Wednesday, December 2, 2015

Acceptance, Part I:

This post is the first of two parts on acceptance issues in therapy for sexual variations that are socially stigmatized.  This section focuses on the social context and role of the therapist.  The next looks at diagnosis, and presentation of acceptance issues.

If we take the work of Erving Goffman seriously, and applaud AASECT’s formal endorsement of the idea that kink is not inherently pathological, it is worth examining the role of acceptance and lack of acceptance in examining why kinky clients come in for treatment.  In this article, general remarks about stigma as a reality will be presented and what it means for a client-centered therapist to be accepting will be discussed.

Why is acceptance so important? 

Because acceptance is the social opposite of stigmatization.  The social context of any treatment of a kinky client includes the realities that sex and particularly sex variation take place against the background of social stigmatization.  Very few clients are unaware of this and even fewer are unaffected by it.  The general culture is not accepting, the client’s family might be rejecting, the client may well have lost valued sexual relationships over differences about kink, the client may be concealing aspects of their kink out of fear of judgment and rejection, and may have self-stigmatized out of identification with stigmatizing outsiders.   Stories of how weird kinky people can be abound.  They are suspected of criminality, get fired from jobs, must fight to retain custody and visitation with their children.  Sometimes they are denied political positions due to their private lives.  In the 1960’s the British government fell over the Porfumo Scandal in which Russian spies manipulated MP’s over their sadomasochistic desires with models Christine Keeler and Mandy-Rice Davies.  In another example from the year 2000, Kofi Annan, then United Nations Secretary General, had to take time out from managing the crisis of performing weapons inspections in Iraq to defend the objectivity of UNSCOM weapons inspector Jack McGeorge, a founder of Washington’s Black Rose Society, a prominent BDSM social organization.  The history of stigmatizing sexuality and kink is sufficiently great that security conscious businesses or governments naturally worry their officers might be susceptible to blackmail if their private sexual behaviors were discovered.  Homosexuality and kink were tops on the list of targets for such coercion.

John Porfumo resigned his position as British Secretary of State for War in the cabinet of Harold MacMillian in 1963.  His affair with Christine Keeler was kinky, but had national security implications when it was learned she was also seeing the Russian naval attache in London.

Jack McGeorge was a senior UNSCOM inspector in Iraq in the highly politicized period of weapons inspections in 2000.  A founder of  The Black Rose Society, his professionalism was attacked over his role as an out kinkster.  Secretary General Kofi Annan backed McGeorgre's role on the inspections, which  subsequently found no weapons of mass destruction. The US invaded anyway in 2002 and never found any.

The abrasive public action to stigmatize kink is sufficiently vigorous that the National Coalition for Sexual Freedom (NCSF) publishes a news feed of kink stories in the media.  For many years, 90% of these were local incidents where the authorities came down on some unfortunate people who were suddenly discovered to be kinky.  In recent years, the media coverage has become more favorable, but oppressive episodes persist.  NCSF also maintains a fund for helping indigent kinksters in legal cases.  That need has not slackened over time despite more favorable press. 

Stigma and acceptance issues may be reflected in real differences between clients and their partners about acceptance of specific behaviors, or clients may have faced some My-Kink-Is-Better-Than-Your-Kink attitudes or behaviors within their kinky community.  In a social climate within a general culture like ours, some confrontations with shame, social judgement and sanctions for unusual sexual behavior are inevitable even for the fervently closeted.  People get the message when they see others receiving social sanctions for kinky behavior.  The steady stream of political revelations that elected officials who supported anti-gay legislation but were later outed as kinky underscores this point.  Everyone, gay, kinky or conventional hears these social messages.

Any client entering psychotherapy for any problem, and who also happens to have a kink, is going to have a relationship to managing the consequences of all that stigma-inducing activity in the cultural context.   It is entirely possible that clients will have unrealistic ideas about acceptance too, but some concern about social acceptance is nearly inevitable.  Those defenses and adaptations have had years to develop before the client comes to the consulting room.  They will be the building blocks and obstacle to devising an effective therapeutic alliance and contract for treatment.

