community information would be especially beneficial. Further, in order to be of significant clinical referential use, the book needs to be updated so that clinicians and the curious can find pertinent information.

Beyond these revisions necessary to a practical manual last published more than a decade ago, my criticism has to do with the style of writing. While I appreciate the humor and candor of Wiseman’s writing, as well as his copious examples of real-life play and eye-catching set of marginal quotes accrued over more than 25 years of experience at the time of publication, the loose colloquial style of his prose are often more reminiscent of a personal account than the educational manual he set out to write. While endearing at times, this type of writing in excess can also undercut the legitimacy of Wiseman’s writing more than it adds to the normalizing efforts he makes; the occasional lack of polish is at times enough to make me pause before recommending it in the context of professional counseling, despite its wealth of positive and useful information. Additionally, while acknowledging that it is in many ways a seminal work for the field of positive writings on BDSM, it would have lent further credibility to Wiseman’s work if more references could have been made to scholarly works—that being said, there is an acknowledged dearth of information on this topic which Wiseman encourages his readers and fellow long-time players to amend with their own works. Acknowledging that SM 101 is not the single authority on BDSM practice is very useful for laypeople to see and recognize.

Focusing on the manual’s strengths, I can confidently say that this manual offers a very comprehensive outline and detailed set of discussions of actual play practices for interested parties to try safely, from beginner bondage to advanced sensation play and more. In addition to technical instructions and advice, Wiseman includes chapters and descriptions for setting up a scene which can act as a useful template for beginners. Of paramount importance, he underscores the need for prearranged negotiations on what, where, when, and how play will go, and to that end offers two (a short and a comprehensive) negotiation forms which are superb in their function as tools for practitioners and a grounding in reality for those who are just curious; the forms and scenes included in SM 101 are what really bring Wiseman’s writing to life. His fairly comprehensive list of reviewed materials under references, excepting online resources, are also very useful for those who need or are interested in more information on almost any topic, as is his section on “related practices” (chapter 21). Just as important as the actual technical aspects, Wiseman is wonderfully sensitive to the multiple levels at which BDSM players become involved in their scene, and takes painstaking measures to cover all aspects—physical, mental, emotional—and all the possible complications that occur with any or all of these. While some of the repetition of safety tips and warnings gets a bit tedious (a new edition would be well served dividing the first “preliminary” chapter into one devoted explicitly to safety and another about how and why Wiseman himself decided to create this book) the nature of BDSM necessitates heavy emphasis on safety, which he certainly achieves.

Possibly the single best part of this manual is the way in which Wiseman approaches his subject, writing in such a way as to reassure and empower his readers, not just so that they can play well and safely, but that they can practice unashamedly and enjoy this aspect of their sexuality as normal, healthy, and fun. Wiseman’s viewpoint is, in fact, a very moral one, which demands in no uncertain terms the need for communication and respect among players and really discusses all sexuality, not just BDSM, as needing this in depth an amount of care, attention, and understanding in practice. This strenuous emphasis on mutuality of respect, participation and enjoyment of the enumerated activities in the book is wonderful to read as a clinician and a consumer, both because it helps to reassure and build confidence in a client afraid of their “deviance” for whatever reason and because it promotes sexuality that is thought-out, safely practiced, and which puts a premium on honest enjoyment of sexuality without shame.

SM 101’s technical format and negotiating contracts are conducive to developing clinical homework assignments for those interested in practicing BDSM. Its discussions of the recognition of feelings of confusion, anguish, and fear in those who have an interest and don’t know what to do with it would be well used in a clinical context, arguably for anyone fearful of their sexual expression. Wiseman’s book is therefore a treasure trove of useful information ranging from the practical to the ethical; its discussions of the topic of BDSM—still incredibly controversial as an accepted form of sexual enjoyment and curiosity—in a sex-positive, life-affirming way encourage all readers, regardless of areas of interest, to enjoy and explore their sexuality, recognizing that safety in body and mind is key to healthy and happy experiences, no matter what flavor.

Disclaimer

I've decided that, given my personal musings, insomnia, and wish to put up something a little more formal for my more technical (read graded, edited, or at least somewhat well thought out) papers, I would make a spin off site and not bother to post papers at my original. See what you think; I have no idea if people have any inclination to read papers I've written, but if they do, please know that this is all my own work, and I would appreciate you not stealing it. Plagiarism is stupid: you don't learn anything from it, and you almost always get caught. I hope it's at least thought-provoking.
Cheers, and happy pondering.