Individuals with a past history of chronic psychiatric illness are often given poor prognoses that can limit their therapeutic horizons for further treatment. This pessimism may be misplaced as is demonstrated by the case of Jay, age 71, and Kay, age 65. The couple presented at the Loyola Sexual Dysfunction Clinic in a program consisting of 7 weekly sessions of 5 hours each with 2 trainee therapists.
Jay was born in 1924 in Gary, Indiana, a steel mill town. He was a child during the economic depression of the 1930s during which his father, though never completely unemployed, was reduced to working half time on the railroad. Though hardworking, the family experienced severe poverty. In 1936, when he was 12 years of age, Jay’s mother was institutionalized with a diagnosis of dementia praecox.
In May 1942, with the U.S. involved in World War II, Jay along with 50 of his classmates dropped out of school 2 weeks before graduation in order to have a choice of which branch of service to join. He enlisted in the Air Force and became a flight engineer on a B-24, serving with the 15th Air Force in southern Italy. On a return from a bombing mission over Romania, his bomber lost an engine as a result of being struck by an antiaircraft shell. A Messerschmidt 109 shot down the crippled plane, lagging behind the main formation, over Hungary.
Jay suffered 20 mm shrapnel wounds and was badly burned. Of the 10-man crew, 1 was killed, 1 could not be accounted for, and 1 fell 12,000 feet to his death when his parachute failed to open. The remaining 7 parachuted safely, and after being rescued by Hungarian troops from vengeful peasants, became prisoners of war. Jay spent 6 weeks in a Budapest penitentiary before he and other prisoners were marched off to a prisoner-of-war camp in Poland.
When the Russian army invaded Poland, the German authorities decided to evacuate the prisoners to Germany. Although already at the edge of starvation, Jay spent 3 months on the march, sleeping in fields, ditches, under trees, and in abandoned buildings in conditions of utter privation.
When finally rescued in southern Germany by advancing American troops, Jay weighed 103 pounds (at least 60 pounds under the minimum weight for a man of his size and age) and was not expected to live. Subsequently, Jay experienced recurring nightmares, reliving some of his combat experiences. Upon his recovery and return to civilian life, Jay found employment as an executive with a large national retail chain in California. After a career of 32 years, he retired to his native Indiana.
Jay met Kay at a roller skating rink and began a year-long courtship. He found her to be attractive and down-to-earth, and she saw him as handsome and a good person. They married in 1949 and had 3 sons. Shortly after the wedding, as the only living relative, Jay was expected to assume responsibility for his mother who was being discharged from a mental institution (due to the development of new antipsychotic drugs). Thereupon, his mother came to live with the young couple, an arrangement Kay accepted without complaint for approximately 5 years until he mother-in-law died at the age of 80 years.
In 1980, approximately 15 years prior to presenting at the Loyola sex clinic, Jay suffered a heart attack followed by repair of an aortic aneurysm at the Mayo Clinic. This was understandably a traumatic time for Kay.
Upon the couple’s presentation at Loyola, Jay was on Inderal (20 mg twice a day) and 1 aspirin daily. He had also undergone knee surgery and had a benign prostate module removed.
Kay had been employed briefly as a bank teller prior to her marriage at age 19. She described her parents as strict, religious, and punitive. Now 65, Kay was physically healthy and kept a good home, but she had a long history of depression dating back to the birth of her third child 39 years before.
The couple’s personal circumstances were further complicated by the treatment of each of their 3 children for acute and chronic depression. Kay described intense guilt whenever she felt sexually aroused by the attractive young men she encountered when shopping. She believed that sexual fantasy was a serious sin and therefore felt guilty. On a number of occasions, she affiliated with and sought advice from a fundamentalist religious group, although she did not divulge her (normal) sexual desires to Jay. He accepted her emotional problems as well as those of his mother, his sons, as well as his own night terrors.
Kay presented at Loyola with a long history of being treated with psychotropic medications and was currently using 6: Eskalith, 450 mg hs; Prozac, 20 mg bid; Mellaril, 50 mg hs; Trazodone, 150 mg hs; Triavil, 425 mg bid (which she had been taking for 20 years); and Xanax, 0.25 mg bid. This polymedication was excessive and blunted her responsiveness. She reported 2 psychiatric hospitalizations—1 postpartum, and the other, at the time of Jay’s aortic valve repair. Several therapists had treated her.
Currently she was being infrequently seen by a psychiatrist to renew her medications. She presented with a pronounced tremor, which suggested Parkinson disease, tardive dyskinesia, or severe anxiety. She complained of increasing memory loss so a CAT scan was done and intracranial pathology was ruled out when this was negative. Her psychiatrist was receptive to our medication reduction proposal.