Having said this, I must caution that just because something is commonly true, it may not be universally true.  In the bad old days, inexperienced clinicians often hijacked psychotherapies in which the client came in with a different presenting problem and later learned the client was into kink.  These clinicians, assuming that the kink was pathological, proceeded to explain all of the client’s troubles with that ‘aberrant’ desire.  Not only is any unicausal explanation of a complex mental health problem often wrong, but focusing on kink as if it were the single cause of whatever problem was presented couldn’t help but result in adding to whatever stigma the client actually felt and crippling the therapist’s capacity to listen to the client.  So assuming that clients must be struggling for acceptance is not going to improve the therapeutic technique.  Some clients may be handling stigma with grace and aplomb.  Some are engaged in a self-destructive struggle over acceptance, but are not ready to admit it to themselves.  Yet others are resigned to feeling unaccepted socially, but are struggling with the other problems they came to the therapist to resolve. It is important to listen carefully to how the client handles acceptance and the problems social stigma poses and to be prepared to interpret its role if the client presents evidence that this is important.  If you are listening for this, you will often – but not always -- find it.

Do you have anything in black?

Acceptance by the Therapist:

The kind of acceptance needed for effective psychotherapy and sex therapy with kinky people is not fundamentally unlike the kind of acceptance for a general clientele:  you have to respect them as people and honor the difficulty of their struggle.  You do not need to do kink to do good therapy with kinky clients any more than you need to be dysphoric to treat depressed people.  The process of confronting your own stereotypes, expectations and preconceptions is fundamentally the same.  While it is possible to gain some insight by subjecting yourself to some of the experiences that kinky people undertake, such experiments hold both opportunity and risk.  Experiencing an effectively analogous experience to something your client faces can be a powerful source of emotional learning.  But trying something as an experiment you can easily walk away from is just one of a host of ways that you may differ substantially from the client, and it is easy to imagine that what you have learned is more useful than it is.  Interviewing kinky people who are not in therapy is a great way to understand more of what kink is about, but there is no guarantee that all of those great insights will apply to the client in front of you for today’s session.

Carl Rogers (1902-87) the founder of Client-Centered Therapy

Inexperienced clinicians often have the idea they need to ban all judgments in order to be effectively neutral.  Psychoanalysis, for example, teaches strict therapeutic neutrality.   The social constructionist view I am articulating here holds that complete neutrality is a utopian ideal.  The clinician is using therapeutic judgments when they diagnose, interpret, choose which of several questions to ask, or decide to remain silent and just listen to the client.  There is no galactic central coordinate from which neutrality is measured.  And your neutral therapeutic intent may not be perceived as such by your client(s).   But mostly your moral judgments are obstacles to a therapeutic process intended to bring clients into a constructive place from which to do their own moral decision-making.  They already live with moralism and stigma, so having a conversation that is relatively free of judgment holds a great deal more promise than reminding them of the obvious.  They already have deeply echeloned defenses, and there is not likely to be much therapeutic gain in assaulting them.

On the other hand, there are times when you may not be able to be neutral – and some when it may be better that you can’t be.  It is quite unlikely you will be able to remain entirely neutral to intense aggressive and sexually provocative material.  We are hard wired to have non-neutral reactions to pain and anxiety, shame and delight.  Kinks push boundaries, and sometimes its practices are unhealthy, self-destructive, disgusting and/or relatively dangerous.  It may be necessary to educate clients about real health and safety risks of their behavior.  So checking all your values at the door is not even an optimal strategy, were it practicable.  But you are being neutral enough if you stay within the limits of law and clinical practice, stick up for a therapeutic contract that keeps the strategic ends of therapy in the client’s control, and provide information that allows the client-informed choice, rather than trying to make the client chose the ‘correct’ one.  This is a crucial difference between therapy with clients engaged in consensually kinky behaviors and those who are perpetrating sexual offenses.  In the latter case, your contract requires that you attempt to prevent some illegal behavior.  In such therapies, you are acting as an agent of social control on behalf of the society that is doing all that stigmatizing and sanctioning behavior.  The kind of therapeutic alliance you can have while doing this is never predominantly between you and the client.

To be relatively therapeutically neutral requires a high degree of self-knowledge.  The more intense and provocative therapeutic material is, the more self-knowledge and emotional control is required of the therapist.  The very best way to gain this is through personal therapy, a tradition that goes back all the way back to the early days of psychoanalysis, the first type of talk therapy.  Sadly, in the past, even very intimate and intense personal therapies often did not delve deeply into matters of alternative sexuality.  In psychoanalysis, it was not unheard of for the clinical supervisors of therapists in training to be in close communication with their analysts.  Sometimes analyst and clinical supervisor were the same person!  The effect this had on openness in therapy can be readily imagined!  Modern training standards require post-graduate training and certification in sexology. The American Association of Sexuality Educators, Counselors and Therapists is the largest and oldest clinical training organization. and it requires affective and experiential sexuality education for certification.  This includes a Sexual Attitude Reassessment, a ten-hour experiential training that is intended to start professionals on the path of examining their values and feelings about sexuality, and features methods to model open and accepting discussions about sex.   These programs provide sexuality professionals an excellent start, but only a beginning, to understanding the feelings that working with clients, including kinky ones, can engender.

