Category: Sexuality/Gender

Therapeutic Fanfiction: Rewriting Society

Posted on by Psychotherapy.net Team

In our work as geek narrative therapists, we’re often asked if we actually use fanfiction in session, and the answer is yes, we really do! For those who are unfamiliar with the term, “fanfiction” refers to creating one’s own stories based on beloved characters from existing pop culture narratives. Using fanfiction in therapy enables clients and therapists to rewrite the hero’s journey using narrative techniques. Since fanfiction is most often character-driven—getting inside the head of a character and asking “what if”—we can do the same with our clients, asking them to explore “what if” scenarios for themselves. For many clients, seeing themselves as the hero feels unfamiliar, and this is where fandom attachment or parasocial relationships can be uniquely helpful. Clients can use their emotional connection with fandom characters to create therapeutic fandom avatars and craft a fanfiction story that mirrors their own lives. With therapeutic support, they can begin to see their own heroism from the perspective of these beloved characters.

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Such was certainly the case for Cas (an amalgamation of several actual clients), a 25-year-old gender non-binary individual (biological gender female) of Ashkenazi Jewish descent, struggling with anger management issues and the fear that they would always be other. During our first session with Cas, they verbally noted our Adventure Time BMO, short for ‘BeMore’ tea mug, commenting that they had never seen a tea mug that was “quite so square.” We took this as an invitation to begin using therapeutic fanfiction early in our work. We shared that BMO, the gender nonbinary robot and video game console, was one of our favorite characters in Adventure Time, and asked Cas if they, too, enjoyed this cartoon. Cas eagerly explained that they loved this cartoon and that BMO resonated with them because BMO is on a journey to be “both a little living boy and girl who drinks tea.”

In the next few sessions, we fully employed the narrative tool of externalizing a problem via everyone’s favorite green superhero, The Incredible Hulk. This conversation was again initiated by Cas who remarked on the Hulk painting displayed on our wall: “Ha! That’s really true: mad does make sad.” We engaged Cas in a narrative therapy discussion around Bruce Banner, a.k.a. The Incredible Hulk, explaining to Cas that just as Bruce was not Hulk, they, i.e. Cas, were not their anger. We explained that understanding themselves as both connected to, but distinctly different from, their anger, might help them start to understand anger’s presence and reason for being in their lives. We then used the language of the Hulk comics to process their recent angry outbursts.

In subsequent sessions, we used the increased insight that Cas was gaining around both anger and the events that trigger anger to help them create a fanfiction action plan using Bruce Banner/Hulk as a stand-in for Cas. As part of this work, Cas was to pay mindful attention to their mood state, and when they noticed that they were beginning to feel angry, to place themselves into an Avengers fanfiction story in the role of Bruce Banner. They were to imagine that the team was working on a case and to ask themselves who was needed most—Bruce Banner or Hulk—playing out both scenarios to determine who would be best equipped to resolve the situation at hand. If the answer was Hulk, then they were to give themselves permission to feel anger without shame. If the answer was Bruce, then Cas was to engage in deep breathing and call upon their inner Black Widow to say soothing words to calm the inner Hulk. This was effective not only because this type of verbal play added a feeling of fun and whimsy to therapy, it also helped Cas maintain enough distance from anger so that shame was not triggered. Over the next three months of weekly sessions, Cas was able to continue the use of therapeutic fanfiction to both develop and implement strategies to de-escalate feelings of anger and to increase their frustration tolerance. They felt more in control of their inner Hulk.

At first blush, fanfiction and the hero’s journey may feel like disparate concepts for clinical work, but we have found that these concepts are not only congruous but incredibly healing in a therapeutic setting. Because there are fewer pop culture narratives made specifically for queer audiences, and because of queer marginalization in general, these conversations are all the more important and powerful. Therapeutic fanfiction allows queer clients to pick up the red editor’s pen and begin to adapt the story of their lives, creating a narrative in which they are the hero.   

Advocating for the LGBTQIAA in Psychotherapy

Posted on by Psychotherapy.net Team

I trace my commitment to serving underserved communities to my Jewish heritage. As a Jewish person, I am a member of a resilient minority group that experienced centuries of oppression and genocide. This cultivated inside me a sensitivity to discrimination and connected me to a passion for social justice. I have become active in my university’s LGBTQ+ club and feel that it is my civic duty to advocate for LGBTQIAA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex and allies) clients so they can be better served.

I’m also sensitive to others’ suffering because I grew up with a speech impediment. As a child, most people didn’t understand that my stutter was involuntary; peers told me to “slow down,” and “just relax and speak.” People didn’t understand my suffering, and I agonized in silence until I learned how to mostly overcome it. Since overcoming it, I’ve hoped to prevent similar suffering in others.

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How would you feel if the general public regularly imposed a gender and/or sexual orientation on you that did not accurately represent who you feel you are?

You don’t have to have suffered like I did to make a difference for the LGBTQ+ community, which is estimated to be 10% (and this only reflects those who feel safe to report) of the world’s population. We all have experienced a little taste of what it feels like to be discriminated against. This community has been fighting an uphill battle for their lives, with their jobs, families, and interpersonal relationships constantly at risk. They endure constant mislabeling, violence and judgment. The most covert, perhaps, is people assuming it to be a choice when it's not. Here are some questions to think about in your practice:

Do you assume couples are monogamous? Do you assume all your clients are cisgender? Do you assume heterosexuality if someone is currently in a heterosexual relationship? Do you assume the client you’re talking to is heterosexual? For example, have you, knowingly or unknowingly, asked if a female client has a boyfriend instead of a “partner(s)?”

The he-she binary inadvertently erases trans people. There is more variation to human gender than merely “ladies and gentlemen” or “men and women.” Since the vehicle of change for psychotherapists is primarily language, we can start by using inclusive, respectful, and empowering language. You can start by using person-first language, identifying your pronouns, calling out the use of terms like “mankind” and “he/she” and the existence of mostly binary bathrooms (unlike other gender-inclusive countries like Canada with primarily unisex public bathrooms). There’s even a case to call history [his-story], “her-story,” “their-story,” or our-story.” No wonder LGBTQIAA+ youth have a high suicide rate. Here’s a case example.

Al is a 14-year-old, assigned female at birth, but who identifies as a male. He has a pronounced trauma history; his father abandoned him to raise another family and, at 5 years old, his mother left him with his grandmother. He was placed in homeschool in 2017, has been isolated, and voiced suicidal ideation in the initial assessment. Virtually all his social contact has been online chatting with other trans youth.

Early in treatment, Al mentioned wanting a doctor’s note for hormone therapy. Not infrequently, psychotherapists working with trans clients receive requests for documentation that a trans person has diagnosable gender dysphoria that has caused substantial mental health issues such as suicidal ideation, and is “mentally fit” for hormone therapy and to make decisions about their own body. This helps doctors/insurers understand that hormone therapy and gender reassignment surgery can support, instead of hinder, a client’s mental health. Insurers and/or doctors may request them.

Contrary to traditional belief, I considered that it was both ethical and empowering to provide Al with this note sooner rather than later in the therapy. Here’s why.

We are not gate-keepers who decide what clients can do with their bodies. We shouldn’t block Al’s access to resources that a cis-person could access without a therapist’s permission. Best practice for me is that if a client wants a letter, I give them one. If a cis-male came in asking for a letter for their doctor to be on hormones and had limited social support, we would not impose stipulations. A trans person is equal to a cis-person and already has enough challenges to overcome to be who they are and have control over their body.

A therapist’s role is to not stigmatize. For example, if we require Al have 6 sessions before writing a hormone letter, it would be stigmatizing something that has nothing to do with mental illness. It would also be operating outside of the scope of our practice because we wouldn’t be determining if their mental stability is interfering with their identity. It is also not our role to determine if Al is sane to make the hormone decision, even if he’s a minor, without his prefrontal cortex fully developed. After we write the letter, it is the role of the medical doctor to determine if the client is medically able to start hormones and the doctor’s job to monitor the client’s physical body.

Al and I agreed that he is likely avoiding social situations because of the chronic mis-gendering he endured, and the invisibility of his identity navigating the world as a trans-person who is not presenting nor is perceived the way he desires. Hormones may be the catalyst that would help Al to make friends once he starts feeling comfortable in his own skin. Isolated, experiencing oppression, lack of control, depressive symptoms and desiring hormones (probably to look a certain way)—not accessing hormones could likely increase depression symptoms and suicidal ideation. After writing the letter, I provided Al with ample resources to connect with other trans-youth.

My role was to support Al where he was at, not dictate where he should be. Since Al was able to make decisions, there was no reason to limit when he started hormones.

I cannot emphasize enough Dr. Martin Luther King’s timeless notion that “our lives begin to end the day we become silent about things that matter.”

* I consulted on this case with Van Ethan Levy, Associate Marriage and Family Therapist, Associate Professional Counselor, and member of the community, who uses the pronouns Van/they.
 

The Masculinity Trap: A Science-Based Response to the APA Guidelines

Posted on by Psychotherapy.net Team

Andrew was a 13-year-old boy who walked into my counseling office with a lot of issues. He had been diagnosed with a learning disorder and ADD, and his parents felt he might be depressed. Like many male clients, he would quickly decide if I as his potential counselor knew how to work with him as a male. If I did not, he would start trying to leave therapy in a few weeks or less.

