Sexual Health Groups Help Patients Avoid Relapses: Breaking Powerful Drug-Sex Links during Treatment Improves Recovery Prospects
Knopf, Alison, Behavioral Healthcare
When substance abuse treatment providers first hear about the sexual health curriculum developed by Douglas Braun-Harvey, MFT, CGP, CST, they think it's about sex addiction, sex linked to crystal methamphetamine, sexually transmitted diseases, pregnancy, or even sexual rule-breaking in treatment programs. In fact, the curriculum, which is designed specifically for providers, helps patients avoid relapse to substance abuse--a central goal of any treatment program.
For drug-sex linked addiction, in which substance abuse is connected with sexual experiences, relapse is more likely if sexual health is not addressed in substance abuse treatment, says Harvey, the author of Sexual Health in Drug and Alcohol Treatment, a facilitator's manual for running sexual health groups. "Many patients have drug-sex linked addiction, which means that their sexual life is so merged with their drug use, they become the same," he says. When they find they have to abstain from the drugs or alcohol as part of being in recovery, this threatens their sexual life as well. And that, in turn, threatens their recovery.
"I never even thought of sex as something I could do sober,'" someone newly in recovery might think to themselves, says Braun-Harvey. Or, '"I've always had a couple of drags of pot first, that's been the history of my marriage.'" Basically, what these patients say when they want to start having sex in early recovery is: '"Now what do I do?'"
With most people in treatment having started their drug or alcohol use in their teens, it's safe to say that their sexual life has been affected, says Richard M. Siegel, MS, LMHC, CST, a Florida-based sex therapist who was a sexuality educator for addiction treatment programs for 15 years. "Almost everyone in treatment has probably never had sex sober," he says, noting that for most addicts, drinking and drug use starts during the teen years. "They're thinking, 'Maybe I can handle being sober, but I can never think about having sex again because I don't know if I know how to do it.'"
Most counseling staff in drug and alcohol treatment don't feel prepared to discuss sexual health, says Siegel, who encountered significant resistance to any changes when he worked in addiction treatment programs. Even programs that hired him to educate patients about sexual health didn't do anything differently once his presentations were over. Siegel hopes that treatment programs will take advantage of Braun-Harvey's approach to start their own groups.
Issues such as sexual desire are rarely discussed in treatment programs, says Braun-Harvey. If someone's erotic fantasies involved drug use before treatment, then these same fantasies could trigger a relapse after treatment. "How can you even talk about this in treatment as a relapse risk factor, if there's no model to even discuss masturbation?" he asks.
In an example of sexual activity in a treatment program, Siegel was providing a regular sexual health group at a treatment program which had an adolescent facility. The executive director found a condom in the parking lot that had clearly been tossed out of the window of the adolescent unit. Siegel, who provided the nursing director with condoms for the teens for weekends when they left the facility, was called into the office and asked to explain what was going on. It turned that that the teens had made holes in the walls between rooms--behind the bureaus--and were going in and out of each others' rooms at night. The treatment center's solution was to take away the condoms.
"Instead of labeling this as inappropriate acting-out behavior, the treatment center should have worked on developing a healthier attitude toward sexuality in general," says Siegel. "Yes, people should be concentrating on their treatment, and not pairing off, but the best thing about a sexual health curriculum is that people can talk about it, instead of hiding it."
Shame and guilt drive treatment failures
In 2003, the California Endowment funded a project for Stepping Stone, a treatment program in San Diego, to develop a sexual health relapse-prevention program, with the goal of increasing client retention and improving treatment outcomes. A key finding, vital to patients with high drug-sex linked behavior, was that individuals who maintained the highest levels of secrecy about sexual behavior experienced higher levels of associated shame and guilt and a greater risk for relapse.
In the Stepping Stone outcome data, the outstanding characteristic of clients with a high drug-sex link was that they had double the level of shame of the other clients, says Braun-Harvey, who consulted with Stepping Stone on the project. After three months in treatment that included the sexual health curriculum, the shame differential disappeared. "The group intervention is a powerful source of shame reduction," says Braun-Harvey.
Shame and guilt issues apply to all people, not just the LGBT (lesbian, gay, bisexual, and transgender) population that predominates at Stepping Stone, says Braun-Harvey, who worries that "because we did our initial data at a treatment center that is 75 percent LGBT, it will be marginalized." The fact that the curriculum reduced relapse and increased retention should carry over to other treatment settings, he asserts. "Sexual health is a universal issue, and the principles of sexual health come from the World Health Organization, not from political movements."
And sadly, treatment programs themselves can often compound the shame. For example, some programs designate one person to be the "sexual health" expert and enable patients with sexual issues to be referred by their counselors to this person. "The treatment center ends up abdicating what should be a program-wide responsibility, and instead one individual becomes the sexual expert, with nobody else having the responsibility to address it." Staff members whose faces express fear, disgust, or no response only add to the shame, he says.