Again, an important corollary of these observations is that you need not be kinky to treat kinky clients, and if you are, what you know from your own experiences must be carefully tested against what clients are saying in the manner just described for open-minded clinicians trying out experimental behaviors.  The notion that you must be kinky, or deviant, or radical to do this work is flawed from the start, as there are so many ways to do those things.  Even therapists who are switches may need to stretch their empathy to relate to the special problems of people who only prefer one role, or who are devoted to a fetish the therapist finds boring.  Your chances of understanding aspects of BDSM or consensual non-monogamy from reading alone are pretty slim.  Even a blog like this which is at great pains to be empathetic and thoughtful, does not convey the bodily intensity that some kinky experience contains.  This experiential problem has not stopped sex therapy dead in its tracks when dealing with non-kinky sex, and it is not an insuperable barrier for treating kinky clients, either.  You do not have to experience top drop, or have been to sub space in order to deal with such material when it comes into treatment.  You are well advised to have researched such things so you can understand the relationship of what a client says about them in the context that others around the client understand them.  That may mean reading one of the “50 Shades” books whether or not you particularly like the writing style.  Or mean learning about sexual practices that make you uncomfortable.  (see also The Squick and the Dead: Intense Countertransference and BDSM, and  What if You Get Squicked? on this blog.)  It is important in our efforts to accept others to recognize the limits of our experiences, theoretical models and worldviews.

Kink events and clubs can play an important part in therapy, or not, depending on the client's needs.
Acceptance of kink as a therapist also does not mean that you should immediately connect your isolated clients up with the hot local BDSM social organization.  This is a therapeutic strategy that definitely belongs in your repertory, and often it will be a constructive step for clients.  But not every kinky client is going to benefit from such contacts despite the valuable education and community they can provide.  Accepting the client means recognizing the client’s goals and fears and their reasons for using the problematical solutions they have come to therapy to change.  If they are too socially inept, afraid of exposure, uncomfortable with the voyeurism or exhibitionism of BDSM social groups, or too anxious and lacking in good safety skills, such groups, which are wonderful for others, may not be right for them.

Likewise, it is not a responsibility of therapeutic acceptance of kink to encourage clients to “out” themselves.  Coming out can be a life and values affirming step.  It should definitely be among the things you are prepared to contract to accomplish with clients who express this as a therapeutic goal.  I will discuss coming out in a later post, but suffice it to say that there are various levels of being out, and it is more useful for clients to consider how those connect to their values and goals.  For many, openness about their kink is crucially dependent on context.  One does not need to be out at work to try some new things in bed with partners.  If, as a therapist you are out and kinky, and recognize how each out participant strengthens the community, it is important to curb your enthusiasm about what is best for the community so as to focus on what is best given the client’s values.
Acceptance does not mean liking everything the BDSM community does, having the same risk tolerance that others do, or minimizing the real health risks of some behaviors.  Being an ally does not mean, contrary to the stance of some advocates, that you check your values at the door and let disadvantaged and marginalized people do all the talking.  But you must let your client do the talking -- not you.   And the acceptance you need to provide does mean tolerating the discomforts that come from someone who is important to you and to whom you have a serious set of professional obligations, yet has different values, morals, ideas, loves, and risk tolerance than you do.  That is a major undertaking, and a true test of professionalism to not attempt to substitute your values for the client’s in the name of acceptance.

Finally, therapists and clients do their best in the face of human vulnerability.  It is an important tenet of genuine acceptance that if you err, you admit it, take responsibility for it, and apologize.  Your goal is to empower the client to make choices about matters like health and risk on an informed basis, and as freely as human fallibility allows.  If you overstep boundaries trying to help a client not make a risky choice, you will cripple your ability to help them take full responsibility for its consequences later.  So it is a powerful sign of acceptance, and great modeling of self-acceptance for the client, when you apologize for overstepping your professional role out of your own anxieties.

Little of what I have said in this section is arcane, or particular to kinky clients.  While the content of what needs to be accepted may be different at times, the process of acceptance is the same for everyone.  Educating yourself to the client’s life and problems, and listening with interest to their concerns, and helping them frame the decision processes about how to better cope with their dilemmas is the same for the kinky and the conventional alike.

© Russell J Stambaugh, December 2015, Ann Arbor MI, All rights reserved

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