After normal intake, the first thing we did together was walk outside, talking shoulder-to-shoulder. Because the male brain is often cerebellum-dependent (it often needs physical movement) in order to connect words to feelings and memories, we sat down only after our walk was finished. By then, a great deal had happened emotionally for Andrew.

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Once in our chairs, we talked with a ball in hand, tossing it back and forth, like fathers often do with children. This cerebellum and spatial involvement help the male brain move neuro-transmission between the limbic system and frontal lobe, where word centers are. We also used visual images, including video games, to trigger emotion centers, and we discussed manhood and masculinity a great deal, since Andrew, like every boy, yearns for mentoring in the human ontology of how to be a man.

I’ve seen hundreds of girls and women in my therapy practice. Few of them needed walking, physical movement and visual-spatial stimulation to help access memories, emotions, and feelings because most girls are better able to access words-for-feelings than boys and men are while sitting still. Girls and women have language centers on both sides of the brain connected to memory, emotion, and sensorial data, while the male brain mainly has word centers and word-feeling connectivity on the left side.

Without our realizing it over the last fifty years, we’ve set up counseling and psychological services for girls and women. “Come into my office,” we say kindly. “Sit down. Tell me how you feel/felt.” Boys and men fail out of counseling and therapy because we have not taught our psychologists and therapists about the male and female brain. Only 15% of new counselors are male. Clients in therapy skew almost 80% female–males are dragged in by moms or spouses, but generally find an environment unequipped for the nature of males.

Male nature, the male brain, and the need to contextualize boyhood into an important masculine journey to manhood are missing from the American Psychological Association’s new “Guidelines for Psychological Practice with Boys and Men.” While the document calls attention to male developmental needs and crises in our culture, which I celebrate as a researcher and practitioner in the field, it then falls into an ideological swamp.

Males, we are told, are born with dominion created by their inherent privilege; females (and males) are victims of this male privilege. The authors go further to discuss what they see as the main problem facing males—too much masculinity. They call it the root of all or most male issues including suicide, early death, depression, substance abuse, family breakups, school failure, and violence. They claim that fewer males than females seek out therapy or stay in therapy and health services because of “masculinity.” Never is the skewed female-friendly mental health environment discussed. The assumption that all systems skew in favor of males, not females, is so deeply entrenched in our culture today, the APA never has to prove it.

Perhaps most worrisome, the APA should be a science-based organization, but its guidelines lack hard science. Daniel Amen, Ruben and Raquel Gur, Tracey Shors, Louanne Brizendine, Sandra Witelson, Richard Haier, Laurie Allen, and the hundreds of scientists worldwide who use brain scan technology to understand male/female brain difference do not appear in the new Guidelines. Practitioners like myself and Leonard Sax, MD, PhD, who have conducted multiple studies in the practical application of neuroscience to male nurturance in schools, homes, and communities are not included.

Included are mainly socio-psychologists who push the idea that boys and men are socialized into “masculinities” that destroy male development. Stephanie Pappas on the APA website sums up the APA’s enemy; “Traditional masculinity—marked by stoicism, competitiveness, dominance, and aggression—is, on the whole, harmful.” Our job as therapists, the authors teach, should be to remove all but the ideologically sound “masculinities” from boys and men, and specifically remove masculinities that involve competition, aggression, strength, and power.

How much longer can our society and its professionals pretend we are developing a saner society by condemning the very parts of males that help them succeed, heal, and grow? In the same way that it is misogynistic to claim femininity is inherently flawed, it is misandrist to claim that masculinity is also thus.

And it is just plain wrong. Stoicism, aggression, self-reliance, and strength are helpful to human growth, healing, and self-development. Steven Pinker recently made this point when he asked the APA to revise its Guidelines, and put to rest “the folk theory that masculine stoicism is harmful.” And, a new study published in January 2019 in Psychology of Men and Masculinities, echoes Pinker, showing that boys and men who adhere to masculine training do better in life, are happier, and become better husbands, fathers, and partners.

I am an example: I was a sexual abuse victim in my boyhood, and a very sensitive boy. My ten years of healing from the abuse came as much from tapping into masculine strength as it did from expanding my sense of self in the 1970s toward the feminine. Both are good; neither is zero-sum, but I could not have healed without the very masculinity Pappas finds suspect.

Part of the problem with the APA guidelines is that, from a neuroscience point of view, masculinity is not as limited as Pappas’ assessment would have us believe. Masculinity is a social construct made of biological material, an amalgam of nature, nurture, and culture that forms an ontology in which a male of any race, creed, or ethnicity commits to developing and exercising strength, perseverance, work, love, honor, compassion, responsibility, character, service, and self-sacrifice.

What professional in the psychology field would not want to embolden these characteristics? Most fathers and mothers would want counselors to embolden them because, as the APA authors themselves point out (somewhat unaware, I think, of their self-contradiction), fathering and mentoring boys in masculine development has been proven among the most important determinants of child safety, school success, and emotional and physical health.

Not the erasure of masculinity but the accomplishment of it is required if we are to save our sons from the crises outlined in the APA guidelines. Without counselors and parents understanding how to raise and protect brain-based masculine development, boys like Andrew drift in and out of video games, depression, substances, half-love, and, often, violence.

As all of us in our profession know, the most dangerous males in the world are not those who feel powerful but, rather, those who feel powerless. “Toxic masculinity” is a convenient academic avenue for condemning males who search for strength, healing, and love by conflating things bad men do with an ontology that is necessary for human survival and thriving.

The masculine journey is not perfect and expanding what “masculine,” “male power,” and “man” mean to a given family and person is a point well made by the APA authors, but trying to hook mental health professionals into this ideological trinity of false ideas—

*masculinity is the problem, always on the verge of toxicity
*males do not need nurturing in male-specific ways because men have it all in society anyway; and
*masculinity is not an ontology, a way of healthy being, but a form of oppression,

—ignores one of the primary reasons for the existence of our psychology profession: not just to help girls, women, and everyone on the gender spectrum be empowered and find themselves, but also to help boys and men find their strength, their purpose, and their success in what will be, for them, a complex male and masculine journey through an increasingly difficult lifespan.

Sources:

Amen, D.G., et.al., “Women Have More Active Brains Than Men." August 7, 2017 Journal of Alzheimer’s Disease

Halpern, D.F., et.al., “The Science of Sex Differences in Science and Mathematics.” Psychological Science in the Public Interest. August 8, 2007

Burman, D., et.al., "Sex Differences in Neural Processing of Language Among Children." March 2007. Neuropsychologia

Benedict Carey, “Need Therapy: A Good Man Is Hard to Find.” New York Times. May 21,2011

APA Guidelines for Psychological Practice with Boys and Men

Stephanie Pappas, “APA issues first-ever guidelines for practice with men and boys.” APA Monitor. January 2019

Steven Pinker. Male Psychology: What is Wrong with APA’s Masculinity Guidelines.

Psychology of Men and Masculinities

Coalition to Create a White House Council on Boys and Men’s meta-study

Erica Anderson on Working Therapeutically Across the Gender Spectrum

Posted on by rezendevknowfully.com

Transgender 101

Lawrence Rubin: Thank you for taking the time to speak with me this morning. Transgender issues have gained much attention in the last several years, but most therapists do not have experience working with these clients. What are some of the issues a therapist needs to know?
Erica Anderson: Thank you for this opportunity. I think it is a topic much discussed in society these days, and you're right that very few psychotherapists are trained to work with people with gender issues. One of the most important things to point out is that in years gone by, those of us in the mental health field were trained to understand gender development in a very limited, binary way, namely that one was born either male or female; "M" or "F" on their birth certificate, and then they just grew up. Puberty constituted a pretty significant change, and maybe at some point, someone would declare that they were gay, but otherwise there wasn't really much to do about the development of gender.

very few psychotherapists are trained to work with people with gender issues
What we now have come to appreciate is that gender identity exists on a spectrum, and that just as Kinsey pointed out more than half-century ago, many more people have complex sexual attractions or are bisexual than we ever thought. The same is true with gender differences. We used to think that transgender people were very rare, but in fact, people who are not binary in their gender identity or whose gender identity differs from the sex that they were assigned at birth, are in greater numbers in society than we ever really understood.

Society has become more accepting of some of these differences so more patients who are questioning their gender are coming forward to therapists. They are exploring who they are and may actually be willing to talk about some of their own self-doubts or self-realizations. So, therapists need to begin to understand how to work with such people by acquiring new knowledge, developing new skills and examining their own biases or potential biases around gender issues.
LR: Can you say more about the knowledge and skills therapists need to have when working with clients presenting with gender identity issues?
EA: The first point about knowledge is reflected in what I said a moment ago; that many people have presumed that gender really is simply a binary trait of human beings, and that is not the case. If you look at the history of human civilization, there have always been people who have not lined up in their gender identity with the sex they were assigned at birth. There have always been transgender people in society. Some of them have been acknowledged, and in some cultures, there is actually recognition of this. Many native peoples have something called "two spirit," which is a recognition of someone whose gender doesn't line up with their anatomical sex—it is a mixture of gender identities. And then there are some other cultures, in India, Brazil and Asia, where there have been transgender people recognized throughout history. We now know that, depending upon what you include in the category transgender, perhaps as many as one in 200 people in America could be said to be transgender (according to a recent study from UCLA).
LR: When we think of addressing diversity issues in counseling and therapy, we think of gender, race, age and religion. You're suggesting that within some populations, their spiritual-cultural practices may intertwine with gender identity issues?
EA: That's right and it’s a very important point here that gender identity cannot be dissected apart from the other aspects of a person. We talk these days about intersectionality and multiple identities, and that becomes acute when we then consider gender issues. This is because the experience of someone who is transgender of a certain cohort and a certain racial, ethnic or economic background might be very different from someone else whose identity is different in some of those aspects. So, it's not a situation where you can say, oh well, all transgender people are X or Y. In fact,
I say all the time, when you've seen one transgender person, you've seen one transgender person
I say all the time, when you've seen one transgender person, you've seen one transgender person. That is part of the challenge in terms of training and education in clinical practice.

