Monday, January 11, 2016

Acceptance, Part 2

Diagnostics

The current diagnostic manual, DSM – 5, has instituted a two-tiered system for diagnosing sexual variations.  Those sexual variations that are nonconsensual, illegal, or cause the problems categorized above are ‘paraphilic disorders.’  A sexual variation that doesn’t cause ‘clinically significant distress or impairment in social, occupational or other important areas of functioning’ is not a mental disorder but is still coded as a ‘paraphilia’, just not a disorder.  This raises the question:  if a sexual variation is not a mental disorder, why should the DSM code it as anything?  That answer is methodological.  It is pretty easy to reliably code the difference between phenotypically different behaviors, such as exhibitionism and sexual masochism, relative to coding the degree to which a sexual variation is a source of clinically significant distress or impairment.  So retaining the diagnostic distinction between stressful transvestism and stressful sexual sadism improves the statistical reliability of all the paraphilia diagnoses, and it saves the entire family from being primarily a matter of client’s opinions about how distressed they are, reserving the diagnoses to the opinions of trained professionals.

Given the potentially stigmatizing consequences of any diagnostic label, why use them at all?  Even clinicians who philosophically oppose diagnostic labels sometimes require them for billing purposes.  I prefer using the following strategies for the sake of patients’ privacy and to add as little as possible to the stigmas to which they are already subject.  First, I rarely make reference to variant sexuality when contributing information to a client’s electronic records, which is where all such information eventually goes, unless it is central to the treatment of a paraphilic disorder.  If the client is complaining of problems related to stigma related to variant sexuality, it is probably best to examine those problems through a lens of acceptance issues and not refer to any sexual variation.  In cases of non-consensual behavior, criminal conduct, and sexual behavior driven by personality disorders such as narcissistic, borderline, or antisocial personality, one is professionally obligated to diagnose a paraphilic disorder.  Note, however, that this is my opinion, and is not acknowledged in the DSM-5 criteria.   The professional reticence I am advocating comes at a price.  We can scarcely expect improvements in the construct validity, statistical reliability, or research utility of diagnostic criteria that are not consistently applied.

Another constructive strategy for dealing with the stigma of diagnostic codes is to avoid using codes that you could clinically justify, but that are not intrinsic to the treatment plan.  Many treatments of the sexually variant are for depression, relationship conflicts, anxiety symptoms and substance problems that barely touch on paraphilias.  Given that clear diagnostic criteria for Hypersexual Disorder and Compulsive Sexual Behavior have never been created to separate these from anxiety disorders or impulse problems, those non-paraphilic codes may be ethically used instead.  If coding a paraphilia creates a social vulnerability for clients while failing to provide them with a compensatory benefit in access to treatment or improved services, clinicians are in an ethical bind to be fully professional and client-centered simultaneously.  I resolve such conflicts in favor of protecting the client, rather than protecting the diagnostic system.

Being accepting of kink does not free licensed professionals from knowing and adhering to the standard of care and explaining the ways in which their practices may differ from it, even where the kink community is directly confronting stigmatizing flaws in the diagnostic process like the one I described above.  For example, when I do not wish to use a diagnostic code so as to protect the client from having material placed in an electronic database, I need to make the choice with the client’s informed consent, rather than just declining to code and telling or not telling that client as I see fit.  In client-centered therapy, the client makes the decision about what code to use.

Symbols, Meaning and Behavior:

How clients present their kink to you as their therapist is important, but the meaning of their choices may not be as clear as they appear.  At the core of this problem is a theoretical conflict in the field that has persisted for over 100 years.  This debate is about whether behaviors and symbols have more or less standard and invariant meanings because of their contexts, or whether symbols are personal and unique, their contexts a function of individuality.  With the publication of The Interpretation of Dreams in 1900, Sigmund Freud claimed that he had discovered universal symbols of the Oedipus complex; the rise of competition, phallic pride, shame, or fears of castration were all determined by unconscious love and hatred for the same-gendered parent. Jung saw the Oedipus complex as a mere example of standard symbols that every person shared as part of a collective unconscious.  So both doctors presumed that similar behaviors in different clients could be presumed to have standard and interpretable meanings.  In the 1940’s with the rise of ego psychology, clients whose personal symbologies lacked conventionality came to be seen as extremely disturbed, even psychotic.

