Therapist Values: Assessing and Treating Traditional and Nontraditional Relationships

Preliminary Hypotheses About Treating Traditional and Nontraditional Couples

Most therapy in the Unites States is individual psychotherapy, although data indicate that couple therapy has more impact on problems such as anxiety, alcoholism, and sexuality. The most striking data are that couple approaches result in less relapse, including for sexual dysfunction (Snyder, Castellani, & Whisman, 2006). Unfortunately, many clinicians lack specific training in couple therapy. They believe that since they have mastered individual therapy, couple work is just an extension. Typically, couple therapists, especially those trained in marriage and family therapy, believe that sex problems are a symptom of a relationship problem. Once the relational problem is resolved through communication and problem-solving, they believe the sexual problem will resolve without needing to be directly addressed. However, sexual dysfunction, especially desire problems, needs to be dealt with directly (Meana, 2010). In couple sex therapy, there are five distinct clients: (a) the woman, (b) the man, (c) their general relationship, (d) their sexual relationship, and (e) their history as an emotional and sexual couple (often the most difficult client).

Intimacy and sexuality issues are best dealt with using a comprehensive couple approach to assessment, treatment, and relapse prevention (Metz, Epstein, & McCarthy, 2017). We advocate this approach for both traditional and nontraditional couples.

The four-session assessment model (McCarthy & Ross, 2017) is commonly utilized, although not in a rigid manner. If possible, the first session is scheduled as a couple session. This provides a strong message that intimacy and sexuality are best understood as couple issues. In the first session, it is important to assess the motivation of both individuals and whether there is a mutual agenda. It is also important to ascertain whether or not desire/pleasure/eroticism/satisfaction has ever been functional, the present state of relational sexuality, and current or past history of therapy. For a couple previously involved in therapy, signing a release of information form may be helpful to gain the prior clinician’s perspective regarding the couple’s presenting concerns. In order to not repeat mistakes, understanding what has been tried in the past to address problems is also recommended. At the end of the initial session, the clinician usually provides the couple with a brief reading assignment to discuss at home. Reading does not cure sex problems, but it destigmatizes (and normalizes) the problem and sets positive, realistic expectations for change.

Conducting the psychological/relational/sexual history individually is strongly recommended. If the sexual history is conducted with the partner present, the clinician will get a “sanitized” version, not the genuine narrative. The clinician starts by saying,

I want to understand your psychological/relational/sexual story with all your strengths and vulnerabilities both before you met your partner and since you’ve been in this relationship. I appreciate you being as honest and forthcoming as possible. At the end, you can red-flag anything you do not want shared. I won’t share it without your permission, but I need to know as much as possible to understand and help you deal with these complex problems.

From clinical experience, 80–85% of clients have sensitive/secret material (McCarthy, 2002). There are two guidelines regarding disclosing information. First, if the secret is likely to be disclosed by someone else, it is much better to share it in the context of therapy (Snyder, Baucom, & Gordon, 2007). Second, if the secret is integral to the person’s psychological, relational, or sexual self, the message needs to be processed. In the vast majority of cases, the material is integral to their personal narrative, so the clinician encourages the client to share this sensitive/secretive material during the couple feedback session. This is especially applicable for clients who have “shameful” sexual secrets. Typically, the partner is more accepting than the client. This disclosure serves to begin a genuine dialogue about sexual issues. When the client does not give permission, the clinician honors the client’s wishes. Typically, the sensitive/secret material does emerge during therapy. Not all secrets can or should be shared. Focus is on the therapeutic meaning, not the “socially desirable” response.

Too many clients and couples have a contingent sexual self-esteem and relationship. The person believes if the partner knew this about them (past or present), they would no longer be respected or loved. This is a very hard way to live. Whether the issue is a variant (e.g., atypical or kinky) arousal, preference for masturbatory sex and highly anxious during partner sex, shame over erotic fantasies, not disclosing sexually transmitted infection (STI) or HIV status, affairs (past or present), sexual trauma history, and/or a partner chosen for anti-erotic reasons, these secrets dominate individual and couple sexuality. The secrets need to be processed in a respectful, empathic, and therapeutic manner.

