Of Potions, Pills and Powders: Gay Therapist Describes Approaches to Drug Use in Gay Men’s Relationships

big silver disco ballDrug use in gay relationships is a common, if controversial, topic to discuss.  Regular readers know that I’m not one to shy away from controversial topics about gay men’s lives, and today I’d like to discuss this.  In the privacy of therapy, even when I work remotely with guys on webcam sessions, we use the luxury of confidentiality (with the usual legal exceptions like child abuse, suicidality, etc.) to explore the issues that guys “can’t” talk about anywhere else, sometimes including with their closest friends.  It’s that intimacy of treatment that I really like, because giving guys the opportunity to talk about the super-secret things on their minds can give them a sense of relief, to speak without being judged, and to get help/consultation or occasionally outright advice (which therapists use very sparingly!) on things they can’t reveal to just anyone.  I’m honored by this privilege, so I do my best to honor their confidence and trust.

Sexual issues are probably the first thing that comes to mind about these sensitive topics, but another topic isn’t too far behind:  Drugs.

Let’s face it; today’s adults all over the world, male/female, straight/gay, and variations, are somehow exposed to drugs.  For some individuals and couples, any kind of drug use, ever, is completely anathema, and I don’t judge that choice (I think there are pros and cons to every option).  Since I work in Los Angeles, I see a lot of guys who work in entertainment, and I always use the joke, “Why aren’t Hollywood pyrotechnicians who blow things up all day all burnt up themselves?  Because they know and respect the dangerous power of the incendiary/explosive materials they use and use them with this respect and safety procedures that keep them from getting burned.”  It’s the same with drug use and the Harm Reduction Model.  The next thing to total abstinence of using any kind of substance recreationally is to know about it and respect its power to get you high and have fun, while still respecting its potential power to cause almost immeasurable harm. People approach substances on a continuum from no use at all, to occasional, moderate, frequent, chronic, compulsive, and chaotic use.  The riskiest part is that no one who gets to chaotic/addicted use ever intended to be there when they first started experimenting, but somehow they can end up there.  It’s a risky game, but many people play this game frequently and without serious consequences, while some face severe hardship.

But it’s also important to note that despite the high profile of addiction issues in the media, and of course the ubiquitous plethora of “recovery” programs (which are inherently a luxury item for the upper classes, or even a status symbol, due to their upwards of $30,000 a month price tag for “treatment”, often staffed not even by licensed or license-eligible, Master’s-level therapists), it’s also true that we have many more users of alcohol, cocaine, etc., who never get addicted.  The tricky thing is, which “camp” does one ultimately fall into over time?  For some, this is a reasonable risk and they can use something potentially addicting for years with relatively little harm; for others, there can be a substance-related deterioration to their lives rather quickly.

Discussions with Your Partner

It is in this background that I work with very many gay individuals, and couples, for a long time now (24 years), and part of the services I offer is helping guys who have developed alcohol or drug problems (more on that, here).  A question came up recently from a client about how to talk to his partner about his desire to want to use a little bit (“like, a few bumps on the end of a key during a few hours at a club”) of cocaine. He was concerned about how his partner would react.  In his past, he did this out at clubs for years in previous relationships, with relatively little harm.  But his new partner was against any kind of drug use at all.  This situation is not unique, particularly when gay men are early in a new relationship.  Just like other variables like how to spend time, how to spend money, what kind of sex to have, whether to be monogamous, etc., I believe a gay male couple should discuss their feelings and opinions about alcohol and drug use.

In couples counseling, I always say that the building blocks of a good relationship include Commitment, Communication, and Compromise (my article on these is here).  It also involves the skills of making your relationship work on four levels:  1) Emotionally (including loving or being “in love” with your partner); 2) Physically (from casual affection rituals to the quality of your sex life);  3) Domestically (making a home together and managing finances, chores, etc.); and 4) Managing “The Other” (dealing with any stressors or intrusions (including people) who undermine or distract your relationship (my article on that is here).  So, the discussion of where the recreational use of alcohol and/or drugs fits in your relationship is part of all of these categories, in some way.

Therapy is tricky because I cannot legally or ethically encourage anyone to do anything illegal.  But there is also a cardinal social work tenet (I practice therapy as a clinical social worker; most people don’t realize that the majority of therapy in the United States is delivered by clinical social workers, not psychologists!) that says “start where the client is”, as well as a client has “a right to self-determination”.  I have worked with many (!) guys in recovery from alcohol (my article on that is here), cocaine, prescription painkillers, crystal meth (my article on that is here) and sometimes even too much marijuana (yes, there is such a thing LOL – my article on that is here).  But for many of the guys I see, they aren’t undergoing therapy or coaching for those issues, it’s about relationship issues or career coaching or something else, and in the course of working on those, they might mention their recreational drug use with their partner or their friends.

