Working With Sexual Issues in Systemic Therapy Australian and New Zealand Journal of Family Therapy / Volume 28 / Issue

04 / December 2007, pp 200-209 Desa Markovic Desa Markovic is a systemic therapist and former assistant director at the Institute of Family Therapy London. This study investigates ways in which systemic psychotherapists address sexual issues. Qualitative data were collected through semi-structured group and individual interviews and analysed using discourse analysis. Particular attention was paid to participants accounts of the resources they draw on and of perceived constraints when approaching the subject of sex. Main findings indicate that systemic training and practice would benefit from greater inclusion of sexual issues to overcome current deficiencies in the field. Key Words: sexual issues, systemic therapy, Foucauldian, discourse analysis My interest in this topic stemmed from my observation and concern that within systemic literature and training there was an apparent gap in the area of sex and sexual relationships. This research aimed to deconstruct ways in which systemic therapists have been addressing sexual issues and to gain understanding of what helps and what hinders them in doing so. I have deliberately used a nonspecific phrase sexual issues to allow the participants own meaning to emerge. Literature Review The Place of Sexual Issues in the Systemic Literature: An Overview Since the 1950s a significant body of texts have shaped the systemic/family therapy field, without mention of the subject of sex or sexual relationships. In contrast, the Handbook of Family Therapy (Gurman & Kniskern, 1981; 1991) includes contributions from psychologists, family therapists and sexologists who provided an historical explanation for the split between couple therapy and sex therapy, and argued for reintegration and overcoming theoretical, practical and organisational fragmentation of these separated fields. Reintegration was also proposed by Sanders (1988), Weeks and Hof (1987), and Kantor and Okun (1989), who created models for treating sexual concerns, encompassing systemic and sex therapy frameworks. Most of the literature on couples listed on family therapy courses does not include sexual relationships. Papp (in Walters et al., 1988) noted that sex was, like money, considered a peripheral issue (p. 217). Byng-Hall (2000) argued couple and sex therapy are divorced from family therapy. The subject of sex is markedly absent from the literature on systemic training and supervision. Dissertations by family therapy trainees confirm this (Kavanagh, 1997; Wynn, 2001). Gorell Barnes et al. (2000) advocate the benefits of a proactive approach to discussing sex and sexuality in supervision. Sexual Issues in Different Family Therapy Schools: A Historical Perspective Ackerman (1958) and Skynner (1976), from psychodynamic family therapy, regarded exploring sexuality as fundamental to therapeutic work with individuals, couples and families. Within the transgenerational approach, Lieberman (1979) argued family therapists should be skilled in working with sexual dysfunction. Sexual Genogram (Hof & Berman, cited in Kantor & Okun, 1989) provides a tool to explore intergenerational stories of sexuality. From the communicational approach perspective, Satir (1972) held that parental accord and validation were the key to a healthy development of sexual identity. Within the structural, strategic, Milan and solution-focused schools, sex and sexual relationships have been regarded as content issues, therefore of secondary importance. From a constructivist framework, Zumaya et al. (1999) critiqued the supremacy of normative paradigms and an emphasis on functioning in sex therapy, while feminist perspectives highlighted gender imbalance as most likely to be acted out in the domain of sex. Hare-Mustin (1994) and Dallos and Dallos (1997), from a social constructionist perspective, researched discourses on sexuality that disguise gender inequality. McGoldrick et al. (1996) and Carter and McGoldrick (1999) offered comprehensive descriptions of the views on sexual practices

and expression of a variety of ethnic groups. A broader history of therapeutic approaches to sexuality seems repeated in the systemic literature in that the most influential discourses about sex are still individualistic and scientific. Foucault (1978) argued that in the 20 th century one of the most dominant discourses on sexuality has been that of science. This was reflected in the dominance of behavioural interventions and medicalisation of sexual concerns. Method The study investigated the following research questions:
1. 2. 3.

What are systemic therapists_ ways of working with sexual issues? What resources do systemic therapists draw on when working with sexual issues? What constraints do systemic therapists experience / construe in working with sex?