A dearth of clinical or empirical data exists to support whether acceptance, compartmentalization, or necessary loss is the best therapeutic strategy to deal with variant arousal. What almost all clinicians agree on is an antishame approach (Braun-Harvey & Vigorito, 2015), shame makes the sexual problem more intractable. An important example is the man with a variant arousal pattern. This was not shared with the partner but controlled his and their sexuality. Variant arousal is an example that “sexually, one size never fits all.” Nontraditional individuals and couples typically adopt the acceptance strategy that may or may not include consensual nonmonogamy (Kleinplatz & Moser, 2004). The necessary loss strategy involves developing a new couple sexual style that can be integrated into the relationship but is not as erotically charged for the man (McCarthy & Breetz, 2010). Healthy couple sexuality is based on acceptance and a positive influence process, not on demands or punishment.

Clinician Pro-Sexuality Guidelines

Annon (1974) introduced the Permission, Limited Information, Specific Suggestions, and Intensive Therapy (PLISSIT) model, urging all health professionals and mental health clinicians to adopt a pro-sexuality value stance. This model has three components: (a) recognizing sex as a positive aspect of life, (b) accepting sexuality as an integral component of gender for women and men, and (c) asking whether sexuality plays a positive 15–20% role in the person’s life and relationship. This same sexual question is asked regardless of the client’s age, sexual orientation, or relationship status. The clinician asks, “Currently, does sexuality play a healthy role in your life or a negative role?” The clinician urges the client to adopt a positive approach by saying, “You deserve to experience sexual pleasure in your life and relationship.”

When clinicians claim to be value-free, they are making two core mistakes. First, they are not being truthful to their clients. Second, they are not being truthful to themselves. By its nature, sexuality and relationships involve personal and professional values. We agree with Annon (1974) that clinicians can and should be pro-sexual and convey validated psychological, biomedical, and social–relational information, so the client can make an informed decision rather than an impulsive, emotional choice. The clinician empowers the client and couple to make “wise decisions,” so that sexuality has a positive role in their lives. Clinicians should not coerce, manipulate, or “play god” with clients, but encourage wise decisions that work emotionally and practically, in the short and long term. Marital therapists worry sex therapists encourage “short-term emotional choices” rather than wise decisions. One reason that sexuality is such a controversial area is that it is so value ladened. A positive value is to encourage clients to be genuine and authentic about whom they are sexually, so that sexuality represents an integration of their attitudes, behaviors, and emotions (Nagoski, 2015).

Clinicians need to be aware that clients can have manipulative or other hidden sexual agendas. An example is websites that claim to be sex-positive but have a financial agenda that takes advantage of vulnerable people. A common theme of those who advocate for traditional values is that sexuality destabilizes individuals and couples. Critics tell stories of the destructive role of prostitution, porn, affairs, and manipulative relationships. A clinical guideline is to emphasize the healthy role of sexuality while remaining aware of possible hidden agendas or manipulation (Shahbaz & Chirinos, 2017). It is crucial the clinician be pro-sexual and pro-relationship. It is also crucial to confront unhealthy sexuality and relationships, whether traditional or nontraditional.

Exploring personal values is even more complex and challenging than professional values. Clinicians are people first with their own histories, strengths, vulnerabilities, and personal challenges. The best measure of psychological well-being is the congruence of the person’s attitudes, behaviors, and emotions. As with any clinical issue, self-awareness and self-acceptance is core in ensuring that one’s personal struggles do not subvert the therapy process. The clinician is not hypocritical being pro-sexual, professionally and clinically, even if in one’s personal life sexuality does not have a positive role. What is not acceptable is the clinician taking a sex negative approach based on personal problems or values. Some medical and mental health clinicians avoid sexually oriented therapy because of personal reasons, but the majority maintain a personal boundary so that sexual problems or conflicts do not subvert the therapy. A guiding principle is that the needs and values of the client/couple are more important than the clinician’s values.