Pros and Cons in the Landscape of Substances

Some of the benefits that clients have mentioned have included using marijuana to manage some anxiety or ADD (Attention Deficit Disorder) symptoms, or even as a stress management resource. Physicians prescribe medical marijuana in states like California (and many others) for these and other purposes.  Alcohol is perhaps the most frequent discussion I have with clients, and I think there is a “sweet spot” of not too little and certainly not too much, and finding that is some trial-and-error of types of drinks, pacing, frequency, and strength of “pour” at different bars.  With couples, I’ve noticed that their worst fights always have some connection to alcohol, which can disinhibit partners up to and including acting out violently with one another.  Safety is always a part of Harm Reduction, so I will often discuss with couples how they avoid driving under the influence, even if we are discussing other topics at the same time.  Too many times, couples have overlooked the drinking/driving mix, in the context of talking about a fight.  Fortunately, with the advent of Uber and Lyft, fewer people are risking DUI, which is a major emotional, legal, and financial hardship.  In my observations in couples therapy, it’s hard to find domestic violence incidents that weren’t preceded by alcohol.

Cocaine is a tricky one.  Some clients report a general “energy” or “boost” from doing “bumps”, which is perhaps safer than doing full “lines”.  From a Harm Reduction perspective, doing less of any substance (while still using some if they want to) is a good rule of thumb.  Don’t do a lot, if only a little will “do the trick”.  The “less is more” approach to a night out can be wise.  Cocaine ban be insidious; while many (!) people do it in relatively small quantities with little demonstrable harm, I’ve also worked with guys who really got hooked.  Having a mindful awareness can help.  How much are you using? How often are you buying it?  How much are you spending on it over time?  If you mark a wall calendar every time you use it, does the number of marks go up over time, or become more frequent?  Is the good time you had the night before “worth it” the day after?  How do you know when too much is too much?

The use of MDMA (“Ecstasy” or, more recently, “Molly”) can actually lead to a positive experience for gay male couples that has been reported to me frequently over the years, allowing them to open up and speak frankly in a certain “truth serum” effect to talk about things (even on a dance floor at a club!) that they have been avoiding talking about while sober.  The trick with that is to carry over the intimacy of a molly-fueled conversation then to the sober times, and learn to communicate with a partner more frankly and intimately.  (Historically, MDMA was used in therapy/treatment settings to enhance empathy, before it was made illegal.)  I have been fortunate to travel to a variety of cities in the world, and visited gay bars and clubs, and seen its use in Puerto Vallarta, Vancouver, Chicago, New Orleans, Orlando, Austin, London, Amsterdam, Berlin, Paris, Barcelona, Madrid, Boston, DC, Atlanta, Miami, etc., and that’s just the gay spots (let alone the far greater number of straight people using it).  It’s important to recognize that this globally-ubiquitous use must point to a certain reasonable safety, although there have been cases of tainted or overdose use that has lead to fatality.  But if it were all that extremely dangerous, we would know by now.

“Special K” or ketamine, is liquid-to-powder snorted drug common in clubs, which has its main (legal) purpose as an animal tranquilizer.  Part of what is of concern from a public health point of view is that ketamine can be dangerous or lethal if mixed with alcohol, as both are “downers”.  From a Harm Reduction perspective, ideally, there would be public health educational information specifically for the gay male community, but as politics would have it, unlike Europe (where public health drug use information is common), the United States government is so knee-jerk anti-drug that they won’t even “dignify” the discussion with actually helpful (possible life-saving) public health information to reduce harm by telling guys what not to mix together.  This is a tragedy, as Harm Reduction education accepts that drug use is going to happen, but warns users of how to use more safely.  Same thing with “poppers” (legally sold as other things) and the warning to not mix those with Viagra, Cialis, Levitra, etc. (the erectile dysfunction drugs) because of potential harmful effects lowering blood pressure.  Same thing with “GHB”, which is perhaps especially dangerous if mixed with alcohol or used to overdose.  Mental health professionals, public health advocates, and even some “Left” physicians encourage public money to be spent on public health safety education regarding Harm Reduction.  It’s a shame that these issues get so politicized by Right-wing politicians as to stifle discussion, but if people are going to use, they need to know the precautions.  Ketamine, poppers, ED drugs, and even GHB can be used relatively safely, but someone (from a physician, to a savvy mental health professional, to a trusted peer) needs to tell the potential user that there are more-safe and less-safe ways of approaching these.  In Europe, the philosophy is that safety is more important than moralism or some kind of “cover your ass” avoidance of the entirety of the issues.