I chose qualitative methodology, using semistructured interviews, as coherent with the aims of the study to gain a deeper understanding and develop a context-rich description of the researched subject. Social constructionism (Pearce, 1994) informed the theoretical framework, allowing for multiplicity of meanings in the communication with participants. Ten white British male and female systemic therapists from diverse cultural heritages were interviewed, five in a group and five individually. Their postqualifying clinical experience ranged from 10 to 25 years. Some also had experience as systemic trainers, supervisors and managers. Interviews The main reasons for deciding on the group interview format were to enable discussion and possible debate, and allow access to social processes through which the meaning of the experience is constructed and reconstructed (Farquhar & Das, cited in Barbour & Kitzinger, 1999). A frequent restraint of group interview, the phenomenon that personal narratives are less likely to emerge in groups, was compensated by the one-to-one interviewing, which provided opportunities for more individualised and detailed accounts. Research Methodology: Rationale for Discourse Analysis Discourse analysis seemed the most appropriate research method, being concerned with the social and cultural assumptions people are drawing on in their thinking and practice. This method is also coherent with the research aims to explore what resources therapists perceived as available; how they used them and what constraints they construed for working with sexual issues. Analysing discourse can be described as searching for patterns that connect (Bateson, 1972) and form larger discourses that become part of common sense (Foucault, 1980). While acknowledging there are many ways to describe what a discourse is, I chose to define it as a socially constructed network of meanings that shape peoples aspirations, beliefs and practice. Discourse analysis requires that discourses and their effects be understood within the contexts in which they arise. For the purposes of my research, this meant appreciating the societal, cultural, and professional discourses people are drawing on in their accounts, originating from their families, religious and cultural upbringing, education and other networks of conversations. Foucauldian discourse analysis (Willig, 2003) was chosen, as it is concerned with the role of discourse in social processes of legitimation and power and draws attention to the power of discourse to construct moral stance and practice and to legitimise and justify certain forms of behaviour. Analytic Procedure Interviews were audio recorded and transcribed. Throughout the project I was aware of bringing a set of personal and professional stories to the research. This alerted me to my responsibility to reflect on my biases and question my involvement at each stage, particularly my investment in the subject, so I kept a diary in which to reflect on my own values, assumptions, and the relationship with participants (Potter &

Wetherell, 1987). It served as a reminder of my hopes, expectations, frustrations, surprises and disappointments, and assisted me in monitoring them while making sense of the data. There is variety in the process of undertaking discourse analysis; Parker (1992) proposes 20 stages; Kendall and Wickham (1999) rely on fewer steps while Potter and Wetherell (1987) suggest the use of a more flowing methodological approach. I chose Willigs (2003) six stages model of Foucauldian discourse analysis as a guideline for exploring various aspects of the research material, rather than as a stage-by-stage procedure. It provided me with the clarity of the analytic process and allowed me to map some of the discursive resources named in the participants accounts and examine their implications. At the first step, Discursive Constructions, I identified the different ways systemic therapists work with sexual issues. The range of clustered discursive constructions is presented in table format below. The stage called discourses located the participants discursive constructions within wider discourses surrounding the topic of sexual issues such as a spectrum of personal and professional resources and constraints. Action Orientation involved closer examination of the moral order guiding the participants accounts. Positioning suggests that discourses offer subject positions in terms of the participants_ rights and duties from which to speak and act. For example, the analysis of the research material in this study discussed the therapists construction of their roles and responsibilities in relation to talking about sex in therapy. The practice stage explored the relationship between discourse and practice, and subjectivity traced the consequences of taking up various subject positions for the participants feelings, thoughts and experiences. TABLE 1 Question 1: What are the Systemic Therapists_ Ways of Working With Sexual Issues? Ways of working with sex Importance of discussing sex with clients Discursive constructions Group interview Sex is a very important subject Sexuality is part of everyday life of adults and children Sex is part of being human Individual interviews Sex is an important and a difficult subject to discuss, like death and money Sex is an integral part of the relationship Sexual issues can underlie what is talked about in therapy Sex should not be divorced from other relationship aspects Therapy is a safe and respectful place to talk about sex

