I grew up in Manhattan in the early to mid 60s. I had a pretty free run of the city on foot, and by bicycle, subway and bus. That meant daily contact with New York City’s racial and cultural diversity. My family’s racial/ethnic awareness was a mix of tolerance, openness, generosity, fear and stereotyping. I went to a private school that was not very diverse.

In college, I lived off-campus on the South Side of Chicago. Then, back to New York City from the mid-70s to early 80s. In the early to mid-80s, I lived in Boston, and traveled on business throughout Europe. I had to learn and adapt to different national and cultural customs.

In the late 1980s, I moved to Los Angeles, a diverse city of neighborhoods.I began my clinical training there in 1992, received my MSW in 1994, and continued my post-graduate work until 1997. Apart from an internship in an employee assistance program, most of my clients were black, Latino, poor, seriously mentally ill and involved with police, courts and probation.

Significant and lengthy personal experience with people different than oneself is necessary, but not sufficient, to practice without prejudice. Despite my life experience, I am still a white, upper middle class man, partially blind to my assumptions of privilege.  But my experience has taught me to face directly and without overwhelming shame, my own prejudice. I accept that it exists, to some extent it always will, and increasing my awareness while struggling to treat people equally is a lifetime project.  I will engage in this struggle with my clients.

All of the above applies to my work with women, gay and lesbian clients and those from different religious backgrounds. To date, I have generally developed better therapeutic relationships because of this painful and often embarrassing approach to my work. Clients are freed to explore their own blind spots too.

I continue to believe that there are some universal values that I can represent and practice with. Genetically, human beings are virtually identical, though the genes may be expressed  differently in behavioral terms. Couples – people in committed relationships – operate by certain rules that can and do transcend ethnic culture, sexual orientation, race and religion. So, while I hope to never ignore culture, race, class, religion, sexual orientation, and more, I cannot be simultaneously guided by them all – all at the same time. We are bound together by our common humanity.

* While President of the WSSCSW Board from 2008-2010, I continued development of the organization’s stance on cultural diversity. I managed the revision of By-Laws to include mandates on programming that focus on diversity clinical practice, as well as surveys to determine progress in developing a more diverse membership.

I am dedicating my year end post to this part of my practice, to express my gratitude and deepest respect to the men and women who I met in this work in 2011 (and really, everyone over the last 12 years). They show me what people are like at their best. Many times, that “best” comes forward not just as deeply sympathetic, supportive or honest grief, but also as startling and even anxiety-provoking honesty.

Even in the midst of expressing the shock and grief from directly witnessing and responding to fear, grief and close proximity to losses of life or health, people can be very honest. They say what’s true about their feelings, the complexity of the situation they face, and their feelings toward those who were imperiled, injured or killed. Within the circle of people who are closest to who was endangered, injured or killed, the honesty is healing, just like the many kind and supportive acts that are performed for families and co-workers.

The humor that people are capable of is also healing and profoundly human; within the immediate group affected by the loss, the humor is always appropriate, without any specific effort to make it so. And that humor, expressed by those further removed from the most immediate group, is either less meaningful, or worse. It’s often put forward by those who thoughtlessly try to make themselves feel better.

To those who suffered and lost, thank you for letting me “in”, and teaching me again and again what’s best in the human spirit. After I left you that day, I believe you continued to develop and respect the grief process that causes us to grow, mature and appreciate the life and health we have.

Apart from the current state of psychiatric diagnosis, I outline some basic questions about what sex addiction might mean for a couple. First, let’s briefly review the latest psychiatric/medical diagnostic thinking.

The official diagnostic reference, the Diagnostic and Statistical Manual (DSM), will introduce ‘sex addiction’ in 2013 (DSM-V) in a brand new diagnosis, “Hypersexual Disorder“. It posits ”normal” sexual behavior - coitus and pornography/fantasy - which is “repetitive, excessive, or disinhibited”. This last part is derived from diagnosis of chemical dependency, even though the overall diagnostic category is a sexual disorder. The behaviors must occur despite “adverse consequences” (also a chemical dependency criterion) to either individual health (higher risk of STDs and sex offenses), relationship/marriage and employment. Research is not conclusive on the neuro-science behind the diagnosis, specifically whether one can become dependent on dopamine produced by orgasm.

In everyday reality, couples begin therapy, and either one partner says the other is a sex addict, or, they agree that one of them is a sex addict (it’s very rare that both acknowledge ‘sex addiction’.)  The sexual history of each partner, of the relationship (including who has been the higher/lower desire partner), past relationships, the partners’ parents’ relationship, the role of pornography, sexual contact with third parties, alcohol or drugs – all of these and more factor into the big picture. A loss of credibility/integrity overarches everything when the sexual activity was covert. Divorce may be imminent, or, a confused, ambivalent period of healing looks like the only option for the future.

Labeling a partner as a ‘sex addict’ confers shame and a simultaneous reduction of choice and responsibility for that partner. Many people question whether addiction can be ‘cured’, and telling one’s partner that they will be in perpetual recovery has consequences. Labeling someone a ‘sex addict’ expresses the intense pain, betrayal, sudden loss of intimacy & integrity. Past deprivation is re-experienced.  The labeling can begin a cycle: 1) immediate relief or “improvement”; 2) relapse; 3) further shame.

