Here's one of the questions that came in. What leads to spontaneous improvement in sexual dysfunction among patients taking anti-psychotics? I know you mentioned that that can happen sometimes. Can you talk a little bit more about that? I wish I knew from a pharmacological statement how that can work. We just know that sometimes it gets better, and that may be that as they begin to improve and the psychosis begins to clear, that really they're more open to sexual relationships and they're more open to taking time and exploring things and not being quite as uptight about stuff, and that's an educated guess there for that one. Can you talk a little bit about how you introduce the topic of sexuality with clients with serious mental illness? It's something that as I begin, when I first prescribe something, if they're not terribly psychotic or terribly manic, then I talk about the side effects and I make sure that I mention in there that there may be some sexual side effects. As they begin to improve, when they come into the office, I set aside some time to have that discussion with them. Sometimes these medications can cause sexual issues. Are you having any problems with it? If so, what kind of problems? I've been surprised with a number of people, men and women, who just open up with just simply asking those questions. It's asked in a very nonjudgmental way, letting them know that there's nothing wrong with them themselves, that maybe it's the medicine. I think that takes some of the pressure off for them, and it's just an open conversation. It took me a while, and I have to be real honest about this. It took a while for me to be able to have those conversations other than, are you having any sexual problems, and just checking off the list. It took a while for me to be comfortable with discussing issues with both men and women about what sort of responsiveness they were having. Were they having lubrication issues? Were they having erectile dysfunction? Many times, they might not tell you right then, but in subsequent visits, they'll begin to get into it. It's just letting them know it's okay, and that you're open to that conversation. An individual wrote in and said, I think you mentioned that hyperprolactamemia can spontaneous resolve or improve. Can you talk about that? No, no. What I was talking about was prolactin levels. Some of the medications, the prolactin levels will rise initially, and then begin to settle back down. I try to stay away from medications that cause hyperprolactamemia, but I had a psychiatrist that I worked with that really, really loved risperidone. He used it pretty frequently, and he kept telling people, just hang out. Maybe the prolactin level will come down. I never saw it myself, but that's what he was saying. Do you ever recommend having props or things that you can show the client to help explain to them how they can improve this aspect of their life? I don't use physical props, but I do bring things up on my phone or my computer. There are some nice anatomical programs out there where you can show how sexuality works, or you can show the different toys, or you can talk to them about what they might need. For instance, if I've got a woman who's had an A&P repair who's having pain on sex, then using some of the dildos and the vaginal dilators are helpful, but talking to them about making sure that there's a bit of an arousal with it as well so that lubrication is enhanced in addition to potions and lotions and that type of thing as well. This question, I had a reaction to it. The person said, how can we ethically and adequately connect our patients with a partner? I think I laughed because we always want to do that because so many of our clients or anybody are like, I want to have a partner. I want to have that connection. That's really important to me. How do you talk to people about that? Wow. That's a hard thing to learn, isn't it? That's like when we were teenagers and started dating, learning how to have a relationship took a while. I don't know about you, but I made some mistakes and I'm sure most people did at some point in time. Talking to them about, and I don't understand the ethic part of it so much, but talking to them about that at some point in time, they may be interested in developing a sexual relationship with a partner and what they might be doing that may get in the way of being able to develop that relationship. I think you have to talk about it on multiple levels, not just the sexual aspect, but the emotional connectedness, the physical connectedness, the intimacy and getting people to move beyond that intimacy only means sex. It means this connectedness, this feeling like you belong with this person. Is it ethically? Yeah. We as human beings need to have connections and those connections don't always have to be sexual, but as humans, we crave that kind of connectedness. Talking to them about relationships in general, and then you can bring sex into it, I think. Yeah. There were two things I was thinking about while you were talking. One was, sometimes this is a really good topic in a social skills development group. Like a group psychotherapy, social skills, where they practice about interacting with each other, starting conversations, reading people's body language, all of those kinds of things. The other thing that it made me think of was using peer specialists to talk about developing relationships with others and how that can be challenging. It just provides another outlet and another