Special Issues for Clinicians With Traditional Values

A challenge for clinicians who espouse traditional values and conduct therapy with traditional couples is to not assume a sexual problem as a symptom of an individual or relational problem. A core guideline is to always conduct a comprehensive assessment and not be influenced by preconceived assumptions. Sexuality is multicausal, multidimensional, with large individual, couple, cultural, and value differences. Sexual problems and dysfunction involve a range of psychological, biomedical, and social–relational factors that need to be explored.

A common trap is an overly narrow focus on resolving the sexual dysfunction and saving the relationship. Although this is the goal for a majority of couples, for some couples the message of the sexual problem is that this is a “fatally flawed” relationship. Most couples see sex therapy as a way of addressing psychological problems with the hope of a healthier relationship and increasing sexual satisfaction, but the clinician should not assume that is the goal for all couples.

The traditional clinician is pro-sexual and pro-relationship but should not be anti-divorce. An empowering concept is to confront the “bad divorce” where the outcome is anger and blaming with continual struggles over why the relationship ended. Instead, the therapist advocates for the “good divorce” where the emotion is sadness. They wish each other well and stay out of each other’s emotional, relational, and sexual lives, focusing on coparenting (Baucom, Pentel, Gordan, & Snyder, 2017).

A possible message behind a sexual dysfunction, especially desire problems, is that the traditional monogamy agreement is not the right fit for this couple. They de-eroticized the partner and the relationship (Perel, 2006). Exploring consensual nonmonogamy is a possible therapeutic strategy. It is crucial to assess whether both partners value a satisfying, secure, and sexual relationship. When partners have different or ambivalent agendas for their relationship, discernment counseling is a valuable approach (Doherty & Harris, 2017).

Special Issues for Clinicians Who Support Nontraditional Relationships

Clinicians who support nontraditional clients and couples, whether “kink friendly,” consensual nonmonogamy, pansexuality, or polyamory, can be so intent on defending the right of clients to be who they are that they do not carefully assess the client and their relationship(s). Opposition to traditional sexual scripts is not enough. The challenge is to ensure that alternative scripts facilitate a healthy 15–20% role for sexuality and establishing the basis of their nontraditional relationship, including whether they prioritize the couple bond. If not, what do they value? For example, polyamorous couples often say the emotional connection and support from couples in the polyamory community is their core value. Or that consensual nonmonogamy allows them to remain a couple and family even though they are not a sexual couple.

It is important for the clinician to help the couple clarify what type of nontraditional value genuinely promotes sexuality for each partner. There is a major difference between “open swinging” (often a triadic sexual scenario) and “closed swinging” (where the partner is aware but not present during the sexual encounter). There is no right or wrong, but what works for these partners and their relationship. Couples need to be clear with regard to boundaries and aware what type of sexuality crosses a “red line” and what subverts the partner or their relationship. Examples include falling in love with the affair partner, not practicing safe sex or using contraception, being sexual with the partner’s best friend or brother, or spending USD$500 a month on sex. Clear, genuine agreements are just as important for nontraditional couples as for traditional couples.

An important factor is whether the alternative scenario has an erotic charge when played out. An example is a man with a powerful erotic response to the fantasy of being sexual with a woman wearing mid-level boots. When this atypical arousal pattern was disclosed (with the support of the therapist), his partner was willing to wear the preferred boot type during sex. The therapist was very enthusiastic about their acceptance strategy. It took the couple three sessions to report that the scenario did not work for the man. They felt they disappointed the therapist. Some men find that the erotic charge comes from the secret sexual life and is lost with acceptance. Other times, it is the woman who is emotionally or sexually uncomfortable with the acceptance strategy. The variant arousal makes a better erotic fantasy than a real-life couple sexual scenario. The therapist urging the couple to be open to experimenting is therapeutic. However, urging the couple to embrace, the alternate sexual scenario may cause anticipatory or performance anxiety.

