Did the drug of choice heighten sexual pleasure for the client?
Did drug or alcohol use contribute to decisions involving sexual behaviors or sexual partners that would be different when sober?
Did the client trade sex for drugs?
Was loss of sexual pleasure a result of using?
Is substance use a trigger for sex?
Is sex a trigger for substance use?
Intake is the place to open up this area for discussion, since treatment planning is often based on areas of concern identified at admission. Questions about intimate relationships should be part of the intake process. Psychosocial histories usually address childhood trauma and sexual abuse, but the quality of intimate relationships less often.
Treatment too often addresses HIV, STDs, birth control and safe sex practices without enough focus on intimacy issues. Treatment planning and ongoing treatment need to address intimate relationships, so that clients throughout the continuum of care understand the specific interaction-unique to each of them-among sex, intimate relationships and substance abuse. Some clients might fear that their sex drive has permanently disappeared, while others might be concerned that the quality of their relationships will decline without drugs.
Aftercare plans should address the lifelong goal of working to continually strengthen our relationships. Clients who have the self-awareness to seek professional help before a relapse to drug use often report relationships as their main area of concern. Relapse prevention plans need to include specific information in this area.
As in all other areas of counseling, care needs to be taken so you don't press your clients to make the exact same choices in their lives that you have made in yours. With some clients we'll be working on refusal skills, assertiveness and ways to avoid feeling pressured into sex. With others we might be working on ways to make better connections and to make sex more satisfying.
Challenges counselors face
To address this area adequately, we need to overcome several obstacles. We might become uncomfortable when clients use street terms instead of the more clinical words we might use to describe sex acts or sex organs. Identifying problems in this important area is a higher priority than using appropriate language. With graduated exposure to this situation we can find a balance between modeling more appropriate language and encouraging discussion by allowing clients to use whatever words are most comfortable for them.
Many substance abuse specialists feel outside the area of their expertise when dealing with issues of intimacy or sex. It's important to listen at least long enough to make appropriate referrals. It's likely there will be times when client choices-past, present, or future-will make a counselor too uncomfortable to be helpful, and counselors should identify in-house or community resources to which to refer these clients. An agenda for programs and practitioners who would like to set up training in this area is offered in the article “Addressing Sexual Issues in Addiction Treatment.”1
Educate your clients
Based on their past histories, our clients might have unrealistically low standards for relationships. The ways we relate to our clients can contribute to a higher expectation for other relationships, but this modeling in itself is not enough. Client education is also important.
Many people who get deeply involved in addiction have had mostly unhelpful and unsatisfying relationships. It's important for them to get a grasp on what positive relationships look like, and to understand some warning signs that a certain relationship is not helpful.
Healthy relationships are mutually satisfying and rewarding. During the course of a long-term, loving relationship there may be periods of time when it seems as if one party or the other is doing the most work. But good relationships are good for both parties and not one-sided.
Healthy relationships are respectful and not exploitative. In a good relationship, both parties feel they have made a choice to participate. In unfulfilling relationships, either or both parties might feel as if they have an obligation to participate.
Healthy sex can be an expression of true love, but never a condition of love. Persons in a healthy relationship feel more in touch with themselves, more confident, and more self-aware than in other relationships where they feel shameful, disrespected, or shortchanged. Healthy relationships have helpful boundaries, where each person's sense of self is completely intact.