Issues for psychotherapists and counsellors

Authored by Henry Strick van Linschoten

Sexuality is such a fundamental part of human life, that it can touch or impact on almost any aspect of psychotherapy. But in practice, the following list of issues may be good to keep in mind when watching the videos and reading the other sections of this guide, as they keep recurring, and are main reasons why extra attention to the field of sexuality and sexology makes us better and more effective counsellors and therapists.

Listening for and recognising sexual and gender issues

The most important contribution of the videos in this module and sections in this guide may be a process of awareness-raising, so that sexual and gender issues, and their role in a client’s life and relationships, become fully present, can be talked about easily, and so that issues are recognised and opened up – of course only with the consent of and when so desired by the client.

Talking about sexual matters, even with partners or friends, let alone with strangers, remains a taboo in many countries, and quite clearly so in Britain. Hence it may not be natural for clients to believe that they can talk about sexual matters with their therapist, and in addition, they may not understand or believe that it may be related to the work of psychotherapy. It is therapeutically most desirable that the counsellor takes a principled stance of openness and is sufficiently trained and prepared so that no conscious or unconscious signals, verbally or through body language, are given to the client communicating the talking about “such matters” as less than welcome to the therapist.

As with all difficult topics (take for instance issues of trauma or abuse, especially when taking place inside the family), the therapist has a difficult balance to keep. The objective on the one hand is to be as open and receptive as possible. On the other hand, leading questions or an inquisitional style are unacceptable, and moreover, any signals or words that a client does not want to talk about something, must be fully respected.

Deciding when and to whom to refer a client

A central issue that this module attempts to give support on, is the difficult judgement about which matters, when coming up, can be dealt with be a (general) psychotherapist or counsellor, and which topics need to be referred to another practitioner. And in the latter case, out of the wide range of specialties, is it possible to decide on the spot – or after review, possibly including consultation with a supervisor -, which specialty to suggest the client to consider? Even for specialised sexologists it is getting more difficult to decide or make a sound judgement whether a particular problem might require, or would best be treated, by a medical intervention, possibly including drugs – as opposed to talking therapy, body therapy, or other methods. When would a sex therapist be best? Or workshops with an educational mission? It is not possible to give a worked-out programme to allow for a simple series of screening questions. It is for the user of this module to go through all audio-visual material with this question in mind: what can I learn from this that enables me to find the best possible support for my client?

The other aspect to keep in mind is that it would not work for any and all sexual issues to refer to other professionals with a major or even exclusive focus on sex and / or gender issues. Precisely because sexuality and gender are fully integrated into the personality, and as such are a deep part of who a person is, their self, and their overall life project and relationships, in many cases it would be desirable if the planned psychotherapy or counselling would proceed, when something sexual comes up, to continue, but with the sexual issues integrated with the overall process. It requires training and reflection, such as provided in this module, to assist the counsellor in making sound decisions in integrating sexuality in the general therapy, or in making the decision to refer. And also to consider whether in the case of a referral a client continues in the existing therapy, or the therapy is ended. And lastly, if another professional works on a sexual problem, and a therapist continues general therapy, is there contact or co-operation between the general therapist and the “specialist”?

As stated elsewhere, there is far less available literature or studies to help in these issues than is desirable. These remain key choices and decisions that stretch the professionalism of counsellors and psychotherapists. Training, reflection and preparation can help to let us make the best possible decisions – within the limits of what we can do.

Learning to normalise the wide range of sexuality and gender for clients

If we continue to be fully or partly involved with a client while they are working on sex or gender issues, it is important that we know enough about the issues involved to remain generally supportive, to have a sense of what to say and not to say, and to remain collegial to other work that is taking place. It is similar to, but at least as difficult as our relationship to what a client discusses with and decides about taking antidepressants, or their participation in AA, or even the therapy process one-to-one with a client who at the same time is engaged in couple psychotherapy with their spouse, partner or partners.

Counsellors and therapists should obey the general edict of being open to the whole range of human experience and ways of living, and of avoiding judgements as far as possible. We cannot try to steer clients away from or towards religion in particular or in general. We cannot advise our client what career to choose, whether to have children, whether to make certain conservative or risky choices in matters of finance or law. However, we have to take positions in certain cases, such as Intimate Partner Violence, abuse, child protection issues, and may need to at least be proactive when clients are openly racist or otherwise engage in unethical or exploitative behaviour.

In line with these general positions which of course are not further dealt with here, there is a general position to be as open as possible about a wide variety of sexual behaviour, to be open to the full range of modern gender identities and expressions, and to avoid advice and judgement, even if our own choices are different. And again, some issues need to be treated differently, especially any non-consensual acts with others, any non-consensual violence, and any abuse or deception.

Helping clients with sexuality, gender and connected relationship issues

The overall purpose of this module is to make us better and more effective therapists and counsellors. All the knowledge offered and recommended reflection in this module share this objective.

Managing transference and countertransference

This is a much-discussed topic, and perhaps derives importance from the concerns that many therapists have about transference as well as countertransference. However, let us picture the standpoint of a person with a positive (or positive and critical) attitude towards sexuality, who is fully all right with their own and other people’s sexuality, sexual and gender expression, over a wide range. In that situation, it is very unclear why or how there would be additional problems arising out of specifically the sexual aspect of transference or countertransference. They are very basic processes taking place in psychotherapy. Transference is always there anyway, as identified by Freud in his “Papers on Technique”, which explained that interpreting and otherwise using transference was an essential part of the process of therapy. Countertransference needs some special attention, and in many cases is more to be raised in supervision. But it is difficult to see what changes when transference or countertransference are sexual, as opposed to transference consisting of non-sexual feelings or impulses. Transference and countertransference are diverse. And in any case that brings us back to the general principle that it is not the existence of transference that matters, but the unique idiosyncratic transference or countertransference in a specific situation, at this moment, between this client and this psychotherapist.

There is a good deal of literature about erotic transference and countertransference, including by David Mann (1997; 1999), Maroda (1998) and Rosiello (2000). A stimulating book that hardly uses psychoanalytic terminology is Constantinides, Sennott & Chandler (2019).

References

Constantinides, D. M., Sennott, S. L., & Chandler, D. (2019). Sex therapy with erotically marginalized clients: Nine principles of clinical support. Abingdon, Oxon: Routledge.

Mann, D. (1997). Psychotherapy: An erotic relationship: Transference and countertransference passions. Hove, East Sussex: Routledge.

Mann, D. (Ed.). (1999). Erotic transference and countertransference: Clinical practice in psychotherapy. Hove, East Sussex: Routledge.

Maroda, K. J. (1998). Seduction, surrender, and transformation: Emotional engagement in the analytic process. Hillsdale, NJ: The Analytic Press.

Rosiello, F. W. (2000). Deepening intimacy in psychotherapy: Using the erotic transference and countertransference. Lanham, MD: Jason Aronson.