One of the things I hear often is, "Oh, well, you know, coming out as transgender, well, that's like coming out as gay." Well, no, it's not. Gender identity has to do with every aspect of who you are. To equate the transition of someone who is trans from maybe being perceived as one gender into being perceived in a different way, is not exactly the same as someone who may have been closeted as a gay person and then comes out as gay and is living more openly as gay. But that's a common thought for some people who are not very well versed in these issues. It’s disturbing to some trans people to be thought of as, "Oh, well, at one point in time, you're just kind of revealing something about yourself." It's a lot more complex than that!

Beyond Binaries

LR: This suggests that clinicians need to be aware of the developmental trajectory, not just of gender, but the convergence of multiple trajectories across the lifespan that include, but are not limited to, gender.
EA: Absolutely. In fact, as we know from the traditional field of developmental psychology, people develop in lots of different ways, and that development is very uneven for most individuals through childhood and adolescence, and even into young adulthood. So, we know that we can narrow in on various aspects of development. I say all the time that everybody has their own individual developmental pathway, and that where they are at any given point in time is simply that, and it's subject to change.

The other takeaway from the emerging knowledge about transgender issues is that gender identity is something that's very fluid. So, there isn't a single narrative that explains the course of development of all transgender people. In fact, people can come to an awareness of themselves very early, in early childhood, or later in adulthood. And there's a mixture of factors in any individual case that may be contributing to those differences.
LR: It seems therefore that one of the core skills for a clinician to master is to think intersectionally—to broaden their case conceptualization and treatment planning to include these multiple converging trajectories.
EA: Exactly right, which is what makes the work so interesting for those of us who are doing it now. The evaluation process involves parsing, where we look at certain aspects of the situation, traits and historical trends of an individual, and interweave these factors. And because of the highly individual nature of gender identity, we really must listen carefully to each person, no matter what their age is. We must listen to what they say about themselves because gender, as identified by an individual, is a deeply internal and personal thing and we cannot assume that we wholly understand, in a simple way, what is going on with somebody unless we spend some time focused on it.
LR: So, one of the skills that a clinician should have is being able to move past not only binary thinking regarding sexuality and gender, but beyond binary thinking about people in general.
EA: I say all the time,
there's nothing about human beings that's binary
there's nothing about human beings that's binary. If you think about psychology as a field that has attempted to study individual differences, there's really no characteristic that is simply binary–yes or no, this or that, black or white, on or off. We're not machines. We generally think about individual differences and the intensity of various traits when we think about personality. Even in medicine, we think about laboratory studies, growth charts and laboratory ranges for all kinds of characteristics. So, there's nothing binary about human beings. But thinking about that in terms of gender requires a fundamental reordering of how we bring together all the aspects of who a person is, and a recognition that they have been evolving and changing and developing, and they're going to continue to do so.
LR: I joke sometimes with my students by saying that there are two types of people in the world, those people who believe in binaries and those who don’t.
EA: I love that. That's really cute and apt.

Words Matter

LR: Therapists not particularly trained or experienced with transgender or transitioning clients may be unsure how to start, what language or personal pronouns to use, or even how to broach the subject. What advice would you give them?  
EA: This is a big challenge for all of us, even those of us who have more experience, because society has been changing rapidly. People are bringing to these discussions whatever they've known or learned or thought they knew, as well as what information is circulating now in the world, on the Internet and in professional circles. And we don’t all mean the same thing when we use the same words. I’ve seen this evolve in my career.

I was trained on DSM II which listed homosexuality as a sexual disorder. That came out in a revision of DSM II. But today's clinicians who have been trained more in DSM-IV and DSM-5 don't think about the fact that there are huge numbers of people who are still alive who were reared in an era when homosexuality was considered shameful and a psychological disorder. I had a patient years ago who was expelled from medical school because he was arrested in a gay bar for soliciting—and that’s in my lifetime.

So, the words that we use continue to evolve. An example is "gay." You know, "gay" used to be a slur, a pejorative word. It still is in some circles. But now we have the word "queer." People are using the word "queer" all the time but don't know what anybody else means by the word. So, if somebody comes in my office—and this is a tip for therapists—and starts using some of the words that have to do with gender and sexuality, I routinely will ask them, "Well, what do you mean by that word? What do you mean by queer? What do you mean by trans? What do you mean by gender? What do you mean by attraction?"
LR: So, letting the client lead in creating the definitions, and even helping them to make peace with a definition that best fits them at that point in their life…
EA:
Dr. Seuss wrote, "You are the you-est you can be. No one is more you-er than you."
Exactly, and I love to invoke my favorite philosopher, Dr. Seuss, who wrote, "You are the you-est you can be. No one is more you-er than you." You know, we really fundamentally have to accept that people define themselves. And people who have deep-seated psychiatric disorders may be defining themselves in ways that are not helpful and maybe even toxic, but we must start there. We have to start with what's going on with someone. And there is no more significant area to do this in than gender and gender identity.

Gender Politics

LR: What if a client comes to you and doesn't broach the subject of sexuality or sexual identity or gender identity? What's the therapist's role? Is it their place to ask a pointed question? Or is it sort of a Rogerian thing, to just let the client be and go with wherever they are?
EA: As you infer, I see a lot of people who come to me because they are dealing with some of these issues that we're talking about today, but not always. I will sometimes see people who are straight who have anxiety or depression. In my long career as a psychologist I've treated people with many different conditions. I don’t assume anything about what someone wants to focus on. On my website, I have a section called "Permission to Be," where I write about my philosophy. If someone comes to me and says, "I'm coming to you because I think I'm trans, or because I am trans, or because I want to explore my gender expression and identity," then we're off to the races. By contrast some clients come to me and say, "Well, I know I'm trans. I don’t really need to deal with that. But I'm really depressed" So, it depends on the particulars of a client.

In terms of advice to other therapists, I would say, don’t assume that something having to do with sexuality or gender is a problem for someone. If it is obviously a problem and they're asking you to help them with it, help them. But if they are coming to see you for other reasons, their relationship with their gender and sexual identity doesn't necessarily require any intervention.

I want to say something else about this that I think is significant. Transsexuality, as it used to be called, was categorized as a sexual perversion, and was nested in the DSM in the section on fetishes-paraphilias. But now we're at a point where we are questioning whether it is true that everyone who has a different-than-heteronormative or cisgendered identity has a psychological problem at all. In fact, the current DSM lists "gender dysphoria" to describe those who are trans, basically. The International Classification of Diseases 11 (ICD-11) that's coming out from the WHO, will be using the term "gender incongruence," and they are taking this label out of the psychiatric section and putting it into the sexual health category.

For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity
There are several reports, including ones published by SAMHSA in 2015 and documents from the American Psychological Association concluding that differences in sexual orientation and gender identity are normal variations. There is no presumption of psychological disorder.

Interestingly, there is a task force on gender dysphoria constituted by the American Psychiatric Association. They are going to be looking at the disparity between the DSM, which does in effect pathologize trans identity, and the ICD. It is going to be a challenge to reconcile those differences. I predict that the APA will come into agreement or alignment with the rest of the world, which uses the ICD and not the DSM. For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity. And I, for one, am welcoming that change. 
LR: If a transgender client visits a therapist who's not particularly experienced in transgender issues, and presents with issues seemingly unrelated to gender such as anxiety, depression or even sexuality; is it a mistake for the therapist to assume that these other non-gender-related issues are the cause?
EA: I think assumptions of any kind about etiology are always suspect. I think we must examine our own biases and expectations. A co-occurring disorder is simply that. It may be a contributing factor to distress about gender identity. Gender dysphoria often is reflected in interpersonal conflict and anxiety, sometimes depression. But it isn't necessary to treat them separately. It also is a mistake to assume that they're related in some systematic way.
LR: Some argue that therapists need not have personal experiences similar to a client’s in order to be empathetic. How does that apply here?
EA: On the one hand, I think sometimes we take therapist-client matching a little too far. On listservs here in the Bay Area, requests for referrals to therapists usually list eight or ten characteristics that they're trying to match up. I think to myself, “whatever happened to general training and the recognition of one's competencies or limitations?” However, I also think that this is an area that one shouldn't enter cavalierly. There is a limit on the empathy that a cisgender person can have towards a transgender person. The level of complexity and the extent of personal transformation that happens when someone comes to terms with a trans identity and then embarks on a gender transition is so complete that it's hard to explain simply, and it's certainly hard to imagine.

I hear all the time lay and professional people alike, saying, "I don't understand how this person can be trans. I knew them before. There was no hint of an identity other than sex assigned at birth. I don’t understand." And I say all the time that it's not so important that you understand. What is important is that you accept that this is a deeply felt identity by this person. And if they are disclosing it to other people, they've probably been struggling with it for a long time. In fact, it's well established that, at least until now, transgender people in American society have suffered trauma and continue to suffer trauma, and some more than others. I believe that if you've been transgender for more than 15 minutes, you probably have complex trauma. And that's a joke. Thank you for laughing. Because nobody is transgender for 15 minutes or three weeks or a month. It's a long, long thing.