The nontraditional clinician needs to be sure her value orientation does not override the needs, complexities, and feelings of the client and couple. Helping clients accept their authentic sexual self and realizing that traditional sexuality is not the right fit is necessary, but not sufficient. More important is finding what does fit psychologically, relationally, and sexually.

In many ways, nontraditional clients are similar to traditional clients. All people and all relationships have strengths and vulnerabilities. Sexuality is integral but not the most important factor in life. It has too much power when the client’s authentic sexual self is controlled by secrecy and shame. Within a new sexual script and scenario, the issue is ensuring sexuality has a positive role for the client and relationship.

Guidelines in Deciding What Issues and Clients/Couples Are the Right Therapeutic Fit

The mantra for the clinician is interest, competence, and values. This challenges the traditional expectation that all clinicians should be able to help all clients and be successful with all problems. This demand is unfair to both the clinician and client/couple.

The first issue is interest. If the sexual issue, or sexuality in general, is not an area of interest to the clinician, she can provide sexual permission and give psychological, biomedical, and social–relational information. Then, she makes a referral to a sex therapy specialist, sharing with the client/couple that this is an important issue that requires a well-trained clinician. “Since I do not have this expertise, I will refer you to a clinician who will be helpful with your sexual issues.” This is beneficial both for clients and clinicians.

The second factor is competence. This does not mean being the sexuality expert in the community, but that the client/couple will be in good therapeutic hands when they see this clinician. Few, if any, clinicians are competent with all sexual problems. Clinicians would be better to emphasize therapy with clients/couples with whom they feel most comfortable and competent and make referrals to sexuality specialists when appropriate.

The most controversial factor is personal and professional values. Clinicians have a duty to facilitate high-quality treatment for all clients. If their personal or professional values subvert their ability to provide clinical services, it is their responsibility to make an appropriate referral. The clinician has a right to her personal and professional values but should not allow those to override the right of clients/couple to high-quality mental health and sex therapy services. In those cases, a referral to a clinician who is interested, competent, and whose values are congruent with the client’s goals is the appropriate clinical strategy.

A concern among professional organizations is that clinicians will use lack of interest or value conflicts to discriminate against sexual minority clients. This is a legitimate concern, and discrimination must be confronted. However, the much more common clinical reality is therapists feeling they must treat clients/couples with whom they are not comfortable or competent. Trying to pretend or fake interest or affirm values in a nongenuine manner is not meeting the needs of the client. Additionally, it puts the therapist in an untenable position. The therapist knows that the client/couple are not in good therapeutic hands seeing this clinician. The professionally helpful and ethical response is to make a referral to a clinician who is interested in the clients’ problem, trained and competent to deal with the sexual concern, and whose personal and professional values are in line with the clients’ values and goals. There are, however, some instances where the clinician will need to treat that client/couple. For example, a rural setting with limited mental health providers or the clients’ lack of financial resources to pay for sexual health services. In these situations, the ethical alternative is for the clinician to seek supervision from a therapist with a specialty in that sexual issue.

Summary

Rather than an adversarial struggle between traditional and nontraditional clients/couples, the sex therapy field has a proud history of honoring diversity. Sex therapists and mental health clinicians have a responsibility to provide high-quality services for both traditional and nontraditional clients and couples. Rather than the assumption that all clinicians can provide therapy for all clients and all problems, we propose the criteria be the clinician’s interest, competence, and personal and professional values.

Many clinicians are comfortable and competent providing therapy for traditional and nontraditional clients. Traditional refers not just to heterosexual married people but couples regardless of sexual orientation and legal relational status. The values for traditional couples are to prioritize the relationship and have an emotional commitment to monogamy. The most common issue with nontraditional couples/clients is consensual nonmonogamy. Some clinicians are comfortable with open relationships and swinging, but not comfortable or competent working with variant (e.g., kinky) sexuality or polyamory.

Awareness of personal and professional values is crucial, including the decision to refer to a clinician where the couple will be in good therapeutic hands. All clients/couples deserve to be treated respectfully and empathically and receive high-quality mental health and sex therapy services.