As mentioned, Jay had a history of nightmares, the most vivid of which was being trapped in a burning aircraft. Kay did not know how to comfort him in these reenactments of his war experience. On retirement, Jay purchased a word processor. In an attempt to deal with his posttraumatic stress disorder (PTSD), he drew upon his diary to author a well-written and detailed autobiography of his World War II experiences (almost to the point of detailing the number of raisins in the Red Cross packages he occasionally received as a prisoner of war).
His nightmares ceased; processing his experiences had permitted him to consign his demons to the written page. His active self-help efforts constituted a strength and an important precedent for both his and her improvement in conjoint sex therapy. Freeing himself was a positive indicator for Kay also.
The therapists began treatment with routine detailed history-taking. Kay disclosed she had never experienced an orgasm; this had gone unmentioned at the initial intake discussion of Jay’s impotence. The 5-hour sessions, part of the normal clinic regimen, fostered an intense dialogue. During the third of 7 weekly sessions, Kay burst into tears and said: “I feel like I have been living in a prison.” The therapists responded that the purpose of the clinic was to assist her in escaping [prison].
They noted 2 things: (1) Kay gained new insight into her own situation; and (2) although her medications had remained unchanged, her pronounced tremors had disappeared (eliminating neuroleptic- and/or lithium-induced drug reactions as causative). She was much less anxious after the modified Masters and Johnson touching exercises (part of the Loyola Sexual Dysfunction Clinic routine) that they had been doing at home.
In the fifth session, Kay revealed that she had become orgasmic for the first time (at age 65) with the aid of Jay and a vibrator. Jay was having sustained erections leading to the conclusion that Inderal (Propranolol) was not a factor in his initial complaint. Both were smiling (and the therapists too!). The therapists heard nothing further about Kay’s memory loss or Jay’s impotence. They had successful intercourse. Subsequently, under medical supervision and in cooperation with her psychiatrist, a 4-week plan was initiated to reduce gradually and eliminate slowly all but 1 of her medications. This resulted in a marked improvement in Kay’s alertness and mood.
In the seventh and final week, Jay reported that he had recently returned home to find Kay engaged in an animated telephone conversation with 1 of her relatives. He noted, “We have been married 47, years and I have never seen her like that.” When Kay was queried about her reaction to encountering attractive young men while shopping, she laughed and replied, “When that happens, I go home.” When asked whether she then “took it out on the old man,” she blushed but did not answer (and he made no complaint!) The observed improvement was confirmed upon a single subsequent follow-up visit 3 weeks later.
Lessons to be learned from this case
–Dialogue can be powerful and effective.1 In a true dialogue, none of the committed participants has control of the process that takes a direction of its own
–Relatively open-ended, 4-hour marathons sessions permit complete and uninterrupted exploration of important issues to a final resolution in the absence of deadline pressures imposed by 20-, 40-, or 50-minute sessions. As long as patients are committed to engaging in meaningful dialogue, there is always the possibility of clarifying issues, resolving conflict, or gaining insight.
–Basing an initial prognosis on the patient’s previous diagnosis of chronic depression is inadvisable. With the exception of organic pathology or delusional states, there is a reasonable chance of sexual symptom reversal (or alleviation of other symptoms), regardless of a couple’s previous psychiatric history.
–There is a problem of over-prescription of combinations of tranquilizers and antidepressant drugs (possibly maintained for years after the depression has lifted). In this instance, “dialogue” proved to be the more effective treatment modality.
–Written autobiographical accounts of stressful experiences (self-dialogue) proved to be a valuable method for Jay in dealing with his PTSD. He concluded his story by describing his stable work and family history, a positive ending. This suggests that having a patient provide a written account of his nightmares—with the inclusion of an ending of his own choosing—may have a healing effect (something known from other contexts).
–Resolution of one problem often makes the resolution of other problems easier. Kay’s observation of Jay’s attempts to resolve his problems set the stage for her to resolve her own (suggesting that therapists should follow the line of least resistance in dealing with various problems presented by patients).
The therapists at Loyola took particular satisfaction in the successful outcome of this case. After Jay’s long early struggles and suffering from childhood to marriage, their combined years of care for his mother, depression in Kay and their 3 sons—both deserved a loving and happy retirement together. Basic discussion between 4 persons made personal and sexual healing possible, even at their advanced age.
Dialogue works—and there are times when it may work better than anything else.
1. Renshaw, DC. Seven Weeks to Better Sex. New York: Random House; 1995.