Frequency of discussing sex with Group interview clients Sex is not discussed enough with individuals Sex is almost never discussed in therapy Pushing the subject of sex in therapy can be damaging Individual interviews Sex is not that often discussed in therapy Sex is more likely to be discussed with individuals than couples Sex is discussed very rarely with individuals It is easier to talk about sex with couples, as you have both sides of the story Sex should not be discussed when working with families and children Self-description of therapeutic Group interview

styles of addressing sex with clients

The subject is approached at arms length Sex should not be discussed unless it was a key issue brought by clients Individual interviews The subject is approached in: circumspect, remote, roundabout, over cautious ways Therapists should be led by what clients want to talk about Sexual issues should be regularly checked for health and safety reasons

Techniques applied

Group and Individual Interviews Helpful systemic techniques in addressing sex are: questions, tasks, strategies, suggestions, normalising, metaphor.

Data Analysis Data from group and individual interviews are presented together within the tables, summarising the material obtained via two methods of data collection in the form of discursive constructions. Question 1 explored the ways in which systemic therapists described working with sex, including frequency and use of systemic techniques. Therapists_ ideas on the importance of discussing sex with clients were explored, to enhance understanding of their attitude to this subject. What emerged confirmed the importance that therapists attributed to the subject of sex; however, reported frequency of discussing it with clients did not match the acknowledged importance, as the table below shows. Within Question 2 participants named a spectrum of resources constructed as helping them address sexual issues. Most of those, however, were suggested as being underused. TABLE 2 Question 2: What Resources do Systemic Therapists Draw on Working With Sex? Resources Therapists personal experience/age Discursive constructions Group interview Therapists life experience helps in working with sex Being old makes it easier to talk about sex with clients of different ages Individual interviews Therapists comfort with own sexual experience enables talking about sex in therapy Open partner conversations about sex enable therapists to talk about sex with clients Therapists personal difficulty with talking about sex helps their understanding of clients difficulty Group and individual interviews Clinical experience helps therapists in working with sex Individual interview Specialised clinical contexts impose the necessity to address sexual issues, for example, working with sexually transmitted diseases Individual interviews Systemic perspective is a limited resource for working with sex

Clinical experience Working context

Systemic perspective

Helpful systemic ideas in addressing sex are self awareness, neutrality and circularity in relationships Systemic techniques Group and individual interviews Systemic questions are the most helpful therapeutic techniques when working with sex Individual interviews Systemic ideas are insufficient; psychoanalytic understanding and the knowledge about child development are necessary for working with sex Individual interviews Gender similarity facilitates talking about sex Group and individual interviews Talking about this subject raises awareness of therapists responsibility to address it Individual interviews Change in social prejudices enables thinking about sexuality in a more inclusive way Individual interviews Post-qualifying training courses can help thinking about the subject Individual interviews In order to be able to work with sexual issues ethically, one needs to learn how to manage personal/professional boundaries effectively Individual interviews Necessary therapeutic skills to work with sex are: ability to be playfully provocative; nonjudgmental; form a trusting therapeutic relationship Group and individual interviews Observing more experienced colleagues working with sensitive issues is a necessary learning tool

Drawing on other approaches

Therapists use of self This research interview

Changing social realities

Workshops and further training

Learning from difficult past experience

Therapists professional skills

Observing other therapists

In Question 3 a wide range of constraints was constructed. Hypothetical situations introduced by therapists indicated anticipation of undesired consequences if discussing sex in therapy. Participants unanimously agreed on certain constraints, such as lack of systemic training and literature, therapists personal barriers, and the lack of therapists expertise in the area of sexual relationships. In relation to other factors, the contradictory discourses emerged; for example, some regarded cultural practices as a constraint, while others expressed views that cultural norms helpfully determine the appropriateness of raising the subject with clients. An interesting debate evolved in the group discussion as to whether the working context was limiting or supporting therapeutic practice. Discussion Group and Individual Interviews: Comparison Group and individual interviews results are discussed together as they largely overlapped; differences were mainly at process level the group interview contained more challenge, debate and diversity of views juxtaposed, while individual interviews involved further personal processing, thinking time and