I think that ‘sex addiction’ is one way to construct what the behavior means for a couple. That isn’t ‘right’ or ‘wrong’;  partners ultimately decide how they make meaning and attribute motives for what’s happened.  But in a case where progress is stalled, couples look for a way in therapy to have things develop further. As always, the questions that get asked are more influential than the answers (advice) I might provide.

Does pornography/fantasy content represent the setup to the addiction, or the addiction itself? Can the ‘addict’ permanently help him/herself? Is he/she out of control?  Is the ‘addict’ truly responsible, truly choosing the behavior(s)? If the ‘addict’ stopped the behavior(s), would the partners resume wanting each other and would sexual relations re-commence? These and other questions may begin to develop progress when the recovery process has stalled.

There may ultimately be a painful acceptance that there is no scapegoat, be it a partner or the internet; in a committed relationship, every meaning is co-constructed. The ‘addict’ partner often claims that they themselves were deprived by the other. It  may become possible for partners to see the covert, repetitive sexual activity for what it says about them both, not just one partner. And then real couples therapy can begins, as distinct from one partner anxiously witnessing the other’s recovery from ‘addiction’.

I’ll close this long post by thanking Esther Perel, who gave me a long answer to a question I asked her about working with the idea of ‘sex addiction’. When I finally de-constructed her response, it was both and empathic and observant (and so clearly the result of long work and clear thought).

Topics include: “Confidentiality, Secrets, and How to Deal with Affairs” (Esther Perel); ”Taking Off the Masks: Truth-Telling in Couples Work” (David Schnarch) and “The Logic of Eroticism” (Marty Klein). In addition to working with the latest material from both Perel and Schnarch, my two greatest clinical influences, this series also gives me a chance to listen and direct questions to some top practitioners who practice and think quite differently than they or I might.

I am just finishing my review of tapes from the series of six hours that I took from Tammy Nelson and Esther Perel. They are brilliant and deeply encouraging people. I will blog some of the thoughts that stand out for me from that work shortly. [UPDATE: My first blog post directly stemming from this series is titled "On (sex) addiction" Your comments are very welcome!]

Too often though I’ve seen that big impact come from assumptions of how trust operates between two partners. Instead of trust being the explosive charge in a broadside complaint or attack (“You can’t be trusted!”), it can become a simpler, useful and practical tool for relationship development.

Trust is usually expressed in terms that are general (“He’s got trust issues”), or binary (“All the trust is gone” or “I trust her completely”).  I believe trust, in everyday life, is variable and specific. Therapy can make use of this different approach.

Why does trust vary? Because it’s a space – between a promise and a risk. Trust is high when a promise outweighs a risk, and low when the risk is more credible. What’s the promise, and what’s the risk? That’s what a couple determines, in any number of contexts.

Trust is also specific: there’s trust in oneself (self-trust), and trust in others.  By asking, “trust in whom?”; “to do what?” or, “to be whom?”, we create a clearer sense of self-in-relationship, and personal responsibility for developing trust. “I trust that you will want me when I’m 64”, “I trust myself that at 64, I’ll be very desirable.”

Another way trust is specific is simple. Partners can trust one another to be “good parents” for example, but simultaneously not to use money wisely, or stay sexually exclusive to each other.

This new blog has a rule that no post be very long. With a complex subject like trust, a lengthy post is a risk. I hope instead to trade some comment with readers, enabling me to keep my promise, and not violate the trust I’m offering early on in my blogging days.

They bring different therapeutic orientations to this subject. While I have long felt an affinity with Esther Perel’s work, my own training and orientation is different. To her credit she is quite familiar with Dr. Schnarch’s work, and studied with the late Edwin Friedman, one of the most widely respected experts on differentiation and Bowen theory. My training is also very different from Dr. Nelson’s.

There’s an old saying in my field: “The better the therapists, the more the therapies look alike.” I believe there’s some truth to this. It advises therapists to be able to stand apart (neither abandon nor be captive to) from their orientations.

Based on my experience listening to this class two years ago, I have some hope that posts I make from this will be directly helpful to you, or in our work.

For people searching for a therapist, I hope that this blog will be informative about my practice. I also hope it can enhance the work with current clients.

As an example, I will try to highlight those moments that, to me, are “of the essence” to psychotherapy, creating change and developing the self. They are brief but unmistakable and emotionally vibrant. We can physically feel them. I hold responsibility for fostering this level of connection, and linking it to therapeutic goals.

Malcolm Gladwell made these kinds of experiences the subject of his book, “Blink”. People can rapidly organize, e.g., synthesize, construct or integrate, huge amounts of past and present experience into a meaningful instant. These moments are remembered, communicated and can be put to use in relationship.

Numerous brain scan studies confirm that these moments, facilitated by specific parts of the brain, are a neurobiological reality. In couples work they are of particular importance. My role is to facilitate this connection between partners.

Initially, clients may combatively defend against them. Then, hopefully, they collaboratively welcome them. That’s self-development in a nutshell. It occurs in therapy, and, even more importantly, in committed relationship – where people develop most actively after they’ve launched from their families of origin.