perspective. I think sometimes multiple perspectives on this kind of topic can be helpful. Yes. I'd forgotten about the peer specialist, but if you yourself are uncomfortable talking about this, and Amy and I discussed this earlier too, find somebody on your team who is comfortable talking about it, because you're going to get better adherence. You're going to get patients who are more satisfied in general in their life. We have to recognize those people and those topics that we do well, and those people and those topics that we don't do well, and trying to make sure that our patients are connected up with an appropriate person for it. I know that you have, one of your current roles is as an educator, and I'm wondering if you could talk for a minute about how you approach this with your students, and if it's an ongoing thing that you go over many times, that you revisit, do you feel like they need to be at a certain stage in their training? Can you talk a little bit about that? Sure. Our very first course for psychiatric mental health nurse practitioners is diagnostics and psychopharmacology. We begin to introduce the sexual issues at that point. As we go through their entire program, it's one aspect of it. I do have, towards the end, a discussion board that specifically looks at sexual dysfunction, and talking about that. It's something that I make sure they're aware of, and they are at varying degrees of comfort with it. Some of us were brought up that sex was a dirty, nasty topic, and you should never talk about it in polite company, and therefore, as clinicians, we should never talk about it as well. However, when we look at these studies, we know that we're doing a grave disservice to our patients. I don't exactly understand this question, but let me try to summarize it. Basically, this person says, how does the therapist's way that they present themselves in their dress impact sessions working on sexuality? I think she's both talking about how do you address a patient when they react to the way you're dressed, and also, how do you talk to your students or your trainees about how they present themselves? I think we have an obligation with students to talk about appropriate professional dress. For women who are well-endowed, that is sometimes difficult to find clothing that covers cleavage, for instance. Different generations look at dress in different ways. The question makes me think of the blaming stuff that we used to do, that somebody is responsible for how another person reacts to them. To a certain degree, I think that we, as mental health professionals, should be aware of that. If you look at Freud's transference and countertransference, you likely are going to have patients who begin to have sexual fantasies about you or them, or you may have the same thing about them. That's where I think that, as mental health professionals, if we have mentors, if we have people we can call and work things through with them, that that helps us maintain that professional distance. As far as how you dress, there is a degree of awareness, I believe, that people ought to have about it, and to make sure that they're not provocatively dressed, that they're dressed professionally. Do you think that answer to that? I agree. Oh, yeah. No, and the person's writing back that you've captured it well. Good, good. One thing, we learned this when we were doing our training, but sometimes we haven't had to practice it so much, but how do you talk to a client, I think this person's also asking, how do you talk to a client when they comment on your dress, or your sexuality, or your relationship? Right, and that is so incredibly difficult from time to time. There are those that I'm able to say, gee, that's a really lovely compliment, and I appreciate that, but let's go back on what's going on with you. There are some that you can redirect quite easily. There have been a couple where I've had to say very clearly, look, I'm married, I am very married, and we need to talk about what's going on in this particular thought process. I remember one client, and this was not a sexuality thing, but she really felt that we were friends, and she was horrified to find out that I can't be your friend on Facebook because I'm your therapist, I am not your friend. Each of us has to practice doing that, I think, and practice figuring out a way to say something gently in a nonjudgmental way. It's okay to accept the compliment, but lead it away from that. Some people I've explained transference and countertransference to, and for some people, that has made sense to them. Then recognizing your own level of discomfort. There have been some people that I just haven't been able to help because it just makes me too uncomfortable, and so I need to figure that out and to pass them on to somebody that's going to help them. Right, right. I mean, we're getting to the top of the hour, but I just think one of the, just to sort of close on what you're saying is, you know, what I talked to you about as we started this talk today before we joined the group is, you know, this is a topic that we all have to get more comfortable with in sessions with our clients because it really does interfere sometimes with adherence and their quality of life, and so I'm really glad that you were able to lead us through this today and give us some really great tips, and I appreciate everybody who wrote in questions.

spontaneous improvement

sexual dysfunction

anti-psychotics

psychosis

sexual relationships