Intimacy, sexuality and psychosis – breaking the taboo

Challenges of dating leads to exclusion in those with psychosis

Healthy romantic relationships can greatly improve wellbeing.¹ For individuals with a psychotic disorder, dating can present several challenges and excludes many from intimate relationships.^2,3 Recently, great emphasis has been placed on recovery in mental illness, including improvements in personal relationships, and while much qualitative relationship data are available, quantitative studies are lacking.

For individuals with a psychotic disorder, dating can present several challenges and excludes many from intimate relationships

Briana Cloutier, University of Montreal, Canada, undertook a systematic review of studies published in the past 15 years on romantic relationships and sexuality in the context of psychotic disorders and which focused on factors facilitating and/or inhibiting recovery.⁴ A total of 43 articles were included in the review, 24 of which concerned negative aspects of intimacy, such as risky behaviors, and 19 of which dealt with positive aspects, for instance, marital functioning.

Emphasis on the negative rather than the positive

What was interesting was that while a host of negative variable were identified that might inhibit romantic relationships (i.e., sexual dysfunction, history of abuse, low self-esteem, lacking intimacy skills, internalized stigma), none of the studies looked at variables that promote healthy intimate relationships in patients with psychotic disorders.  This highlights the need for greater communication about the intimacy needs of those with psychotic disorders and the development of better tools and services to help meet these needs, for instance, improved staff training, intimacy skills building and couple therapy.

The need for greater communication about the intimacy needs of individuals with psychotic disorders was highlighted by a recent meta-analysis

Five factors influence the experience of intimacy in patients with psychosis

In depth, subjective information about the problems those with psychotic illness experience in establishing and maintaining an intimate relationship were reported by José de Jager, Maastricht, The Netherlands. In total, 28 patients with a diagnosed psychotic illness being cared for in the community undertook semi-structured, in depth- interviews about intimacy. Patients were aged between 18-62 years, were mostly male and mostly single.

From analysis of the interview data, five factors emerged that influence the experience of intimacy in patients with psychosis:

• Psychiatric complaints – paranoia is a big barrier to sharing feelings as patients perceive that intimate moments could be captured and used against them
• Medication issues
• Stigma and self-stigmatization – fear of rejection because of mental illness is common
• Lack of social skills and experience – while their peers are dating, young men are often being admitted and receiving treatment thereby missing out on important social milestones
• Sexual abuse – high barrier to intimacy when patients feel they have previously been used as an object and have trust issues about whether or not this might happen again

It appears that these five factors hamper the preconditions of self-disclosure and responsivity needed for intimacy, and it is thought that self-esteem underpins this process. Data to support this hypothesis are currently being assessed.

We need to talk about intimacy with our patients!

What has emerged from the work reported here is that patients enjoyed talking about intimacy and 33% welcomed follow-up. Sadly, only 25% of patients were ‘brave enough’ to address the topic of intimacy with their caregiver themselves - caregivers assume that patients will present the topic.

Only 25% of patients were ‘brave enough’ to address the topic of intimacy with their caregiver themselves - caregivers assume that clients will present the topic, a study found out

Relationship satisfaction status guides mental wellbeing

Rebecca White, University of Manchester, United Kingdom, investigated whether being more satisfied with a romantic relationship increases wellbeing in people who experience psychosis.

Unhealthy or tumultuous romantic relationships can become stressors and risk factors for relapse. She reported that relationships with higher levels of ‘fearful attachment’ or ‘partner criticism’ were associated with lower levels of relationship satisfaction status (RSS). However, overall, having a partner was associated with increased levels of RSS. In turn, improved RSS was associated with better mental wellbeing, lower Community Assessment of Psychic Experiences (CAPE) depressive scores and reduced symptoms of psychosis (assessed through measures of loneliness, internalized stigma and self-esteem.

Having a partner was associated with increased levels of RSS and associated with associated with better mental wellbeing

She concluded that romantic relationships should be considered an area for support by mental healthcare professionals, particularly for those patients dissatisfied with their romantic relationship status.

The Power of Two

Romantic relationships should be considered an area for support by mental healthcare professionals

Professor Tania Lecomte, University of Montreal, Canada, described the Power of Two initiative – a program that helps young men with psychosis build romantic relationships. Development of the program went through several stages.

First, it was determined that single, young men with early psychosis had a more anxious attachment style, linked with increased self-stigma, fewer social and intimacy behaviors and were less self-confidence compared to single men in a relationship.⁵

Identifying obstacles to intimacy

Next, a qualitative study was undertaken in young men with psychosis who, had been in a romantic relationship at least once.⁶ This identified the obstacle to intimacy that would have to be overcome, including self-stigma and awareness of social skills deficits. Intimacy was an abstract concept to many study participants possibly due to social cognitive deficits and sexual trauma in childhood in some. Interestingly, most felt more comfortable with sexual rather than emotional intimacy.

Intimacy was an abstract concept to many study participants

Finally, a pilot intervention - the Power of Two - was generated and trialed on 7 young men with early psychosis.⁷ Recruits attended 12 sessions offering cognitive behavioral training, social cognition, psychoeducation and social skills training on topics as diverse as how to prepare for a date and sex and intimacy. Assessment showed that in this pilot, improvements in social functioning, especially romantic functioning, were apparent as was an improvement in theory of mind (recruits could better gauge the other person’s intentions).

Improvements in social functioning, especially romantic functioning, were apparent as was an improvement in theory of mind

Preliminary results from the pilot program are encouraging

Currently, the Power of Two program is being rolled out at a number of sites. Despite the COVID19 pandemic, 11 of the 40 intended participants have been recruited. Preliminary results already show statistically-significant improvements in romantic skills; intimacy skills are also improving.

As Professor Lecomte concluded, Power of Two program should help patients with psychiatric disorders achieve their recovery goal of developing healthy romantic relationships. Service training must change so clinicians can feel comfortable discussing such issues.