Braun-Harvey knows that patients continue to go through substance abuse treatment that fails to address their sexual issues and drug-sex linked behaviors and that this has led to relapses. In fact, many of these individuals are his patients. "I had a client who had been through a very well-respected treatment program, and it was only after a year into counseling with me that he was finally able to say, 'When I was drinking I raped three women.' He had so much distress, and no idea where he could talk about this."
It's all too easy for treatment providers to send a tacit message that sexual issues shouldn't be discussed. Another example: A man in recovery goes to a prostitute and ends up sharing crystal methamphetamine with her. "She beats him up and robs him, and he goes home to his wife and comes up with a story--he tells her he did relapse, he used crystal, but says he got mugged," says Braun-Harvey, adding that the man then flew to a nationally-known residential treatment program and told the doctor about the experience--including the prostitute.
"The doctor says, 'You'll have plenty of time to talk about that, but we're going to focus on your drug treatment now.'" Braun-Harvey notes that such a response sends a clear message to the patient that the topic--a source of shame in the first place--is firmly off-limits. The result is that the patient talks less and less about this story in treatment. He becomes terrified that the incident with the prostitute will come out during family week. His shame becomes even more entrenched.
The treatment program failed this man, says Braun-Harvey, because it didn't evaluate the drug-sex link, and therefore was unable to clinically empower him to deal with it. "In effect, it was a secret, even from him."
It's not necessary to be a certified sex therapist to implement this curriculum. "A counselor can pick up the book, and if they do their homework, they can do a good job of teaching this class," he says.
Braun-Harvey's second book, Sexual Health in Recovery: A Professional Counselor's Manual, will be published in December. It's meant to be a companion to the first book, which is the group curriculum. The second book, designed for an individual counselor, explores how he or she feels about doing this intervention, explains how to use an assessment instrument, and teaches the counselor how to adapt the skill sets used in a sexual health group setting to the needs of an individual client.
Alison Knopf is a freelance writer.
RELATED ARTICLE: How one rural program is implementing a sexual health curriculum
Sexual health is important to recovery because relationships are often a cause of relapse, explains Pam Quinn, director of Douglas Place, a substance-abuse treatment program in East Grand Forks, Minn.
The decision to implement Braun-Harvey's curriculum "was controversial" because "the area we live in is pretty rural and conservative." But, Quinn asserts, "It's a good idea for people to address one of the biggest relapse triggers while they're still in treatment." Douglas Place launched the sexual health curriculum with female patients. Now, 14 women and 34 men are getting involved in the curriculum as part of substance-abuse treatment programs.
Jill Kuntz, LCSW, who was hired to run the sexual health program, says it's vital to create a safe place for women to talk about sex and sexual relationships. "This is a scary thing for all of our clients," she says. "It's kind of a faux pas to talk about sex." But it's important to be able to talk about it, in order to be able to process it. "They have to learn how to do a lot of things sober--like having sex. And they have to learn how to build intimacy without having to have sex."
If the only time someone has had sex is when they are under the influence of a chemical, they think that's the only way they can feel comfortable having sex, says Quinn. "That drug-sex link is state-dependent learning," she says. "At the end of their addiction, everything becomes dependent on that state." Recovery means learning how to do everything without being in that state.
Kuntz was chosen to implement the curriculum because she is "not a quiet person as far as that goes--I'm from Minneapolis," she laughs. Kuntz works with counselors to foster a climate of open communication. And, although she is the curriculum leader, if a client brings up a sexual issue with another counselor, that counselor will not simply refer the client to Kuntz. "The counselor isn't going to stop the client in that process," she says, adding that she and the counselors address issues collaboratively. "The counselor will offer my services, either for the sexual health group or for a one-on-one talk," she says.
Douglas Place started the curriculum with the women's unit. "It was a new program to me, so we started with my most comfortable demographic," Kuntz says. "Next we'll move into the young adult population." When male groups are added, male counselors will get involved as well, she says. "In our facility we're dealing with mainly heterosexuals, as far as we know."
Initially, clients are apprehensive about the sexual health groups, which meet once a week. "They've never been able to do this in treatment before," says Kuntz. "And they don't know if they want to talk about sex at all." But as the group progresses, the women feel more comfortable.
The program started in late spring and has already seen important breakthroughs. One client had been involved in a relationship in which both she and her partner used drugs many times together, Both went to treatment and, upon completion, back to the relationship. Both relapsed.
But, the woman then returned to treatment--by herself. And she saw that she was only letting one person into her life--her partner. "We talked about how that affected her recovery," says Quinn. After seeing how this strong sex-drug link hurt her chances at recovery, the woman underwent a dramatic change. "Within a few weeks, she went from being cranky to being in a good mood, and motivated to find work," says Quinn. "And now she can talk about how to build intimacy with other people in her life--healthy intimacy."…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Sexual Health Groups Help Patients Avoid Relapses: Breaking Powerful Drug-Sex Links during Treatment Improves Recovery Prospects. Contributors: Knopf, Alison - Author. Magazine title: Behavioral Healthcare. Volume: 30. Issue: 10 Publication date: November-December 2010. Page number: 12+. © 2009 Vendome Group LLC. COPYRIGHT 2010 Gale Group.