There's another controversy in that regard that is currently swirling. There's a term being thrown around, which is not a scientific term: rapid onset gender dysphoria. Have you heard that term?

Families in Transition

LR: No. Is that like acute stress disorder affecting gender?
EA: It's a term made up by parents who are concerned that their teenage children are asserting a trans identity from out of the blue. They are worried that there's some kind of social contagion going on with teenagers where it's cool to be trans. More kids are trans than ever before, and they wonder if maybe they catch it from each other. But
I can assure you, transgender identity is not something one catches. It's not infectious
I can assure you, transgender identity is not something one catches. It's not infectious.
LR: Toilet seats and door knobs won't do it?
EA: Nope, won't do it at all. Even sexual contact between two consenting adults will not affect someone with a transgender identity. But this term has been thrown around. And one of the key issues is that teenagers, as they always have, talk with each other about things that they don’t talk with their parents about. And so they're exploring this with each other. And now we have the Internet, so they're going online and finding out all kinds of stuff, and they have friends online, and so forth. They explore for a while, and they get affirmed by their peers, and they draw their own conclusions, and then maybe they tell their parents, "I think I'm trans." The parents are, in some cases, surprised. In many cases, they're not, because there were indications earlier in the life of this child. But for those who are totally surprised, they think this is a recent phenomenon. But in reality, probably it has been percolating with this child for a while, and finally they come forward.

One of the issues for us in evaluating kids, though, is to be cautious about offering medical interventions—you know, puberty blockers or hormones, certainly surgery—until we're pretty satisfied that this really is an enduring identity of this person, and that it's the right thing, it's affirming of them, and it's medical necessary. I work at the Child and Adolescent Gender Clinic at UCSF and we see kids and their families, all ages, young children, preschool children to older teenagers and young adults. And as I was saying earlier in our conversation today, there's no one narrative, there's no one pathway that explains everybody. So, we have to be cautious where there isn't an obvious track record of development of a gender different than the assigned sex. But it doesn't necessarily rule out the legitimacy of it. It may mean that we'll have to have a longer period of observation than with some other kids, where it's quite obvious to everybody that this is a trans kid.
LR: I wonder if there's a correlation in the literature between children with rapid onset transgender disorder and parental unawareness disorder?
EA: Yeah, that's a good one. Certain parents, as you were implying by your very cute comment, find it harder to accept the reality of a child whose identity is very different than what they expect. They may have somewhat rigid views of sex and gender, and they may subscribe to the dominant gender schema of binary, and they may be, as you say, unaware of the fact that gay and trans people have been around throughout human history.
LR: How can therapists help parents enter the conversation once the kid or teen begins talking about it, even though it may have been evolving for years?
EA: Some of the basic principles that have peppered our conversation so far are relevant here, and that is, as a therapist, try to avoid bringing your own bias into the situation or the conversation. Try to maintain an open mind and be focused around listening carefully to the various people. Everyone in the family—no matter what kind of family, if it's a traditional heterosexual couple with kids or whether it's any one of the many versions of "modern family"—is coming at this from a different perspective. The
older people are coming at it having grown up in an era that was less open and less aware of some of these issues
older people are coming at it having grown up in an era that was less open and less aware of some of these issues. Kids may be bringing their own perspective, which could be quite spontaneous and quite free and quite direct. And so we need to listen to each other.

The word that's often bandied around and disregarded is "transition." A trans person goes through a transition of sorts to bring their life and even their body into consistency with their identity. Everybody gets that. But everyone else around that person is also going through a transition, and it's very uneven. Some resist it, some embrace it, and some are more troubled by it than others. Literally, I've had parents of teenagers cry in the consulting room, saying, "I thought I had a daughter, and I guess I have a son, but now I'm grieving the loss of my daughter." Or the other way around, "I thought I had a son, and now I know I have a daughter, but I'm grieving the loss of my son." These are very personal and poignant moments when someone is really trying to come to terms with the reality of what's going on. It's a very tender time and we have to be kind to each other about what we're going through. 
LR: Everyone is in transition and may have been struggling to come out of their own mental closets in acknowledging and embracing that their child or their teen has been struggling for so long.
EA: Every family is different. There are some themes that are common and that are often shared, but the nuance can be so subtle and important. I had a trans teenager in my consulting room last night, and we were talking about the resistance of their mother to their identity and the struggles that this teenager has had for years with a mother who has not found it easy to accept her child on the child's terms. It was really quite a pivotal moment in my work with this young person in that they disclosed for the first time the extent of verbal abuse that their mother had given to them throughout the years. And the child's efforts to cope with this meant that they kind of shut down and are currently afraid of going forward with transition, because they’re worried that their mother is going to say, "I can't accept this," and that their father would side with the mother. And my client is saying to me, "I'm worried they're going to kick me out. They're going to kick me out of the house."
LR: So, these kids are sometimes put in the position of bearing the burden of holding the family together or reducing conflict by remaining silent? You must be so skilled as a therapist to address this once you open yourself up to the systemic and contextual nature of it.
EA: It's a challenging thing. But in the case of this young person, critical. I have to address the dynamics between the parents and between the parents and this teenager because they’re really hurting.

Complicating Issues

LR: You were just talking about transitioning, so I'm wondering if there are different clinical needs for clients who are in surgical transition as opposed to those who, for whatever reason—health, finance or choice—can't or don’t pursue surgical transition?
EA: Each of the phases of the transition has its own set of challenges. One of the things that I'm impressed with by those who get surgery is that the characteristics of the person are all-important. So, if they're healthy, have realistic expectations and a good surgeon, they have a good result and there are no consequences. That's one process. Another might be someone who has health issues, who might be a little more likely to have some kind of untoward consequence of a surgical procedure and are then frustrated afterward because their recovery is a little choppy, and maybe the result isn't exactly what they had hoped.

The differences between people are clear. Historically, surgery has been largely confined to adults 18 and over. But more and more, the trans kids that we're working with whose identity is clear at a young age and who have been on puberty blockers and cross-sex hormones as young teenagers, are getting surgery in their teenage years. This is, of course, with the full consent of their parents when everyone agrees that it's medically indicated.
These kids are being given a gift that someone in that situation a generation ago would never have had
These kids are being given a gift that someone in that situation a generation ago would never have had, which is to avoid some of the life experience in the gender they don’t want, and some of the physical changes in their body that they're not completely comfortable with. They're able to move ahead with their physical transition in such a way that by the time they're in middle to late teenage years, they're fully embodied as the person they see themselves to be and the gender that they assert. From that point on, all their experience is in that gender. So, they go to college and the people at college only know them that way. They've done their name and legal gender change, and so forth. That's a whole interesting set of patients.

By contrast, you also have people who are married, have children, have started a career or are deep into a career, and then they come to terms with who they are, and they transition. And I'm thinking of two people I’m currently working with who were assigned as male at birth. They are in their 30s and 40s, married with children, going ahead with the transition and all the complications that you would expect based on having to deal with the reaction of the spouse, the children and the people in their professional world. It's a whole different set of issues.

The Psychologist’s Role

LR: More and more, psychologists are being called on by doctors who are working with patients contemplating anything from gastric bypass surgery to—I don't know if I'm using the right word—gender reassignment?
EA: Currently, gender confirmation surgery.
LR: Thanks. These psychologists are being called on to perform evaluations to provide physicians with concrete validation that this person is psychologically ready for surgery. Do you have any recommendations for these psychologists?
EA: There are guidelines for this, we call such reports "letters of support." They're really what you and I would consider evaluation reports. They are a review of this person, their history, any co-occurring issues, and their life circumstances. In addition, as we would agree, a necessary part of this is essentially the informed consent, you know, to talk through what is going to happen with this surgery by a skilled surgeon who is well trained and experienced with this procedure. And then, does the person really understand the risks and the benefits of this surgical procedure? And what are their expectations of what it's going to be like for them after they have this surgery? I was referring to that earlier today as we were talking about how realistic the person’s expectations are about surgery.

Most people who think about gender confirmation surgery have done extensive research on it. So, I find that—maybe it's a selection bias—the people who come to me are those who are a little more sophisticated. But I must satisfy myself that they've gone through that process, and that they've asked and had answered all the questions that they have, and that they've thought through whatever the likely consequences are, and they've considered the possible unexpected consequences. And if they have, if we've done all of that, and if there isn't an outstanding psychological issue or an acute psychiatric problem, then I'm inclined to write the letter and say, yes, I recommend that this is medically necessary for this patient.

Surgeons do require such letters still, at least according to the standard of practice. There is an organization called WPATH, that has standards of care, currently in its seventh edition. These are standards of care for medical and psychological service to trans people. The 8th edition is currently under preparation. And just like everything else that we're talking about today, things are moving in the direction of de-pathologizing. The question in the future will be, "What is the purpose of the evaluation? Is it to screen for any contraindications? Is it to satisfy the psychologist and the surgeon that this person is a good candidate for this surgery?” Those are open questions as far as I'm concerned. But I do believe that because of the wide-sweeping consequences of a gender transition—and if you add into it gender surgery which is irreversible—that performing these evaluations requires serious skill and should not be done lightly.  
LR: Therapists and clinicians want to render the most competent services in a way that is correct, ethical and moral. So, it's not just laying a quick MMPI on someone and saying, "Yeah, ready to cut."
EA: Exactly.

