4.3 Forming Relationship
4.3.3 Shared Understanding
While therapists indicated that they see the client’s transference as offering the opportunity to form an immediate bond with the client, they also mentioned the co-creation of understanding of sexually compulsive problems to be key to the process of forming a working bond. Therapists described these as involving more explicit and cognitive processes, including dimensions such as using assessment tools and questionnaires, taking lengthy and thorough client history and psycho-education. While this was seen to provide the client with information about the diagnoses and treatment it was also mentioned as part of the early forming alliance, based on establishing sharing understanding and agreeing goals. There was also a tension in the data between the notion that thorough assessment could create an initial feeling of trust and safety for female sex addicts, and, in light of their high levels of secrecy,
confusion and shame, be too pragmatic and hinder open disclosure and bonding. This was a process in which there needed to be a human-to-human connection.
They are not going to be able to get going in the relationship with me if I am standing with a clipboard. They are only going to do that in relation to another human being, before they are going to do that with a therapist. The fact that I am a therapist and have a background of information and experience running at the same time is not the point. The point is it is in the human relatedness of it. (P5/30)
An interesting finding is that therapists mentioned approaching the work in the beginning more cognitively with men than with women (P3/35).
4.3.4 ‘I–It’, No Mutuality
Although analysis revealed therapists aimed to create an interpersonal experience of ‘being
with, in a mutual, giving and taking type of relationship’ (P11/23) with their female sex
addict clients, they described the relationship in the beginning of therapy as being more characterized by properties of an I–It position (Buber, 1958). Despite this being typical of the early formative stages of the therapeutic relationship, they also mention it might continue for years.
Now although I am in the room they don’t really see me in the room. I am an object and it could be like that for a few years. (P4/14)
Analysis revealed therapists to feel like the client was an object and ‘not a person in the room
opposite them’ (P4/14). One therapist described perceiving his client to be so removed from
his reach that he experienced her as a ‘dead object’. In describing her as an object to be observed, admired from a distance, he conjured up an evocative and complex image of both her beauty and deadness by comparing her to a white marble Michelangelo sculpture. While he described properties of aesthetic beauty he also recognized little or no potential for human relatedness. This tension was reflected elsewhere in the data: anything authentically erotic or creative was reported as being unreachable, heightening the therapist’s struggle to find something on which to build some, or any, spark of vitality in relational connection.
She is a very, very beautiful object to look at. It was like looking at a beautiful statue by Michelangelo. There was a deadness about her but at the same time she had a beautiful smile. I perceived her as not so much an object of sex, not even desire, but an object of beauty. (P9/21)
Therapists also reported experiencing a pull within themselves toward passivity which seemed to mirror some of the clients’ deadness with one saying ‘I won’t have to work very
hard – I will listen and just be supportive and empathic’ (P10/21). Therapists also mentioned
their interventions particularly tended to implement early nonverbal proto-communications and core conditions such as empathy and support.
While findings showed therapists as seeing sex addiction as a reflection of the client’s derailed attempt at consummation and union, they mentioned any shift into a more intersubjective or mutual connection in the therapeutic relationship as being managed both slowly and carefully. They described the movement toward mutuality as not to be forced, and noted if they moved too quickly or interpreted things too promptly they were in danger of evoking shame in the client. One therapist described ‘holding back on interventions and
questions to build the relationship and the contact slowly and gradually’ (P11/53). Therapists
talked about avoiding a premature or misplaced attempt to move the early relationship from a one-person to a two-person to a three-person as it risks triggering her interpersonal defences.
In a one-person relationship position, if you introduce them to a two-person they will freak out and try to ban you or get rid of you. It is slow and difficult work. (P11/51)
Therapists reported that in the early relationship there is little or no interpersonal energy, or
flow, despite attempts to enliven the inner deadness of the client and get a relational flow
going. The clients’ fragile sense of self and intolerance for any deep relational contact or exploration meant that close relational contact can be experienced as overwhelming.