detailed deconstruction of clinical episodes. Personal constraints were shared more in individual interviews. Individually, therapists related confessional narratives about their family background, parental messages and cultural upbringing, and the impact of those throughout their personal and professional lives. On the one hand, the dynamic quality of group interaction provided a range of different perspectives, contributing to the richness of the material. Participants confirmed they found the discussion thought provoking. Three group members subsequently reported the group discussion having enabled them to initiate conversations about sex more directly and confidently. Thus group discussion demonstrated possibilities for negotiating new forms of public knowledge (Farquhar & Das, 1999). On the other hand, I observed how the group process reflected ways in which talk about sex is regulated in Western society where sex is a taboo, and highlighted ways in which deviant experiences are silenced or incorporated in the existing views and practices. The group process that emerged demonstrated the contested nature of sexual issues, by the strength with which some views are held, and the ways in which those are rationalised and defended. TABLE 3 Question 3: What Constraints do Systemic Therapists Experience/Construe for Working With Sexual Issues? Constraints Therapists personal barriers Discursive constructions Group interview Talking about sex causes discomfort Lack of conversations about sex in therapists personal lives makes it difficult to address the subject in therapy Therapists personal curiosity about clients sexuality can present ethical professional dilemmas Therapists lack of confidence prevents dealing with sex Individual interviews Therapists personal inhibitions, embarrassment and reticence prevent them from approaching the subject of sex Therapists religious, cultural, class, and familial context of upbringing constrain them from working with sexual issues Therapists lack of comfort with own sexual experiences is a constraint to discuss sex in therapy Group interview The subject of sex is titillating Discussing sex in therapy would make a therapist become a voyeur Individual interviews Discussing sex with couples will lead to seeing therapist as seduced by the opposite gender partner Talking about sex in therapy is likely to be offensive and intrusive Group and individual interviews Lack of personal therapy renders therapists vulnerable to approach a sensitive subject like sex Individual interviews Being a parent of teenage children makes a therapist vulnerable to discussing sex Group interview High severity of the sexual problem is a counter indication for

Risks to the therapeutic relationship

Lack of personal therapy

Therapists current life stage

Therapists professional insecurity

systemic work Individual interviews Discussing sex in therapy can make it more difficult to manage boundaries between intimacy and working relationship Working with sex requires knowledge and skills which systemic therapists are lacking Therapists construction of their professional role Group interview Sex is an area of expertise of individual psychotherapy Therapists protect clients privacy by not discussing sex Individual interviews Therapists should not dig in the area beyond their professional expertise Systemic therapists should not act as if they are sex therapists Therapists might get bad reputation if they get overboard mentioning sex Group and individual interviews There is no systemic literature on sex There is lack of evidence based research to prove positive outcomes Group and individual interviews Systemic training is deficient in providing an input on the subject of sex Group and individual interviews The absence of the subject of sex from clinical practice is mirroring social conversations Group and individual interviews Societal double standards are preventing therapists dealing with sexual issues effectively Societal narrow views such as seeing sex as separate, distinct and belonging to adults only, limits therapeutic practices Therapists should respect clients_ cultural norms and, within that, what is OK/not OK to talk about in public Group and individual interviews Finance driven agency policies and the power of money and hierarchy determine the therapists role Adult mental health labels desexualise a person and create an unhelpful split between sexual and mental health difficulties The subject of sex does not fit with working with children and families Group and individual interviews There is no forum for systemic therapists to discuss working with sex, during or post training Individual interviews Therapists are not convinced about the positive outcomes of addressing sex Individual interviews For therapists own legal protection it is safer not to discuss sex with children

Lack of systemic literature

Insufficiencies in systemic training Cultural practices

Ways of sexuality being treated in the wider culture

Context of work

Lack of professional support

Lack of sense of positive reasons

Legal risks/child protection

Theoretical constraints

Individual interviews There is no coherent systemic theory on sexual development and sexual relationships Individual interviews The subject of sex is exposing, complicated, confusing and risky and is bound to make therapist feel vulnerable Individual interviews It can be complicated to decide whether to talk about the couples intimate relationship if one person wants to and the other does not Individual interviews Public expectations put therapists under pressure to prove successful treatment so they avoid the subject of sex as too risky