Closing Thoughts

LR: What should therapists be wary of within themselves when working with clients who are either contemplating surgery or thinking and feeling deeply about gender identity?
EA: I have been doing a lot of thinking in the last few years about our whole paradigm of transference and countertransference, and how that might need to be adjusted for work with transgender people., I myself am transgender. I ask myself all the time, "Do I bring any bias to my work with an individual client or patient?" I try not to, of course. But, in a slightly different way, I know that some people come to see me not only because I'm a qualified psychologist, but because I'm trans. They want to know about me and will ask me personal questions which is historically seen as being out of bounds. And I wonder, how is that related to transference or not?
My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them.
My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them. These include questions like, "What is it like to go through hormone changes? What happens in the surgery?" And I will selectively tell them a little bit about me, because it does reassure them. It's kind of like, "Oh, yeah, she went through this, so I can do that too."

Some of the questions therapists can ask themselves could include, “What are you bringing to that discussion with someone? Do you really have empathy for what they're going through? Do you have a bias? Have you examined your perspective about this?” I think the therapeutic pitfalls are to assume that someone is too young to decide, to assume that someone is neglecting their family responsibilities if they transition and they're married with a family, to assume that someone is not going to be able to have sex if they change their body. There are a lot of potential assumptions, and we just have to be careful not to hold them because we have a bias.
LR: So, the same general concerns about countertransference, self-disclosure, presumptions and biases, but a little bit more finely tuned to the needs of clients who are in transition.
EA: I am concerned that therapists who are relatively inexperienced in this area may have a hard time parsing the co-occurring disorders. And so they might think, "Okay, we can't go ahead with hormones or anything else, or certainly not transition, until we deal with your depression. And we've got to cure all your psychological problems before I feel comfortable encouraging you to go ahead." That is, in my judgment, a mistake, and often kind of a rookie mistake. I think the literature on co-occurring disorders suggests that there are many situations where we treat concurrently, not consecutively. To pretend that we can separate aspects of a human being and treat one part and ignore the other or set aside the other for a while doesn't work very well in this area.
LR: We can’t surgically remove pieces of pathology, revealing the true issues—it is simplistic and naïve.
EA: Here's the challenge! We have inadequate empirical bases for a lot of the things that we're doing. We're doing what we're doing based on the data we do have. This includes longitudinal information we have about patients, comparing and contrasting patients who do well and patients who don’t do as well, and bringing into our work in this area what we know about other clinical challenges. If we waited until we had long-term treatment outcome studies on all these things, there would be a lot of people who would struggle.

As you know, the rate of suicidal ideation and suicide attempts is very high in trans people. So, we're going to lose a lot of people if we deny treatment to trans people until we have what the rigorous scientists consider to be adequate empirical justification for what we're doing. There is a five-year research study going on at UCSF, one of four sites for a multi-site NIH study of transgender kids and the first of its kind. But that's a five-year study. The research is looking at both medical and psychological factors having to do with how kids do when they go on puberty blockers and how kids do when they go on cross-sex hormones. And in five to ten years, we'll have some data that will help illuminate what we're doing.

Hopefully it's going to confirm what we think we know about best practices with kids. We're one of the more advanced centers in terms of embracing what we call the gender affirmative model. We're very interested in affirming kids and their gender, and not putting roadblocks in their way to living authentically. We work hard to reach consensus about the truth about any individual kid, and then a consensus about what we know about this kid and what we are going to do. We ask important questions including, “What's the timing of various things? Are we holding off on things for specific reasons?” It's a very individual matter with both kids and older patients and it’s about crafting a plan for the gender journey heading towards transition. It is about trying to responsibly approach each of the potential decisions and make the best decision that we can at the time based on what we know for each patient. And that is, I think, a sound approach, but it isn't necessarily justified by empirical findings.

Gender identity isn't something that easily lends itself to measurement. Earlier, you invoked the Minnesota Multiphasic Personality Inventory (MMPI). I was at the University of Minnesota for a number of years, and I interpreted thousands of MMPIs. I don't know that we're going to ever have, at least in my career, any kind of test for who's trans and who isn't, or what level of trans-ness exists, and, oh, this means that they should proceed at this kind of pace in terms of decisions regarding medical supports for identity. 
LR: You're a transgender woman. How has your own personal journey prepared you to work as a therapist? No easy question, right?
EA: Like most of us who have been psychologists or therapists for a long time, every chapter in our lives does inform who we are and gives us insight into how life is for other people. I emphatically believe that I could not do what I do without incorporating some of what I've learned about myself and the world.
I will tell you that it is amazing to have lived as a man in society and now live as a woman in society
I will tell you that it is amazing to have lived as a man in society and now live as a woman in society. Sometimes I joke with other women and say, “I’m on our team now, and I get it. I get what it's like to be treated differently by men.” I had another interview recently in which I was “mansplained” many times. It's really hilarious when I get mansplained.

The subtlety of what I've experienced is not lost on me or some of my clients in that I know what the experiential aspects of this are, exquisitely! And although I didn't keep a careful journal of what I went through, I remember many aspects of it very, very clearly. I sometimes bring this subjective understanding into my work. I'm sure you could appreciate this. Sometimes, when my clients or patients are really struggling, I lean in, and say, "You know, I really do understand what you're going through, and I want to help you." And they realize that I'm being honest and direct about it, and it means something to them.

I'll tell you one other little anecdote which is kind of special for me. When I see trans kids at the UCSF clinic, I'll say to them, "Do you know any other trans kids?" Sometimes they shake their head, and say, "No, I don't know any other transgender kids." I'll then say, "Well, do you know any other transgender adults?" They'll shake their head, and say, "No, I don’t know any other transgender adults." I look at them and say, "Well, honey, you can't say that anymore, because I'm trans." Their eyes get big, their jaws drop. Sometimes they gasp, sometimes they break into a big smile. And it's such a sweet, special moment for me. Sometimes the parents are not surprised and other times they say, "Really?" And then they say to their child, "See, honey, you can be a doctor. You can have a good life." And I feel, in that moment, like this is a gift to me, to be there with that child.
LR: A gift to you, indeed. I was reading a book by Fred Rogers who quoted someone something along the lines of, "You're not just your age; you're every age you've ever been." And that makes me think of what you just said. You're not just your gender; you're every gender you've ever been.
EA: Yep!

Lynn Ponton on the Challenges and Joys of Working with Teens

Posted on by rezendevknowfully.com

A Delicate Balance

Rachel Zoffness: Lynn Ponton, you are a practicing psychiatrist and psychoanalyst who has been working with teens for over thirty years, and are author of the books, The Romance of Risk: Why Teenagers Do the Things They Do and The Sex Lives of Teenagers: Revealing the Secret World of Adolescent Boys and Girls. Let’s start with some of the salient issues that come up when you’re working with children and teenagers. I find that confidentiality when working with kids and teens is often a tricky subject because teenagers have rights as clients and they want to maintain their privacy, which is critical to the alliance. But at the same time parents want to know what’s going on with their children. How do you maintain this delicate balance?
Lynn Ponton: I think it begins with the first session, and even before, when you talk with the parents on the phone—you have to alert them about how you run your therapy practice and your work with kids. I almost always say that I try to encourage privacy with the teens so that they feel open to talk with me, and I will tell their child during the first session that I’m going to try to keep things confidential, but that there will be some exceptions, and I let parents know that right away on the phone. In general, I meet the teen with the parents before I even start and I alert everybody to the parameters and the boundaries around confidentiality.
RZ: So that both the teenager and the parent are on the same page and know exactly where you stand.
LP: Exactly. The kinds of things I would need to share with parents, which I’m clear about right from that first session, would be drug use that was risky or risky behavior that would result in serious self-harm. And sometimes other things—abuse when it’s disclosed has to be shared with the parents for a variety of reasons, and because I’m a mandated reporter.

It’s often hard for a teenager to tell their parents these things directly, so I’ll offer to meet with them and their parents and we’ll work together to help them disclose this material. Collaboration with the young person assures them that even if they do tell me something, it’s not going to be reported over the telephone to their parents. They’re not going to find out about it by surprise. Instead, we’re going to collaborate together as a team to make sure that parents know this.

Of course there are times when this doesn’t always work perfectly. Having worked with kids for more than 35 years, there have been exceptions where I’ve found out quickly that a teenager is suicidal and I have to let the parents know. Maybe we have to work toward a hospitalization period or something like that, but I try as much as I can to have the teenager be part of this process and be involved with it.

Cutting

RZ: You mentioned a very hot button and interesting topic, cutting, which to me seems to have become almost a contagious and trendy behavior among teenagers. What’s your thought about that?
LP: Well, self-mutilation in all of its forms is something that therapists have to learn to feel comfortable with working with teenagers. It’s a big part of our work to connect with them, to know about it, to seem comfortable with it and not put off by it when we hear about it in a session. I first saw it about 30 years ago and wrote a paper on it in the ‘80s, which talked about self-mutilation as a communication. As you point out, it’s a contagious risk-taking behavior. In a group of teenagers, one will do it and the others will copy. They’ll think, “I’ll try it and see what I can learn from it.” That’s how that process really starts. In the ‘80s there were big concerns about self-mutilation because of sharing of implements and a lack of understanding around HIV risk, so we had to be very careful about that until we better understood it.