"My words mean what I want them to mean."  Not necessarily, but don't be put off by his untimely demise!

After 50 years of hegemony, psychoanalysis encountered a backlash from the popularization of psychology and the rise of the counter-culture.  Psychedelic experience challenged the idea that all symbols automatically meant the same thing.  Psychotomimetic experiences might be freeing and self-exploratory as one explored and even created personal symbologies.  Lucid dreaming meant the client might control one’s own dreams, rather than treating them as the royal road to discovering the unconscious.

The social constructionist position of this blog is a partial compromise between these positions.  While I do not believe that there is a collective unconscious, there is a zeitgeist around the individual that provides a constant stream of symbols and meanings.  Conventional meanings are privileged in this massive discourse, and some symbologies are so pervasive, such as green for go and red for stop, that clients can scarcely avoid being influenced by them.  But personal symbologies expropriate selectively from these, and similar behaviors cannot be assumed to have similar causes.  For Freud, acceptance of clients meant listening to the inevitability of their penis envies, their castration fears, and their guilty rivalries with their same-gendered parents.  For Jung, acceptance of clients meant interpreting their conflicts in terms of universal and transcendent symbols.  For social constructionism, acceptance means probing the clients’ accounts for how their sexual expression taps idiosyncratic, sub-cultural, and conventional understandings of the meaning of sexuality.  For Liang and Leery, exploring your unique experience was a rejection of societies authority to dictate what your symbols mean.  “Tune in! Turn on! Drop out!” demanded that you find transcendent meaning in your own consciousness, not the social context.  What is it that you accept or reject, and how do you know what is sexy, good, or painful?  It might be all up to you!

Timothy Leary (1920-96) was a promising personality theorist before grief and LSD made him an advocate for hallucinogenic drugs and the spirituality of idiosyncratic meanings

My suggestion is that there is no simple formula for a right answer.  Therapy explores the client’s personal symbolism, noting where common symbols have been expropriated from the social context and sharing understandings that are unique and idiosyncratic (all the while holding these up to the client’s conscious goals and contract for treatment).  Acceptance means continually testing whether clients really want what they say they want when they see new complications and implications of their desires.  It is strongly recommended that in therapy, the clinician use the language of the client.  In order to do that effectively, the clinician must understand their meanings, a problem I will address explicitly in a later post on the Tower of Babel.  But it will do not good to use the client’s language if you do not have a good understanding of the client’s personal symbols.   Often that language will be deliberately vague, politically incorrect or downright transgressive, or based on obviously false assumptions.  There are times and places where the most accepting of clinicians may need to point out such things, or provide specific psychoeducation about clinical, medical, or conventional social meanings.  All of this is made more effective from a position of understanding and accepting the client’s inner world and how it is represented.

Initial Presentation:

Clients who bring up their kink right away, for example, may be expressing considerable initial trust in you as a clinician.  Or they may be pressured by acute anxiety over the social consequences of its discovery.  They may lack the boundaries to withhold it, or have the boundaries, but feel overwhelmed by the emotional pressures to keep their feelings private.  They may already have been outed, and hope that rapid disclosure will end discrimination quickly.  Or they may find the burden of secrecy crushing and look to therapy as the first place they feel safe to have a face-to-face conversation.  Some will eroticize the therapy and look upon the discussion of their kink as an opportunity to seduce the therapist, be seduced by them, or simply use therapy as a place where it is safe to turn themselves on. Notice that all of these different initial presentations manifest conflicts about acceptance, but in very different ways.  Not only do problems with acceptance take many forms, but clients bring widely differing adaptations, skills, and defenses to the therapy in managing acceptance challenges.  That often means that in early sessions, many good interventions by the therapist are about establishing a safe environment for clients to tell their stories, and it is best to wait to interpret a client’s stories until you have a pretty good idea about what they mean.  In complicated or ambiguous initial presentations, that may mean contracting from session to session until you understand the client’s definition of the presenting problem and the contract and consent to treatment.