Crystal methamphetamine (“crystal”, “tina”, etc.) is in a class by itself.  Honestly, I have never seen “recreational” use of crystal that was ever maintained without serious addiction or harm developing.  This is one area where I will be quite directive with clients in encouraging them not to use or even experiment with this drug, because I have worked with many guys in recovery from crystal addiction and while it’s possible to recover, the “casual” use is just not worth it.

The lesser-known drugs like “magic mushrooms” or peyote I see so rarely as to not even have an opinion on those.  I have only seen heroin use rarely in my practice, and my sense is that it’s not really a commonly-used drug among gay men.  I have worked with guys who have become addicted to prescription opiates (painkillers).  My focus today is really on the most common drugs I see in my practice, which are the ones above.

Another whole category, anabolic steroids, is somewhat controversial, but the use of steroids by gay men was life-saving back in the days of AIDS-related Wasting Syndrome.  I don’t really put those in the same category as “recreational” drugs, even though their use is widespread (by BOTH gay and straight men — much more prevalent than most people believe).  More on that at another time.

Therapy Has a Left and Right

I have always said that just like there is a political Left and Right, there is a clinical Left and Right, from medicine to therapy.  A more “liberal” therapist (and there are many of these) would consider the variables and risks/benefits, or pros/cons, in what is called “Motivational Interviewing” or even just critical thinking.  A more “conservative” therapist (and there are many of these, too!) would take the stance of what I call the “all’s”:  all drugs are all bad, all the time, for all people, in all circumstances, always.  I believe talking about these issues can be valuable in session, so that a person brings a certain mindfulness and careful judgment to whatever they are doing.  Not just regarding drugs, but also sex, how they spend money, how they eat, how they approach self-care (including medical care, or even dental cleanings!), and how they monitor for HIV (if HIV-negative) or how they approach self-care if living with HIV (medication adherence), or other self-care habits (STD screening, sleep, stress management).

How to Talk to a Partner About Drugs

If you’re in a relationship now, have you and your partner ever talked about drug use?  Do you feel like you could open this topic and have a frank discussion of what your opinions/preferences/philosophies are, and ask him about his?  If you disagree on how to approach this, could you discuss compromises, such as phrases like, “What if we…?”.  Sometimes, if you had parents who were in over their heads with alcohol or drugs, that can have a strong impact on you, and you might fear that your partner might “act like” your parent did.  In a case like that, can you ask your partner to find a way to reassure you?  Family of origin issues often figure very prominently in couples therapy, because those experiences in our own families (or even in previous relationships!) can strongly affect your current relationship.  Your psychological defenses will be activated if you see similar situations now that you somehow saw in your past, which can lead to sadness, anger, or anxiety.

Many therapists can be uninformed about even what the Harm Reduction approach is, and take an “abstinence only” approach, particularly if they specialize in substance abuse recovery.  Even physicians will generally take a conservative approach, with the “all’s” theory, because they don’t want to be seen as “condoning” or “recommending” your doing something illegal or “unhealthy”.  But if they take too blanket an approach, it can stifle a client from asking hard questions and having a frank discussion.  In therapy with me, I don’t “tell” or “direct” a client to do, or not do, things.  We have an open discussion, and bring critical thinking to all situations, assessing the pros and cons of various options until you come to your own decisions about how you want to handle things.  This is true of both individuals and couples.

Next Steps

If you have any concerns about the topic of alcohol or drugs in your relationship, try to muster the courage to sit your partner down and open the topic for discussion.  Write down a list of questions or concerns for him.  Use some joining language, like, “What do you think we should do regarding…?”  Or, propose something: “What if we…?” and see how your partner responds.  Discuss the pros and cons of any ideas.  If this is difficult to do at home, consider having some couples therapy or relationship coaching on these issues, so that we create a safe space for frank discussion that would help relieve any anxiety you have on these topics.  There are many options that work for many couples, and it’s really up to every couple to negotiate what is right for them.  This is a topic many people don’t realize can be part of couples therapy, when it’s actually quite common and can lead to decisions and agreements that feel good to both partners because they have been forged through sensitive and candid discussion, guided by a therapist who has helped many gay male couples through these same situations before.  Call or text 310-339-5778 or email Ken@GayTherapyLA.com for more information on sessions in person or through phone or webcam.

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