Behavioral Health Brief: Intimacy and Self-Love in Individuals With Mental Illness
By David Kamnitzer, LCSW-R, and Jose Cotto, LMSW
Social Work Today
Vol. 18 No. 6 P. 8

Social work has always been about "meeting people where they are." As clinicians, we were taught to respect self-determination and to conduct psychosocial assessments so that we can get a better understanding of a person's family of origin, history of trauma, and education, among other dimensions.

The curriculum that many of us were working from was timely and effective. Groups on communication skills, medication management, and symptom management seemed purposeful—particularly for individuals who were known to have a severe mental illness (SMI). We are in a new place in our profession—a place where diagnosis becomes less important and viewing the whole person who is capable of full community inclusion is paramount.

As social workers, we must look at our practice and ourselves. We must be willing to have difficult discussions with the people we work with on topics such as trauma and feeling marginalized but we must also be willing to discuss connections, relationships, self-love, and intimacy—topics that were often considered sacrosanct and taboo, particularly in our work with individuals with schizophrenia, major depression, and other mental illnesses.

Paradigm Shift
There is an important paradigm shift occurring today, one that promotes the belief that individuals diagnosed with chronic mental illness can lead healthy and normal lives and that a satisfying sex life complete with dating and courtship can be recognized. Yet too often, discussions with mental health professionals around sex and intimacy involve conversations about condom use, medication side effects, and the risk of contracting sexually transmitted diseases.

Unaware of their own personal biases and preconceived stereotypes, mental health professionals may avoid discussions about sex and intimacy without realizing the negative effects on individuals and how they may internalize such messages. Similarly, many inpatient hospital settings and community residential programs have strict, often controlling rules and regulations that discourage sexual relations and intimacy.

Social workers have always been faced with complex issues around the topic of boundaries and therapeutic rapport, especially when working with individuals with SMI. Questions often surface about "just how deeply" social workers can engage with people. Some worry about exacerbating symptoms and individuals unraveling due to histories of trauma. Others may be concerned about their own well-being, fearing that if they discuss topics that seem too sacred that they too may experience their own discomfort (Holloway, 2018).

Today, these discussions are more important than ever. As we begin to obtain data related to whole health, there is clear evidence emerging around the correlation between social isolation and depression (Teo et al., 2018). As hospital beds close and we enter into a new era of prison reform, social workers must start thinking about both social policy and new programming opportunities.

It is indeed this new paradigm that raises the question: Are we doing a good enough job talking with people about social connectedness and self-love? In most cases, we are not.

Expanding the Boundaries of Care
So, how does it begin? It begins at intake. While we're obliged to inquire about trauma and events that some people are uncomfortable disclosing, we also need to ask clients about their social network, love life, or lack thereof. We need to ask about the last time they went on a date with another person and also with themselves.

Some agencies are asking people about their natural supports but tend to keep it simple and limited. To be even more person centered, individuals should be given the opportunity to invite their loved ones and/or significant others to participate in the early stages of enrollment (Adams & Grieder, 2014). This can lead to a significant increase in motivation for change and accountability.

The notion of expanding the boundaries of care reinforces our ethical responsibilities as social workers: to truly be committed to a person's recovery and their interest to connect with other people and/or be intimate with others. It speaks to the core value of the "importance of human relationships [and] the dignity and worth of the person" (National Association of Social Workers, 2017). Moreover, it helps people to self-actualize by creating an attachment to another person and creating what many of us seek—a romantic relationship and a family of our own.

How do we best understand touch, intimacy, and relationships in one's road to recovery? Some of our approaches and interpretations derive from object relations, relational theory, attachment theory, cognitive behavioral therapy (CBT), motivational interviewing (MI), and a few others.

We pull from object relations to address transference and countertransference during supervisions and to explore safe objects (Cashdan, 1988). We refer to attachment and relational theories to explore various relationships throughout the person's life beginning in early childhood and the impact these relationships have had on a person's trajectories and their environment (Wachtel, 2008).

CBT and MI help us choose the appropriate interventions to expedite recovery. When utilizing CBT interventions, aside from helping people explore and comprehend the connections between their thoughts, feelings, and behaviors, it is important for social workers to determine some of their core beliefs and through what lens the person is viewing the world. This will help individuals make more sense of their current connections to others (feeling unworthy and therefore avoiding opportunities to connect). With that understanding can come change.