Acceptance can take several common forms as a therapeutic issue.  Because sexual expression is partially about private behavior, many clients set boundaries between their different social role performances.  Clients are often not used to talking about their sexual desires with anyone other than their partners (if that), and it is not uncommon for them to hide their kink from therapists in their initial presentation.  Since Sigmund Freud’s Three Contributions to a Theory of Sexuality in 1905, sexual science had known that kinky clients are often less repressed than so called ‘neurotic’ clients.  I guess there is something about knowing that what you desire is regarded with judgment and suspicion by the surrounding society that interferes with forgetting the dangers of what you like and its potential rejection!   It is a reality that kinky people lose jobs, relationship partners, family support, child custody, get forced into various conversion therapies, and have their personal affairs discussed in judgmental and public ways.  This means a certain reluctance to bring kinky interests up early in a treatment the client believes might be about something else is often a sign of healthy boundaries and rudimentary social skills and sensitivity.  As kink becomes less stigmatized, it is not only reasonable to expect fewer acceptance issues in treatment, but it also might lead to clients bringing it up earlier and in more matter-of-fact clinical presentations.

Sigmund Freud (1856-1939) suggested that clients suffering from 'perversions' were the opposite of neurotics.  Neurotics suffered from too much repression, 'perverts' were not repressed as much as society prescribed.  As Freud matured, he became increasingly critical of societal repression.  Perhaps Nazis had something to do with that.

Taking a sexual history, and explicitly asking about sexual variations during that history, can speed up bringing sexual variation into the conversation.  Taking a full sex history models and normalizes frank sexual discussion in treatment.  But it does not mean that clients are ready to disclose sexual material early on about which they are intensely conflicted.  If you ask too forcefully, or flat out include direct inquiries about kink in tests or intake forms, you may speed up revelations from clients before they are ready and even be experienced as laying an agenda on the client.  It is the responsibility of the clinician to exclude otherwise useful assessments from their repertory if they stigmatize sexual variation by conflating it with pathology, such as sex addiction measures that count BDSM as proof of ‘addiction.’  While variant behavior may involve “excessive” sexual expression, it is culturally incompetent to consistently interpret that it is an indicator of sex addiction.  Sometimes the frequency of sexual expression is an expression of general anxiety, fear of social judgments, or realistic worries about a partner’s feelings about the client’s sexuality, not ‘addiction.’

The reputation of kinky clients to be low on repression and unusually ready to speak of material that is typically repressed by others is evident in many cases, but not characteristic of all of them.  And being open and aware of aspects of one’s sexuality does not mean that clients may not be unaware of other aspects of their narratives or histories.  Creating an accepting environment for the issues of alternative sexuality means remaining open to these possibilities, but being prepared for exceptions.  The foremost proof of acceptance is listening to the client and reflecting accurately back what you have heard to them in ways that they can recognize.

Power and boundaries:

The early readiness of many clients with kink to talk about socially disapproved of sexuality often has provoked complaints from therapists that the kinky have ‘bad’ boundaries.  On the face of it, this is an open and shut case.  Hetero-normative people mostly avoid making public displays of their sexuality even though, if they did, their practices would be familiar, albeit out of place.  On the other hand, many sadomasochistic practices, even though the practices themselves risk opprobrium, also involve dramatic boundary violations as part of explicitly consensual play.  This does not mean that kinky people usually have ‘bad’ boundaries; new boundaries have been agreed to that are appropriate to the desires of participants and their cultural context.  It is quite possible to violate these new negotiated boundaries.  But romantic assumptions in hetero-normativity idealize naturalism, spontaneity, and imply that boundaries do not need to be articulated or negotiated.  In such situations, a therapist may feel invited to mediate what acceptable boundaries ought to be.  In most situations, this is a bad idea.  Even when a client directly requests help with boundaries, it is often wise to question closely why the help is sought and what difference the client imagines the therapist’s likely responses might make if the client were to act on them.  How does the client believe that the therapist would be better at this decision than the client?  Such therapist interpretations are, on the other hand, are likely to be needed in cases where clients with low social skills and difficulty internalizing social expectations make a direct request for this kind of help.  There are kinky people who have problems with their personal boundaries.  But for clients with ordinary or good social skills, the question of boundaries is best left to be a decision of values and self-control that the client needs to make.  Often, this type of decision involves the client’s need to face and work through some feelings of loss that the general society, partner, or parents lack the capacity to be more accepting of the client’s private feelings.