I think it’s often scariest for parents. So how do you work with teens around the cutting for parents? How do you help a teenager who is cutting really find other ways to cope with some of their feelings and to develop identity in a healthier way? In general I try to educate teens about cutting. I often employ them to get involved in it, to look online, look up articles about cutting. We’ll have conversations about it so that it’s really an educational process with them.

Some teens don’t want to engage in that process.
They may tell you they’re cutting, but they don’t want to learn about it, they want to do it.
They may tell you they’re cutting, but they don’t want to learn about it, they want to do it. This is something private that they’re going to do to help themselves feel better, so I’ll respect that, but I’ll still engage in conversations with them about it. I want to make sure that if they are cutting that it is safe in other ways. There’s significant risk of scarring, of infection—there’s a whole lot of risks that are associated with it.

Many teens cut because they say they feel better afterwards. A number of papers point to the beta endorphin release with cutting—the focus then becomes the physical cut and not the emotional pain that they’re feeling. So it accomplishes a lot for teenagers, but it is an unhealthy coping strategy and risk-taking behavior that you have to work with teens to limit. There are many different ways to do that.
RZ: The way you talk about cutting, it sounds like it might serve an important function for the teenagers who are doing it. What would you say to people who say that it’s just an attention-seeking strategy?
LP: Your question is well placed because I think a lot of times therapists who work with teenagers are faced either by teachers or parents or even other therapists who say, “I don’t want to work with those teens. They’re engaged in a lot of attention-seeking behaviors. How do you handle that?”

I think many behaviors in life are attention-seeking, and often we’re seeking greater attention from ourselves, that we pay attention to our own pain. Teens usually cut because they’re in pain and they don’t necessarily understand their own emotional pain but when they cut, it allows them to at least understand that it’s a painful thing that they’re dealing with. So, yes, it is attention-seeking, and adults will often be drawn in to it. Teachers at school are shocked when they find out about it and they’re worried other kids will cut.

But I think there are a lot of other factors that play in to cutting besides seeking attention. I’m also interested in questions about molestation with cutting. Were they ever hurt? Did they ever suffer abuse? Are they using that in the context of cutting? Has it become very ingrained, so it’s a behavior that they use as a coping strategy that they may have done thousands of times and they find themselves unable to stop? How does it fit in with their family?

Does their family know much about it?
There are many, many reasons why young people cut, and attention-seeking is only one of them.
One of the cases that I worked on for a long time, a girl cut because her father was a surgeon. He talked about cutting all the time, a different kind of cutting, but she imitated him in a kind of identification with her father. It took a long time to unravel, as it wasn’t obvious at the beginning of her treatment. There are many, many reasons why young people cut, and attention-seeking is only one of them. And it’s not often the major one. You have to address the complexity of the behavior and also the feelings that go with them.

Five Perspectives

RZ: I think some professionals are concerned that giving too much time and attention to cutting might be positively reinforcing. So it seems to me that as a clinician addressing it you want to find a balance between over-reacting and under-reacting.
LP: I think that’s more of a strict cognitive behavioral model way of looking at it, and it gets to the question of models and how they affect our work. Cutting is a behavior, but it’s attached to many other perspectives that we look at when we’re engaged in therapy. I try to look at things from at least five perspectives.

One is the more dynamic-relational, where you engage and are looking at aspects of the relationship—how it affects you, the parents, the cutting behavior, all of that. How disclosure plays a role in that. Attachment. Therapeutic alliance. Then there’s the behavioral model. A lot of therapists don’t use that model, but I think it helps to focus on the behavior. I often have kids keep a timesheet or a workbook on their cutting behavior and have them draw their feelings at the time that they’re cutting in addition to recording the number of times they cut. It’s a kind of cutting journal that we look at from a behavioral perspective. We also look at their thoughts that are occurring at the time that they’re cutting, so we can target really negative thoughts.

Then there is the family system. Cutting is usually very much connected with parents in some way or another—they’re worried about the parent’s reactions; they’re worried about feelings they have that they feel the parents can’t help them with. A lot of our kids have trouble with self-soothing, so they’ll cut to self-soothe. The parents might like to learn how to help soothe their teen, or help their teen gain self-soothing mechanisms, but they don’t even know the cutting is going on so they can’t focus on that area with them. Or they, themselves, may be unable to self-soothe and not know that it’s an important skill that you need for raising teenagers.

Carl Whitaker always said, "You lose the parents, you lose the family, you lose the case."
And then there’s the aspect of meaning for the teenager. What does cutting mean to them? Do they think about suicide? Some cutting is related to suicide. Self-harm that is related to suicide is very important to pay attention to, not just for our board tests but in our office with our kids.

Lastly there’s the biological perspective. With some kids that I work with, they carry biological conditions which may lead to increased cutting behavior. Prader-Willi Syndrome is one of those that has some increased cutting and self-harm. You want to be thinking about underlying conditions that might contribute to this behavior.

All of those things are going through my mind, so I’m not thinking, “if I pay attention to this behavior I will reinforce it.” Instead I’m working on all of these levels if I can. I didn’t start with this in the first year or two of being a therapist working with kids, but the longer I’ve worked with kids, the more I’ve been able to see the complexity of so-called simple behaviors.
RZ: I really appreciate that more systemic approach to working with families because when you work with children and teenagers you’re never just working with a child. You’re always working with the family and the larger system.
LP: One of my greatest teachers was Carl Whittaker, a well-known family therapist I worked with as a young medical student therapist in Wisconsin. He always said, “you lose the parents, you lose the family, you lose the case, Lynn.” I kept that in mind and it’s really helped me with all of these cases.

Manualized Treatments

RZ: Apropos of what you just said, I was trained in manualized treatments and I do see a use for them. But a lot of therapists think they’re mumbo jumbo and that they don’t address and can’t respond to the spontaneity of what happens in treatment face to face with clients. How would you make a case for manualized treatments, if at all, or what would you say to people who don’t believe in them?
LP: Well, there are now manualized treatments in dynamic relational work. There are over 400 manualized treatments that I know of in working with children and adolescents from a behavioral modality. Family therapy, too, has manualized treatments. I don’t think there are any in the more existential perspective, because it kind of runs counter to manualization. In biological therapies they have always had manualized treatments for how you evaluate symptoms and work with things.

When I work with young therapists—and I supervise a lot of residents, fellows, psychologists, psychiatrists who are at all stages of training—I really encourage them to pick one or two manualized treatments and really learn them—go away for a day or a weekend, learn the strategy, practice it, and try to become familiar with it. Even if you’re going to be a strict psychoanalyst or family therapist, I think they’re valuable because they teach you how to focus on specific things, how to evaluate. Often manualized treatments have an evaluative component built in, so you have to look at your actions and evaluate how they’re working at the end. That’s a very important part of all therapy.
RZ: Measuring one’s progress?
LP: Exactly. That’s the key, I think, in mastering some of our work. Now, which ones would I recommend? I think one of the best ones to know about is the basic cognitive behavioral therapy approach as developed by Aaron Beck at Pennsylvania. He was my supervisor when I trained there as a resident, and it’s a very successful modality to use. It helps us understand the impact of negative thinking. Another supervisor of mine was Joe Weiss, who worked on Control Mastery theory—which is about negative thoughts and ideas and the power of unconscious beliefs. I admire Marsha Linehan a great deal and the Dialectical Behavioral Therapy model. I’ve had some wonderful conversations with her about her work with adolescents and I think she really grasps what it’s like to work with high-risk adolescents. I would encourage almost anyone to look at her book on working with high-risk adolescents. It’s a wonderful model and it adds much to the work we do with young people. A third area that I think people should look into is trauma. We work so much with trauma as child and adolescent therapists. There is a trauma focused interview that we can do with kids that I use all the time. It’s very useful in diagnosis and at looking at symptom category.

I think learning a little bit about any one of these models helps any child and adolescent therapist function in a more complete way.
RZ: So it sounds like what you would advocate for is an understanding and knowledge of these manualized treatments because it gives you, as a clinician, more tools in your tool belt to pull out for individual clients as they come to you with their individual differences.
LP: It’s one of the reasons the tool belt concept is helpful. But it also makes you feel more comfortable as a therapist, knowing that you have some grasp of these different ideas. Knowing that you’re not following one dogma, but are open to new ideas, because I think ultimately as therapists we end up constructing our own way of working. The theories that we use to support our work, the collection of tasks and techniques that we define and use—these form the basis of our work . It’s very valuable to look at other people’s constructions, integrate them into our own work and say, “hey, this is useful for me. It works with these patients. I can really take this and run with it.” I mentioned five perspectives that I’ve accrued over maybe 35, 40 years of work, but I anticipate over the next 40 years there are going to be others that will greatly benefit our work as child and adolescent therapists.
RZ: There are therapists and other mental health practitioners who would say that defining yourself as eclectic dilutes your work. Do you believe that that’s true? How do you define your theoretical orientation when asked?
LP: I remember that same question from 35 years ago in residency. I think having multiple perspectives strengthens our work, and there are multiple perspectives within each of these theories, so it’s not like people who belong to one model are necessarily doing some ossified therapy that was created by some individual or group of individuals. In my work, I want to stay open and patients open me up.