There was no way I could get any flow in any kind of conversations without her either collapsing again, and more often than not at the beginning, into terrible anxiety which would be overwhelming for her. (P10/21)
4.3.5 In Here/Out There
A salient property of Forming Relationship involved a process of bringing the affective material, which is sexualized and acted out by the female sex addict, into the therapeutic relational space. Findings indicated that while clients frequently arrive ‘with a huge excitation
to act out’ (P11/15), the formation of the relationship relied on a shift in the female sex
addicts’ centre of regulation from an externalized and sexualized behavioural pattern of
acting out to an internally experienced process of self/other-soothing. This acting in was
mentioned as occurring in the therapeutic relationship with the therapist as well as with significant others outside the therapy.
It is so much about bringing that affective energy back into a relationship and not having it split off. Then I think the affect regulation changes. But that’s the difficult bit I think. They want to take it outside rather than bring it in. (P11/30)
Their dysregulated affect gets pushed all over the place and as they have no internal objects to regulate this so they want to get rid of it outside of themselves. (P12/23)
While analysis revealed therapeutic contact to stimulate affective and erotic experience, abstinence from sexual acting out led to ‘the return of some of the affect that has not been
regulated’ (P5/9); as one said, ‘when the behaviours stop it (affect) is brought inside the relationship and into the therapy’ (P11/30). Therapists reported helping clients to identify the
boundary between their feelings and their behaviour and helping them to see that, while they can have their feelings, they cannot act them out (P12/46). Findings also showed sexual abstinence to be a key and contentious dimension and mentioned it as either underpinning or undermining the therapeutic relationship.
Analysis showed the forming of relationship as central to the work and that this included relationships in and out of the therapy room. Therapists saw female sex addicts’ capacity to use intimate partners and social relationships (particularly in groups with other women) as being as important as the processes which occur inside the therapeutic space with the therapist. In fact, a client’s relationship with her intimate partner is often mentioned as being the focus of work in sessions.
A lot of the time I am doing couples therapy even though there is only one person there. How to manage a relationship and how to manage yourself in the sense of asking for your needs to be met and your feelings to be dealt with effectively. (P2/13)
Therapists described how these interventions inside the therapy room are designed to have a direct impact on how the client uses her relationships outside the therapy.
She needs to be able to do this with her partner and that is the key. She has to be able to do that with her partner – in partnership and say to her partner this is what I am feeling and this is what I am thinking. Maybe she needs reassurance or maybe she needs him to stop doing something. (P2/12)
Therapists reflected that each therapeutic dyad comprised unique conscious and unconscious, co-created dimensions and said that they work differently with each female sex addict. While one expressed the consensus of approaching the work without any ‘pre-constructed
framework’ (P3/33), another reflected on the uniqueness of each woman and described a
group therapy in which she observed her female clients engaging in individual ways with the same task and remembered that ‘each woman did it differently’ (P1/31).
I have worked with some very badly damaged clients and each one I work with differently. I don’t mean unethically or improperly, I mean I am going to have a different relationship with each one. Every client I am going to have a different relationship – it has to be different for each one. (P3/20)
Findings exposed a tension in the data between the pull to approach the client in a top-down or bottom-up way. While therapists mentioned the importance of seeing the subjective individuality of the client, and described their focus as being on the person sitting in front of them rather than the symptoms of the condition, they mentioned wrestling with seeing the uniqueness of the person versus the sex addict.
I am getting to know the person sitting in front of me and am always looking to see what the addiction is about for the woman sitting in front of me and always looking at the primary issue going on underneath the sexually addictive behaviour and asking what this constitutes. (P5/12)
Analysis showed that forming a relationship involved a unique set of responses to one another and this to involve an inherent quality of multiplicity in the emerging multi-layered relationship. Therapists commented that each dyad co-creates a set of unique responses and acknowledged that what was therapeutically helpful for one client may not be as helpful for the next.
You are getting to know the person, your responses and her responses to you, both conscious and unconscious. I mean you sort of find your way into the person. Your response to her and her response to you, both conscious and unconscious. (P3/10)
The following section reflects therapists’ descriptions of their personal characteristics, professional training and beliefs and attitudes to women, sex, and affect as it is mentioned as influencing and shaping the process of affect regulation in the unfolding relational processes.