The nature of sexuality

The nature of couple work

Therapists public image

Research Questions Discussion Using Foucauldian Analysis How Systemic Therapists Work With Sexual Issues in Clinical Practice Data analysis revealed ways in which discursive constructions and therapists_ positioning within them open up or close down opportunities for action (Practice). Sexual issues were constructed as very important; however, the resulting infrequency of such discussions in practice is overridden by a powerful discourse that sex is a difficult subject. In the context of constructing conversations about sex as dangerous, inappropriate, titillating, self exposing, and unsafe, therapists positioned themselves (Subject positioning) as experiencing inhibition, reticence, and anxiety (Subjectivity). In addition, it could be argued the contradictory discourses from the interviews (Figure 1) create dilemmas and uncertainties regarding the subject, which then contributes to it being treated with avoidance and apprehension (Action orientation). The above dominant discourse (Sex is a difficult/inappropriate subject to discuss) and the subject positions contained within it, located therapists within the structure of rights, duties and responsibilities from which to speak and act (Action orientation). Discursive constructions about the inappropriateness of discussing sex in therapy became bound up with a cultural discourse which constructs talking about sex as offensive, intrusive, and incompatible with cultural respect (Discourse). These discourses then formed a legitimate basis for making decisions about not addressing it in clinical practice (Practice). Constructions of therapists role and therapeutic relationship as protecting privacy, following the clients lead and respecting the clients cultural context allow therapists to justify and continue existing practice. Foucauldian discourse analysis thus demonstrated the power of discourses to facilitate and limit, enable and constrain what can be said, by whom, where and when (Parker, 1992). Resources That Systemic Therapists Draw on When Working With Sexual Issues A range of personal and professional resources was constructed (Discursive constructions), from therapists personal background and life experience to the clinical experience and learning from colleagues (Discourses). However, these were frequently described as being underused in systemic practice (Practice). The study material pointed to strong views about a lack of resources and support systems, from systemic therapy training through to post-qualifying levels. Within the research data, therapists seemed unaware of a useful and informative, albeit modest, systemic writings on sexual issues. This can be understood in the context of the reported lack of support, through which the existing literature could be made available. Equally, systemic ideas and techniques were constructed as limited resources in the reported absence of opportunities to discuss applying them to the area of sexuality.

FIGURE 1 Discourses on ways of working with sex in systemic therapy.

FIGURE 2 Constraints that systemic therapists experience/construe for themselves in dealing with sexual issues. Constraints that Systemic Therapists Experience/Construe in Working With Sexual Issues Figure 2 shows numerous constraints; some were depicted as unhelpfully limiting clinical practice, others as justifiable reasons not to address sex. Conversely, no participant reported any negative experiences from discussing sex with clients; moreover, when discussed, the results were described as therapeutically beneficial. Thus, the numerous hypothetical obstacles introduced by therapists far outweighed the stated resources. The therapists self as a constraint dominated the data directly, through their admission of lack of confidence and personal inhibitions, and indirectly, through apprehension, justifications for not addressing sex and by presenting numerous hypothetical scenarios where addressing it would damage the therapeutic relationship. Figure 3 shows contextual influences from therapists past and present lives that constrained them. Conclusion The findings reflect wider social ideas or dominant discourses so entrenched they become common

sense (Foucault, 1980), governing participants ways of accounting for their lack of engagement with the subject of sex. Sexual issues in systemic therapy surfaced as a marginalised discourse, constrained by societal contradictory and ambivalent treatment of sex: as a taboo on the one hand and on the other as sensationalist; and additionally, by the prevailing cultural norms whereby conversations about sex are surrounded by secrecy, shame and anxiety, and are regarded as socially and culturally intrusive. Within these dominant cultural constraints the place of therapeutic work with sexual issues is seen as limited, inappropriate, and even potentially harmful. Therapists language constructions such as: not pushing the subject, otherwise it can be damaging or the suggestions that therapists can be seen as unprofessional, crossing the boundaries and making clients feel coerced, wrong, blamed and invaded if sex were to be discussed in therapy, indicated the powerful impact of the aforementioned constraints. Furthermore, data analysis revealed how discourses are bound up with institutional prac tices in that participants discursive constructions offered legitimisation of existing social and institutional power structures (Willig, 2003). The study pointed to another aspect of excluding practices reflected in the discourse: Systemic therapists are treating sexuality as belonging to adults only. Data analysis indicated that sexual issues are kept out of family work and child focused practice in child and adolescent mental health services. Indeed, this is supported by the omission of the subject from the majority of systemic literature on working with children. This is in spite of a number of pioneer family therapists (for example, Ackerman, 1958; Satir, 1972; Skynner, 1976, 1981, cited in Gurman & Kniskern) having emphasised inclusion of issues of sexuality and sexual relationships in treating childrens problems. A reported absence of conversations about sex from family sessions and working with children raises questions about the place of therapy in creating a secret and taboo subject out of the topic. In this way therapy may become a problem-maintaining factor.