Because boundaries are often about power, client-centered therapists must be exceedingly careful about inadvertently power playing clients when calling them on boundary issues.  Such interpretations are essentially disciplinary when the therapist sides with social conventionality to try to modify a client’s behavior.  In such cases, the therapists must ask themselves, ‘What about my restatement of conventional wisdom is likely to be effective where the aggregation of similar sanctions in everyday life have failed?’  Interventions that target the client’s explicitly stated values and contract for treatment are much more effective.  The client is confronting their own values, rather than substituting yours for theirs.
Not all kinky clients play with power, but it is the broadly unifying theme in BDSM.  So it is routine to encounter power dynamics in treatment.  For all of psychotherapy’s sincere concern about keeping our conversations client-centered, the professional role is one of inherent power imbalance.  Clinicians are professionally trained, degreed, licensed, command fees, set their schedules, enjoy a substantial measure of earned privilege and social authority.  So the opportunities to idly, unconsciously, or deliberately power play clients in psychotherapy abound.  Braun-Harvey and Vigorito have eloquently articulated the dangers in Chapter 1 of Treating Out of Control Sexual Behavior:  Rethinking Sex Addiction.   Genuinely accepting therapy for sexually variant clients is not only alert to the problems of social stigma that surround variant desires and behavior, but actively seeks to level clinician’s power imbalance over clients in the office.  Clients are in more danger from us than we from them.

Acceptance is also often an issue for people with variant interests who are conflicted about joining available organized BDSM and poly organizations.  Although such organizations can be very accepting of sexual minorities and gender expressions, they do have hierarchies, rules, power differences, and orthodoxies of their own.  Client issues can magnify these, fight with them, and render the potential support of communities unavailable.  It is not just kinky communities that display acceptance issues.  Clients may resist of some of the common practices in these organizations, such as consensual non-monogamy, altered gender roles, exhibitionism, or the need to be an initiate in a new organization where one lacks power or status as a new and unproven member.  They may be intolerant of some roles they see others taking in kinky communities, or see behaviors that make them uncomfortable and fear that they will lose control of their values in such a group and come to desire behaviors that are currently off-limits for them.  In such instances, it is unwise to refer clients to otherwise safe and helpful kinky organizations until the client has contracted in therapy to become ready for a successful entry.  Just as remaining closeted has costs and consequences, so does the act of joining a private social club.  Acceptance means understanding what those expectations might be for the particular climate in the social group and arming the client with the information to make their own decision about joining.

It must be noted that clients come to treatment with widely varying degrees of acceptance of their own identities, fantasies, desire and behavior.  While the clinician may be clear about the degree client behaviors vary from the norms of the conventional and variant communities, the client may not be accepting of any of this.  Clients who embrace polyamory may come in tortured by jealousy and separation issues that are normative in the general society, but at extreme variance with the consensual non-monogamy community.  Clients may be in extreme pain because they cannot accept sexual fantasies that clinicians regard as typical.  Efforts to give clients permission to express their feelings or act on their fantasies may face clients who are extremely reluctant to license any such things.  Clients who are intensely conflicted about the conflicts between their desires, values and behaviors, and prone to externalizing defenses may not feel like therapy is neutral, and may have trouble establishing a sound therapeutic alliance.

Sometimes acceptance issues manifest as relationship conflict. Clients come into therapy together as romantic partnerships.  One partner craves a certain sexual behavior, the other(s) don’t want to include this in their sexual repertory, and they come in hoping the therapist will mediate the dispute.  It is sometimes possible to do this mediation, but desire differences were among the presenting problems sex therapists have regarded as challenging since Masters and Johnson first discovered they did not submit easily to behavioral therapy.  It can be hard to use sexual pleasure to solve desire differences when which activities bring pleasure aren’t shared.  But desire differences become entrenched and compounded when partners define desire differently, when romantic ideals leave them feeling that love should solve all problems, and that failure to do one’s favorite sexual behavior is ‘proof’ that your partner is not accepting.  This type of conflict is often about something more than acceptance, but becomes stuck on it.

