Therapist Values: Assessing and Treating Traditional and Non-Traditional Relationships Barry McCarthy & Lana Wald Ross
American University
Author Note
Barry McCarthy and Lana W. Ross, Department of Psychology, American University.
Correspondence concerning this article should be addressed to Barry McCarthy, Ph.D. at American University, Department of Psychology, 4400 Massachusetts Avenue, NW,
Washington, DC 20016. Email: [email protected]
Abstract
A common mental health assumption exists that all clinicians should be able to treat all problems and all clients. An unspoken belief among many clinicians is that non-traditional sexual preferences and feelings are driven by psychopathology. In contrast, in order to provide high quality clinical treatment, a positive sexual health model advocates that the clinician exhibits interest in the client’s sexual issue, be trained and competent with the presenting problem, and provide therapy congruent with the clinician’s personal and professional values.
Non-traditional clients and couples deserve that sexuality play a positive role in their lives and relationship. Although the clinician needs to assess for psychopathology, it is crucial that the therapist not assume that non-traditional sexuality is motivated by psychopathology. All clients/couples deserve to be treated empathically and respectfully, and receive high quality mental health and sex therapy services.
Therapist Values: Assessing and Treating Traditional and Non-Traditional Relationships Contrary to media articles, the majority of couples, regardless of sexual orientation (e.g., lesbian or heterosexual) or relationship status (e.g., partnered, cohabitants, or married) adhere to a traditional model of fidelity and monogamy. While a dearth of representative empirical
research exists on this issue, it is estimated that about 85% of adult couples report traditional values (Gottman & Silver, 2015). The traditional approach to marriage/life partnership emphasizes partner and relationship fidelity, and an emotional commitment to a sexually monogamous relationship. And, while this may be the case, many couples, regardless of sexual orientation or relationship status, also have non-traditional values and agreements. Non-
traditional fidelity agreements might value family, social status, children, home, financial, or other factors rather than the foundation of the primary relationship (Conley, Matsick, Moors, &
Ziegler, 2017). The most common non-traditional agreement is consensual non-monogamy (e.g., open relationships, swinging, or polyamory; Haupert, Gesselman, Moors, Fisher, & Garcia, 2016).
A recent movement in sex therapy, both in the culture and among professionals, is to accept, if not advocate for, non-traditional agreements regarding consensual non-monogamy (Nichols, 2014). This is in line with the field of human sexuality honoring diversity more than any other mental health field, especially advocating acceptance of differences in sexual orientation and gender expression.
The new mantra in the sex therapy field is desire/pleasure/eroticism/satisfaction (Foley, Kope, & Sugrue, 2012), with desire as the most important factor. Desire problems are the issue most likely to bring couples to sex therapy and the sexual factor which most affects relationship satisfaction (Leiblum, 2010). McCarthy (2015) advocates for satisfying, secure, and sexual
relationships. The function of sexuality is to energize the couple bond and reinforce feelings of desire and desirability, with sexuality having an integral, 15-20% role in the relationship. The paradox is that dysfunctional and conflictual sex, and especially sexual avoidance, plays an inordinately powerfully negative role, demoralizing the person and threatening relational security (McCarthy & McCarthy, 2014).
Unfortunately, couple therapists and sex therapists are often in conflict about the role of sexuality in a relationship and in therapy. Couple therapists focus on intimacy, a secure bond, and loving communication as the foundation for sexual desire. From this perspective, enhanced communication and a securely bonded couple is the key to successful treatment (Johnson, 2008).
Sex therapists emphasize the challenge of balancing intimacy and eroticism, each person’s sexual autonomy (i.e., sexual voice) with being an intimate sexual team, and the role of erotic scenarios and techniques (Perel, 2006). Some marital therapists accuse sex therapists of not valuing traditional marriages, emphasizing individual differences and eroticism at the expense of the couple bond, and accepting extra-marital affairs. Some sex therapists believe marital
therapists promote mediocre, stable marriages, do not understand the value of eroticism and the role of erotic fantasies, and view sex as a symptom of a relationship problem rather than dealing with desire problems directly. Most, but not all, couples affirm the value of a satisfying, secure, and sexual relationship. The struggle between couple and sex therapists is not in the best interest of the couple or the field. An integrated, couple psychobiosocial approach to sexual problems is optimal (McCarthy & Wald, 2017).