MI techniques become pivotal to eliciting that change by tapping into the person's intrinsic motivation and implementing stage-appropriate interventions to increase or improve their readiness for touch, intimacy, and relationships.

The therapeutic rapport is an intervention in and of itself. It becomes a vehicle for individuals to work through areas of vulnerability related to intimacy and relationships. As social workers, we are trained to foster safe and affirming environments. Through relationship building, the social worker becomes a safe object that allows people to be vulnerable and work through feelings they would otherwise avoid expressing. This is tantamount to the world extending beyond those professional walls.

Social workers have the ability to provide a "corrective emotional experience" for the people they serve, helping them work through feelings of rejection and abandonment. The space becomes a place for individuals to play out different roles and experience unconditional acceptance and positive regard.

Teaching and Learning Opportunities
As social workers, we provide learning and teaching opportunities through different modalities, one of them being workshops. For example, an agency can host workshops on self-love and community meetings that become speed dating socials.

Our agency has held workshops on self-love to help people identify and embrace their strengths, allowing them to make space for healthier connections out in the community. We refer to them as workshops as opposed to treatment groups because the former sounds more appealing and normalizes the experience for participants.

To further integrate topics on intimacy and mainstream the message, we tap into existing social media that can help foster intimate relationships. We help people navigate virtual communities to ensure safety and enhance their own skills, which in this case involves technical savvy, particularly when it comes to dating sites and apps.

This dialogue and psychoeducation requires providers to step out of their comfort zones and reexamine their professional boundaries. The online world simply cannot be dismissed or set aside, because it impacts the people we work with when it comes to their self-esteem and socialization.

We also aim to include the themes of sex, love, touch, and intimacy on staff agendas as a standing item. Social workers must maintain ongoing dialogue and to strive for competence (National Association of Social Workers, 2017) by providing and linking staff to relevant trainings in this area to become more efficient change agents. This is especially field-based; it behooves us to consider how we engage with people in our programs and how we can best help them thrive.

The topic of intimacy and relationships often evokes strong feelings. For individuals diagnosed with major mental illness, articulating such feelings and the personal expression of romance and sexuality may be more complex than for most individuals. The lack of intimacy and/or social isolation, depressive symptoms, psychosis, and a general sense of feeling stigmatized may often lead to low self-confidence and despair.

At the cornerstone of psychiatric rehabilitation lies the promise of hope and connection. As human beings, people have an innate desire to be loved, touched, and cared for, and this same principle applies to individuals who have been labeled with mental illness. As advocates for change, we are able to provide "holding environments" for people who seek our help. Social workers are at a pivotal place in time where realizing such constructs can become the new reality for persons served.

— David Kamnitzer, LCSW-R, is chief clinical officer at ICL, Inc.

— Jose Cotto, LMSW, is vice president for residential, rehabilitation, and support services at ICL, Inc.

References
Adams, N., Grieder, D. (2014). Treatment planning for person-centered care: Shared decision making for whole health. 2nd ed. Waltham, MA: Academic Press.

Cashdan, S. (1988). Object relations therapy: Using the relationship. New York, NY: W. W. Norton & Company.

Holloway, K. S. (2018). Examining counselors' level of professional experience with adult attachment style and comfort with emotional intimacy. Retrieved from Mercer University Research, Scholarship, and Archives.

National Association of Social Workers. (2017). Code of Ethics. Retrieved from https://www.socialworkers.org/about/ethics/code-of-ethics.

Teo, A. R., Marsh, H. E., Forberg, C. W., Nicolaidis, C., Chen, J. I., Newsom, J., et al. (2018). Loneliness is closely associated with depression outcomes and suicidal ideation among military veterans in primary care. Journal of Affective Disorders, 230, 42-49.

Wachtel, P. L. (2011). Inside the session: What really happens in psychotherapy. Washington, DC: American Psychological Association.

Additional Resources
Farkas, M. D., & Anthony, W. A. (1989). Psychiatric rehabilitation programs: Putting theory into practice. Baltimore, MD: Johns Hopkins University Press.

Irene Ward and Associates (Producer) & Anthony, W. A. (Writer). (1996). Choose-get-keep approach to vocational programming [Motion picture].

Kadushin, A. (1990). The social work interview: A guide for human service professionals. 3rd ed. New York, NY: Columbia University Press.