FIGURE 3 Therapists self as a constraint to working with sex. Discourse analysis showed how therapists anxieties about sex talk reflect some of the tensions and

ambiguities in the wider systems, located particularly within child protection and legal discourses, exacerbated by the new legislation regarding sexual abuse of children. These attitudes contradict systemic discourses defining the tasks of therapy as opening up conversations, bringing the unsaid into focus and encouraging active exploratory curiosity. Therapists seem to be drawn into a double bind (Bateson, 1972) whereby they are set up to fulfill an impossible task, to be all inclusive and yet left with no guidance as to how to perform it. In addition, therapists are caught in the contemporary postmodern world with its radically pluralistic, radically changing structures and values (OHara and Anderson, 1991), which brings new uncertainties and dilemmas and opens up layers of anxieties in personal and professional relationships. In this climate, professionals may feel they could be thought of as abusive or harassing others by discussing sexual matters. Findings indicate a need for systemic training institutions to enable future therapists to develop confidence, knowledge and skills in this area, covering both all training levels and post-qualifying practice. Given the delicate and sensitive nature of the subject, systemic training courses have the responsibility to encourage a self-reflexive approach to sexual issues. Data analysis also confirmed the potential for systemic conversations to promote new thinking and practice in the area of sexual relationships. It showed systemic therapists place a significant value on systemic conversations about sexual issues. In research interviews alternative constructions began to emerge, such as counter-discourses, that it is anti-systemic to separate sex out; that sex should be integrated in individual, couple and family work; that adult mental health labels desexualise a person and that cultural norms are constraining therapists in addressing sex. The study also demonstrated systemic therapists would welcome more opportunities to share ideas and learn to include this area as a topic integral to their practice. This research experience reminded me of the provocativeness of the subject; the vulnerabilities it can trigger; judgments and prejudices it can spark off, and the pervasiveness of deeply embedded inhibitions and anxieties with regards to topic of sex. At this point the research has further consolidated my impression that systemic resources are undervalued and underused in addressing sexual issues and at the same time of the great potential of systemic conversations in this area. Further research could bring more valuable insight into this area, employing different methods, and might also include clients views. Acknowledgments I would like to thank all the participants in the study and to Teresa Wilson for her helpful reading of the final draft. References Ackerman, N. W., 1958. Psychodynamics of Family Life, Basic Books. Barbour, R.S., & KitzingerJ. (Eds), 1999. Developing Focus Group Research, Sage. Bateson, G., 1972. Steps to an Ecology of Mind; Mind and Nature, Jason Aronson. Byng-Hall, J., 2000. On Therapist Reflections: Diverse Developmental Pathways for the Family, JFT, 22: 264-272. Carter, B., McGoldrick, M. (Eds), 1999. The Expanded Family Life Cycle. Allyn & Bacon. Dallos, S., & Dallos, R., 1997. Couples, Sex and Power: The Politics of Desire, OU Press. Foucault, M., 1978. The History of Sexuality, Random House. Foucault, M., 1980. Power/Knowledge, Pantheon Books. Gorell-Barnes, G., Down, G., & McCann, D., 2000. Systemic Supervision, Jessica Kingsley. Gurman, A. S., & Kniskern, D. P. (Eds), 1981, 1991. Handbook of Family Therapy, Brunner/Mazel. Hare-Mustin, R., 1994. Discourses in the Mirrored Room: A Postmodern Analysis of Therapy. Family Process, 33, 1: 19-35.

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