One reason I like adolescent work, even though I feel like I’m getting older, is that it keeps me young. It keeps me open to new ideas. My patients actually taught me how to text on my cell phone; my patients are coded in by their first name so that they can call me and have a relationship with me.
My patients actually taught me how to text on my cell phone.
I remember one of my other supervisors, Hilda Brook, who worked a lot with eating disorders, was working with teens into her 70s and early 80s in a wheelchair, and she had greater facility with them than even I have today in my 60s. We can continue to grow in our work with teens if we stay young in other ways.

Texting

RZ: You bring up a very important and hot button issue when working with teenagers, which is texting. And I think doing therapy with teenagers and kids today is a whole new world because teenagers and kids are used to communicating through their technology. What are the upsides and downsides of deciding to be a clinician who texts with your clients as you are?
LP: I think it’s important to be aware of some of the legal parameters around texting. Many of us work with large organizations, and it’s important to be aware of HIPAA regulations and such. HIPAA doesn’t regulate all therapists, only certain therapists who are involved with electronic billing, which you might be if you work in a large institution and you bill electronically. In that case you are HIPAA regulated and with regard to texting, HIPAA states that you cannot be sending clinical decisions through a texting modality or an unsupervised modality. You have to have some regulations around it.

When I worked at UCSF for 35 years, I was in a large system that was HIPAA regulated. My texts, which I did with teenagers for 10 years during that period, dealt with scheduling, and if they texted me about an issue that I was clinically concerned about, I’d have them come in so that we could then talk about it and then work on it in person.

But the texting connection I think is very, very important with teens and therapists. Not all therapists can do it for a variety of reasons. Not everyone feels comfortable with it and not all teens have phones. I’ve done a lot of work with homeless teens, who usually don’t have phones, so you have to figure out other ways to communicate with them.

But the bulk of teens out there today do have access to texting and they will communicate that way, often just to check in with you. They may just want to know you’re there and I think that sets up a relationship with them. I don’t always respond to those texts, but they know that I’m receiving and reading them.

But let’s say you’re not HIPAA regulated, so you can put anything on text. I would still say if you’ve got a big clinical concern with a teen—let’s say they text you, “I’m cutting, I think it’s out of control, I’m feeling really anxious”—I’m going to call them immediately rather than text, and most likely try to get them in to see me if I can. So it’s not that I’m sending long texts back and forth about that type of behavior. I’m really using it as a way to communicate to stay in touch.

Other ways that teens will keep me informed, they’ll often text me, “Saw an article you should be reading, doc,” or “thought you’d like this.” Those things are important because it is a reciprocal relationship. I’m largely involved in educating young people, but they help me a lot, too, and I get a lot from them.
RZ: For therapists in private or group practice who don’t work for large organizations, is there a downside to texting? For example, what if you lose your phone?
LP: I think that gets back to just have their first name, maybe an initial afterwards, but no way that they could really be identified. And if they’re very sensitive texts you can also erase them, although we all know that things are out in the cloud forever. So be aware that that information is out there.

This is also one of the things that you should discuss in the first session. I often discuss with my patients my availability, how they can get a hold of me, so they know that I will have their first name on the cell phone, and their phone number, and that I’m fairly easily accessible. I believe one of the reasons I’ve been so successful with teenagers and their parents is because I have very good accessibility. I take my cell phone all over the world when I travel. I do have somebody on call to cover, but I’m available in that way. But let’s say that cell phone is lost, and I’ve never lost my cell phone, though I fear it all the time, Rachel. I’m looking around for it and I worry about memory loss and loss of cell phone. But if it’s lost I think you have to alert the patients, especially those that you’re texting with, that there is a risk and the cell phone was lost. Most of them are not that concerned about it because their whole name is not out there. There’s not a lot of information out there. But I think it’s important to do that. But I also know from forensic cases that you can actually remove data from a distance off of a cell phone, which might actually be required if you work for a university or large organization.

Sexting

RZ: Technology and internet use seems to be a primary source of conflict between parents and kids. Do you see this a lot in your practice? And how do you go about addressing it both with the parents and with the children?
LP: Very young kids, 9, 10, 11, 12 are using the internet or videogames or other media for large periods of time, and parents are often seeing symptoms—kids are struggling with school, their concentration is impaired, and they’re not engaged in other activities or relationships.
Some boys are being prosecuted for texting sexual photos and parents of boys are very concerned about this.
I think that that’s a very important area to be aware of. Parents need education around the signs to be looking out for when kids are struggling. We need to think about their media profiles, how much time are they on TV, how much time they are playing videogames, how much time are they on internet, and what different modalities they’re involved with.

When families come in, I’ll have both the kid and the parents keep a journal and write their feelings down about what’s happening when there’s a confrontation at home regarding this behavior. And all of that comes back into the session. I often will use the family modality to meet at that point and we’ll talk about what’s going on in that type of interaction.

The other area that comes up frequently with teenagers is sexting—texting sexual material. During the past five years I would estimate I’ve had 50 teenagers referred to me who have been involved in sexting activities.

In general, the girls are involved in sexting pictures, nude photos of themselves that have caused some great difficulty. These are often selfies where the girls will hold the camera out in front of themselves, often in their bedroom or bathroom, sometimes partially clothed, sometimes not, and then they’ll text the photo to a friend or friends, and then it gets texted everywhere. That type of interaction is very important to pay attention to and I’ll generally work with the teenage girl alone and talk with her about what happened. The feelings around sexual development are very private and tender, and it’s deeply shocking that this is suddenly exposed to a large group of people. I work with the family around this behavior, too, and sometimes will meet with parents alone to help them understand why this behavior might have taken place.

I would say a smaller number of the sexting cases, roughly 20%, are boys texting nude photos of themselves, but they’re mostly texting nude photos of girls. There are also laws involved with this and I’ve been involved with the FBI and other law enforcement officials around how to handle these cases. There’s awareness in high schools now that they have to report these cases when they discover that boys are texting sexual photos of girls. Some boys are being prosecuted for texting sexual photos and parents of boys are very concerned about this.
RZ: How do you handle those cases when they come in?
LP: First be aware of the legal ramifications. Second, encourage them to get legal advice, because we as therapists can’t provide all of that. Third, I often will meet with the boy individually and try to get a sense of what happened and work with them around that. Many boys are shocked that this has happened. They may have thought they were doing what the other guys at school were doing, that it was cool, they were getting more status. But I’ve also seen boys who’ve had long-standing problems and the texting of the sexual photos is connected to other sexual difficulties that they’ve been struggling with. They may have been molested. They may have molested another person. So to be aware of that, to be open to hearing about that is very important.

Parents of boys are often very angry about this process. They feel that the boy is at a disadvantage because though he sexted the photos, it was the girl who originally sent the photos out so it should be her responsibility. Helping the parents see that we have to take a deeper look at what’s going on with their son under these circumstances is really, really important and not easy to do. You have to stay open to their feelings about their boys being scapegoated, but at the same time point out this is something we have to pay attention to.

The intersection of online work and sexuality is really a key area to focus on, to get as much help as you can as a therapist. Sometimes if I have a question, even today I’ll go to another therapist that I think has more expertise in this area and get supervision.
RZ: Are there particular resources for therapists who want to learn more about how they can be better clinicians when addressing something like sexting?
LP: Yes. I’m not going to toot my own horn about this, but I’ve written an article that’s online about sexting and working with clinicians that I think is very helpful. It has a literature review of a couple of cases and ten guidelines for parents and therapists around this area. There are not recent and current books because it’s a fairly new topic, but I think it’s something we’re going to see more of in textbooks and articles. A lot of young psychologists’ dissertations have been done on sexting, and those are valuable if you can get a copy and read them.

Learn to Like Kids

RZ: What advice do you have for beginning clinicians treating kids and teens?
LP: The most important thing about doing this work is that you have to be knowledgeable about your own childhood and adolescence. You have to have thought about it, its impact on your own development, the issues that you might bring to the work, questions and preconceptions about it, etc. I encourage almost all therapists to have their own experience in therapy and to explore some of these issues.

Second, what helps the most in this work is really loving children and adolescents. Having a strong love for that age group or working toward it. Let’s say you don’t love it, you’re kind of afraid of it, maybe you’re going to work toward a passion in that area. You’re going to learn why you’re afraid of that age group and you’re going to try it out and get supervision with somebody who is really very good at it. It is a group that is fun to work with, is very challenging, and can really be a growth opportunity for you as a therapist. But I’d say try to develop a passion for it. Learn to like kids. Learn a lot about child and adolescent development. I think either being a parent or playing a role with your nieces and your nephews and other kids is really important.

Third, you’ve got to be able to work with parents. When I was younger and starting out one of my mistakes was that I thought I knew what it was like to be a parent long before I was a parent, and I was often angry with how parents treated kids. By now I’ve gone through decades, I’ve had my own kids and I see it differently. I see myself as a valuable resource to parents and I have great empathy for them.

Sometimes I have to do very difficult things with parents.
Once I had to climb through a glass window when a young mother was holding her new baby and was psychotic and trying to do something to the baby.
Once I had to climb through a glass window when a young mother was holding her new baby and was psychotic and trying to do something to the baby. The police were there and there was obviously a lot involved with this, but we had to save the baby and rip the baby out of the mother’s arms. So there are things that you often have to do in this work that are not very easy with parents and I think I’ve learned how to do those with concern and empathy as I’ve grown older and become an older therapist. But at the beginning I would say stay open to the work with parents. Keep your eyes open. Realize you don’t know everything.