Although most couples begin in a romantic love/passionate sex/idealized (limerance) phase, this is very fragile, commonly lasting six months to two years (Tennov, 1998). The challenge after the limerance phase is to develop a couple sexual style that promotes strong,
resilient desire (McCarthy & McCarthy, 2009). Many couples, perhaps the majority, do not meet this challenge. For traditional couples, marriage or a partnered relationship meets needs for intimacy and security better than any other relationship (Epstein & Baucom, 2002). The
vulnerability, or trap, for traditional couples is treating sexuality with benign neglect. Even if sex is functional (e.g., arousal and orgasm), it is not vital or special, and does not reinforce desire and satisfaction. Approximately 20% of married couples are non-sexual, with higher rates of sexual problems for cohabitating and partnered couples who have been together 2 years or longer (Lauman, et al., 1994). Unfortunately, there is limited data for non-traditional couples (Rubel &
Bogaert, 2015).
Therapeutic guidelines advocate that non-traditional couples deserve empathy and respect, especially their right to quality mental health and sex therapy services. Rather than the traditional approach of assuming their sexuality is motivated by psychopathology, the clinician conducts an assessment and outlines treatment based on the values and goals of the client/couple.
The clinician ought to exhibit competence with the presenting issues and treatment of non- traditional individuals and couples. The values of non-traditional couples and the clinician’s professional values need to be congruent.
The myth that all clinicians are interested and competent in dealing with all problems and all couples is destructive for clients and clinicians alike. Clients, especially non-traditional couples, deserve respect, empathy, and high quality treatment. Ethically, clinicians who are uninterested in non-traditional couple issues, lack competence or training in non-traditional sexuality, and whose personal or professional values undermine their ability to be empathic and respectful in working with this population, should refer to a clinician who is. While a clinician may exhibit competence dealing with consensual non-monogamy, she may not be comfortable
dealing with transgender issues, polyamorous couples, or “kinky” couples. While there is a significant overlap between polyamory, kink, and sexual orientation issues, especially pan- sexuality (Nichols, 2014), these are separate phenomenon. It is not realistic to expect clinicians to be competent with treating every type of nontraditional sexuality.
The clinician needs to be transparent with clients, and honest with herself, about her level of comfort and competence providing sex therapy for specific types of clients, problems, and issues, and to refer when necessary. There is a great need for empirical research on this important clinical and ethical issue.
Preliminary Hypotheses about Treating Traditional and Non-Traditional Couples
Most therapy in the Unites States is individual psychotherapy, although data indicates 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 non-traditional 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). Two guidelines to disclosing
information include 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 great majority of cases the material is integral to their personal narrative, and 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 (atypical or kinky) arousal, preference for masturbatory sex and highly anxious during partner sex, shame over erotic fantasies, not disclosing 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 anti-shame approach (Braun-Harvey &
Vigorito, 2015); shame makes the sexual problem more intractable. An important example is the man with a variant arousal pattern. While this was not shared with the partner, it controlled his and their sexuality. Variant arousal is an example that “sexually, one size never fits all.” Non- traditional individuals and couples typically adopt the acceptance strategy that may or may not include consensual non-monogamy (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 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, not negative, 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%, versus a destructive, 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, bio-
medical, 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. Traditional 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 (Shahraz & Chirinos, 2017). It is crucial to be pro-sexual and pro-relationship. It is also crucial to confront unhealthy sexuality and relationships, whether traditional or non-
traditional.
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 a core skill 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 multi-causal, multi-dimensional, with large individual, couple, cultural, and value differences. Sexual problems and dysfunction involve a range of psychological, bio-medical, 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 co-parenting (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 non-monogamy 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, in press).
Special Issues for Clinicians Who Support Non-Traditional Relationships
Clinicians who support non-traditional clients and couples, whether “kink-friendly,”
consensual non-monogamy, pan-sexuality, 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 non- traditional 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 non-monogamy 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 non-traditional 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). This is not a “right-wrong” decision, 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 $500 a month on sex. Clear, genuine agreements are just as important for non-traditional couples as for traditional couples.
An important factor is whether the alternate 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 non-traditional 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, non-traditional 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, and 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, bio-medical, 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 their 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 to address this sexual issue or problem. Trying to pretend or fake interest or affirm values in a non-genuine 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 non-traditional
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 non-traditional 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 non-traditional 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 non-traditional couples/clients is consensual non-monogamy. Some clinicians are comfortable with open relationships and swinging, but not comfortable or competent working with variant (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.
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