"The Suitor"  Theodore Levinge (1848-1912)
As Esther Perel has repeatedly and wisely pointed out, problems of acceptance often hamstring couples because of the pervasive influence of romantic idealization in Western society.  This is frequently expressed in the lovely notion that love means infinite acceptance and that one can bridge any difference if one is loved deeply enough.  This adage is troublesome because it is not true that love means infinite acceptance, and that acceptance does not mean that anyone can be taught to enjoy all sexual activities.  Acceptance does not imply that differences will evaporate, loss does not need to be tolerated, or that loving partners can stretch their self-concepts and eroticism to embrace all behaviors.  Romanticism implies that acceptance is an all or nothing proposition.  Realistic social acceptance instead suggests that we can accept more things than we can do, and that even the most experimental and open-minded partners are going to have limits.  It is an acceptance issue when one partner says to the other(s), ‘If you love me, you’d do this thing with me’ and the partner(s) reply, ‘If you loved me, you wouldn’t ask!’  Urging more acceptance does not often break such deadlocks:  acceptance cuts both ways in such arguments.  In therapy, this must often lead to another confrontation with the implications of romantic idealization:  love and sex do not automatically or entirely erase the need to face feelings of loss.

No matter how judgmental the external world is, acceptance issues often become internalized.  It is difficult to be self-accepting if one’s passions are shared by few, provoke disgust from others, make one the butt of jokes and jibes, or if you hate them yourself.  Internalized shame, fear or disgust at a client’s own desire is often the focus of therapeutic attention.  Different therapies handle this ‘internalized kinkophobia’ very different ways.  In ‘sex addiction’ therapies, labeling kinks as addictions is a common strategy.  Quality sex-positive treatment opposes this as alienating clients from their own desires by relabeling them as a kind of pathology -- an ‘addiction.’  Not only is the ordinary neurobiology of attraction making use of the rewards circuitry of our brains to motivate us to focus upon and pursue a partner, but that same circuitry is involved in many other reward-seeking adaptations.  Calling such behavior an ‘addiction’ artificially sides with therapeutic solutions that seek to reduce and control sex behaviors rather than those that encourage their expression.  This may seem reasonable when behavior is illegal, intensely socially stigmatized and the client is intensely judgmental, but can pose real problems when it comes time to license other sexual expression which the client deems to be more appropriate.  Often sex addiction treatments require the client to accept a deviant or devalued label as the precondition to treatment, leaving the problem of excessive shame and self-criticism untreated.  Where possible, clients need to be taught to manage their feelings in ways that prevent shame from inhibiting sexual satisfactions, rather than harnessing sexual shame to stop behaviors.

Echo and Narcissus by John William Waterhouse (1849-1917) Another painting in the Romantic tradition.  In modern clinical theory, narcissism is far from romanticized!

Self-acceptance also has important implications for client self-centeredness and narcissism.   It can be quite difficult to maintain a healthy self-concept when you imagine judgment and ostracism for your values and behavior.  Indeed, social stigma is administered precisely to help conventional members of a group to refrain from prohibited behavior by inculcating the belief that no good person would do such things.  Most of us refrain from bank robbery not because we lack a good plan for stealing money, but because we do not care to think of ourselves as bank robbers.  So internal conflict about one’s kink is likely to take a considerable toll on self-acceptance.  Ironically, this can lead to grandiose, domineering, haughty, and intensely self-centered behavior.  While this is not a perfect definition of the clinical concept of narcissistic personality disorder, it does conform well to the general social concept of narcissism.  And narcissistic defenses are commonly encountered in persons who are unable to get enough recognition and satisfaction from ordinary activities.  No well-designed study has been conducted and replicated demonstrating that the kinky are, as a group, more narcissistic than the general population, but clinical examples are out there to be found.  Narcissism often involves inordinate demands on others, boundary violations and feelings of entitlement that seem exaggerated.  Demanding exaggerated submission or high pain tolerance from one’s partner might be examples.   This can come from a diagnosable personality disorder, and/or from problems recognizing the needs of others through the din of the client’s neediness.   It is important to remember that clients who have long dwelt in a fantasy world, but have been unable to bring themselves to act on those fantasies, are very likely to show self-concept problems and judge themselves on the discrepancy between their dreamed of and achieved sexual adventures.  Given the risk of stigma in diagnosing such already-vulnerable people, diagnostic labels can potentially do more harm than good and therefore should be considered a last resort.  Process interpretations that focus on empathy with others or developing ways to recognize social acceptance are far more likely to be helpful to such folk.

This section would not be complete without a word about transference.  This blog has already taken up extreme countertransference reactions, which is about how the therapist is feeling.  Like The Force in the Star Wars mythology, the client’s transference pervades everything we do in therapy.  If acceptance can underlie so many different presentations in therapy, how is the clinician to decide where to intervene to help kinky clients?  Often that answer lies in the client’s process of relating to the therapist and how the therapists feels about the client’s narrative.  Teaching therapists how to use transference has gone out of fashion as society and the field have instead become enamored of cognitive behavioral techniques.  These techniques work great for clients who start with pretty good affective and behavioral control, but for cognitive behavioral therapy to work, the client and therapist must know and agree what the cognitive rewards are for the client and must be able to design interventions that use them.  When clients poorly understand their own values and rewards, they tend to enact feelings rather than deliberately discussing them in treatment.  Understanding how the client makes you feel and how they are feeling in therapy become the bases for understanding whether acceptance is the main issue, or whether it is just a stand-in for something more important that is bothering the client.

"Good fences make good neighbors" R Frost.  Boundaries are important.  On the other hand, the Great Wall was built because China did not have good neighbors.  It was designed to make retreat difficult for mounter raiders, rather than to seal them out.  It is an important case study in the many ways boundaries can function.
Acceptance of kink requires the therapist to set boundaries on what work they are prepared to undertake. Many therapists are not set up with the proper training and context to handle non-consensual behavior or clients requesting help with criminal sexual preferences.  Some decide not to work with co-morbid conditions such as psychosis, substance abuse, personality disorders or certain mental disabilities.  Some work with kink, but must decline cases that involve edge play that upsets or frightens the therapist too much to professionally treat such cases effectively.  Others refer out clients to community specialists whose expertise is better suited to specific client problems or conditions.  Knowing one’s own limits as a therapist is perhaps the toughest and most profound expression of acceptance possible, for it properly places the welfare of clients first even in the face of financial self-interest, ego, or the therapist’s own self-concept.

The history of therapeutic work in this field shows substantial risk from well-intentioned clinicians listening selectively to clients, siding with one dimension of an ambivalent and ambiguous client presentation and urging the client to accept the doctor’s expert interpretations.  In these stories, even when the clinician proves correct in one case, the theory is deployed in subsequent cases where the fit is not so good, and the professional rewards for greater glory and the wish to help more clients leads to over-generalization.  Castration anxiety, masculine protest, evolutionary fitness or degeneracy, identification with the aggressor, poorly internalized identifications: all these and many more have been evoked to explain kinks.  In my experience, explaining any individual’s kink is a cottage industry, not an opportunity for grand theory construction.  Clients chose their kinks because, no matter how deviant, dangerous, or socially outre they might be, they are the best route to sexual satisfaction, identity construction, human closeness or spiritual connection they can manage.  However painful the client’s adaptation may be, the struggle with stigma is more painful.  For therapy to be of any value, therapy needs to avoid being yet another venue in which stigma is inflicted.
References:

American Psychiatric Association (2013)  Diagnostic and Statistical Manual of Mental Disorders- 5. American Psychiatric Publishing.

Freud, S (1900) The Interpretation of Dreams SE, 4-5.

Freud, S (1905) Three Contributions to a Theory of Sexuality SE, 7: 125-245.

Braun-Harvey, D. and Vigorito, M (2015) Treating Out of Control Sexual Behavior:  Rethinking Sex Addiction. New York: Springer Publishing.

Perel, E (2007) Mating in Captivity: Unlocking Erotic Intelligence. New York:  Harper Collins

© Russell J Stambaugh, January 2016, Ann Arbor MI, All rights reserved

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