Fourth, Don’t just accept a dogma. Try to integrate and construct your own idea of how to do the work. I talked earlier about the five perspectives I use but think about those that work best for you, yourself, as a therapist, and with the patients you’re working with.

Lastly I’d focus on the first session and developing a good alliance with kids relatively quickly. That first session is really important—how you connect to your passion, staying open, not being judgmental. Watching tapes of other therapists do first sessions can be really helpful, or being in a study group where you share information about your sessions with kids. Or even observing preschool teachers, who are often very good with kids, welcome kids into the classroom, integrate them, and get them playing and involved in activities. All of that adds to our abilities in that area.
RZ: What do you think has helped you become a better clinician?
LP: Years of experience have helped a lot. Reading widely has helped a lot. Having my own children has helped a lot. I have four—two step sons and two daughters—and I’ve learned from all of them. It’s not been easy.

Supervising younger therapists has also been really helpful, because I’ve listened to their problems and I really try to figure out what they’re going through, which keeps me more in touch with what it’s like to start this work. This is not easy work. There’s a lot to learn. We make a lot of mistakes in it, but we do a lot of good.

Maybe the last thing I’d say about it is I’ve been so impressed over all the years of working with adolescents how many return. They bring their own kids back for treatment. That keeps me in it more than anything—having the kids come back with their own children, and seeing that they’ve shared things I said to them. This is not everybody, of course, because I’ve had over the course of my career two adolescents who killed themselves. I’ve gone through a lot of difficult experiences, as have my patients, but I am impressed with this type of work and how much we can help kids if we stick with it.

It’s wonderful work that makes you feel very good about your life’s work at the end of it. I don’t see myself at the end of it, but I have talked with others, like James Anthony, a role model of mine who was a wonderful child therapist who worked with Anna Freud. When I was a very young student I had the opportunity of working with him in London. He loved the work and he still continues to teach me things—and he’s in his late ‘90s. He talks about having patients come back and treating the grandchildren of the children he saw. That is an amazing thing. It’s a chance to be very connected with others in life really.

Suicide

RZ: It sounds incredibly powerful to have had such a positive impact on someone as a teenager that they want to bring their own teenagers to you once they have had children. It also sounds incredibly powerful to have lost an adolescent client to suicide and I’m wondering if you feel comfortable talking about that a little bit.
LP: It’s a reason that a lot of therapists seek out supervision.
RZ: It’s admittedly my worst fear.
LP: I think it is for all of us. It’s not just the legal aspects of it. We all carry liability insurance and we’re worried about that part of it—but it’s also just the connection. I will say that I really remember these patients and their treatment very, very well because of going through this and thinking about it a lot. The first was a young man who killed himself when I was the director of the adolescent unit at UCSF.
RZ: How old was he?
LP: He was 19 and he had very severe bipolar disorder. He stopped his medicines when I went on vacation and then went into the woods and shot himself. I had arranged for somebody to cover me during this period of time. It was a short vacation, but still enough for this to happen. I’ve thought about it a great deal, of course. It’s changed the way I take vacations. I still take them, but I’m very alert, thinking about coverage and concern about these teenagers and children when I leave.

I spent several months working with his family. They had anticipated it more than I had and that surprised me. I went to the service and worked with them in a collaborative mode, which I did not charge them for, and they were very grateful. I’ve stayed in touch with them in some ways, though that happened I’d say roughly about 30 years ago now.

The other suicide was about 20 years ago and was a patient I’d worked with for years. She had a chronic psychotic condition. She was a very bright young woman and I had spent a lot of time with her. She had promised me that she would not harm herself until she was 30 years old, and then she killed herself not long after her 30th birthday. So she stayed alive working with me for years I think to try to get better, and we tried everything. Family therapy, medications—and it was clear that she was going to be living with a chronic psychotic illness that was incredibly painful for her.

I still think about her all the time. I think she helped me in many ways to understand that sometimes we work with individuals who are suffering so much that from their perspective, their life is really not worth living.
Sometimes we work with individuals who are suffering so much that from their perspective, their life is really not worth living.
We can discuss that with them, we can work to help them, many different things can be done, but there are limits to the work that we do. She left me a number of drawings she drew and painted. I think a lot about her family. I worked in much the same way that I described with the earlier boy. I met with her family and had contact with them for a long period of time. I still think about her all the time.
RZ: I bet. I think this is particularly important to talk about for young therapists who are, as you mentioned before, maybe put off entirely by cutting because they’re so scared of it, or don’t want to work with suicidal clients because they’re so afraid of losing a patient. It’s really valuable for me as a young therapist to hear you talk about having gone through this worst fear with a couple of your clients and not only did you get through it, but it made you a stronger clinician ultimately.
LP: I think ultimately it did. Of course, a big part of this was questioning what I had done with them and if I had made the right decisions.
RZ: Of course.
LP: Had I done something wrong?
RZ: That’s natural.
LP: I think any therapist who has had a patient suicide question their work. Families question their interactions with their children after suicide. We all think about it. I work with many teenagers, especially here in the Bay Area, who have had friends suicide, and the young teens question what they could have done to help their friend. It’s not only us as a group of therapists who question ourselves, but it’s really the world that comes forward to question itself around suicides.
RZ: It seems like that’s the first question people ask friends, family, and therapists alike: What could I have done? Could I have done something different or better? And I think that is a real challenge.
LP: It’s natural and appropriate to ask those questions and explore them, but it’s also important to really understand that there are limits in life to what we can do. It’s important in this line of work to talk about this aspect of it.
RZ: That’s a very realistic and compassionate perspective. Thank you for your time and for your wisdom.
LP: And thank you for your good questions, Rachel.

Psychotherapy with Transgender and Gender Nonconforming Clients

Posted on by rezendevknowfully.com

The Unbearable Otherness of Being

Imagine making your way in a world where your physical appearance makes others uncomfortable, anxious, confused, or uncertain about themselves. Your very presence may be perceived as a threat to another individual’s sense of self or sexual orientation. Everywhere you go, people stare at you—sometimes discreetly, often blatantly—leaving you very little room to walk unselfconsciously through life. The reactions you experience from others, while the result of ignorance and sometimes mere “curiosity,” do nonetheless harm you, for you are perceived as “Other.” At times, people’s reactions are more hostile, the result of conscious and unconscious fears about what it means to deviate from gender norms, and you may be verbally or physically assaulted just for being you.

This is what it’s like to be a gender nonconforming or transgender individual in today’s world. Though there is increasing awareness and tolerance around gender issues in certain small segments of American culture, the truth is, the level of misunderstanding, ignorance and prejudice that surrounds gender nonconforming people as they go about their lives has created a mental health crisis in our society. To illustrate the epidemic nature of this crisis, here are a few statistics from the American Foundation for Suicide Prevention’s 2014 Report, “Suicide Attempts among Transgender and Gender Non-Conforming Adults.”

In a pool of 6,000 self-identified transgender respondents:

  • 41% had attempted suicide
  • 60% were denied health care and/or refused treatment by their doctors.
  • 57% had been rejected by their families and were not in contact with them.
  • 69% had experienced homelessness.
  • 60-70% had experienced physical or sexual harassment by law enforcement officers.
  • 65% had experienced physical or sexual harassment at work.
  • 78% had experienced physical or sexual harassment in school.

For gender nonconforming individuals, the very nature of their sense of “self” lies in marked conflict to society’s gender identity “ideals” and social scripts. The resulting prejudice (transphobia and homophobia), whether explicit or covert, often manifests in forms of denial, invisibility, harassment, bullying or, in more extreme cases, assault and murder. As if this weren't enough, gender nonconforming and transgender persons may be further marginalized by their ethnic and racial identity, economic status, physical abilities, and age.

More subtle forms of discrimination exist, many occurring within the helping professions, including mental and medical health, nonprofit support services, legal and government institutions and public schools. Overpathologizing, misdiagnosing, maltreatment (including refusal of services), neglect and demonization are just some of the ways transgender individuals are routinely discriminated against within systems whose mission is to support and serve. These discriminatory practices are carried out by providers who fail to become educated and respect, protect, or provide treatment that is appropriate, impartial, and equal to the care given to other clients. Following, I will attempt to provide the nuts and bolts necessary for aspiring clinicians who wish to work in a culturally competent manner with their gender nonconforming and transgender clients.

Gender and Language

I often remind my colleagues, students and clients that we all have a gender identity and diverse manners in which we choose to engage in self-expression. As a cisgender female (i.e., I identify with the gender I was assigned at birth—female), I am conscious of the great extent to which I can embrace the everyday conveniences of being privileged. I am not ostracized for my gendered self, and no one questions my choice in using a public restroom. For gender nonconforming and transgender clients, this problem is known as the “bathroom issue.”

We practitioners need to become fluent and speak the same language as our gender nonconforming and transgender clients. In doing so, we demonstrate the intention of promoting respectful communication that expresses an intricate set of thoughts, ideas, and feelings associated with sex, gender, sexuality and identity. The language used among this diverse community is multifaceted because finding words to articulate complex notions of identity is arduous. In fact, the youth in my office frequently inform me, a gender specialist, how some of the language and concepts I use are now outdated. Nonetheless, staying current with the language being used within the gender nonconforming community is an important part of being not only a culturally competent therapist, but an empathically attuned therapist. Such language literacy also enables mental health professionals to understand concepts, organize thoughts, foster discussion, exchange ideas, and support the community in the least confusing, shameful, and harmful way. Familiarity with the community’s positive expressions of self and identity not only helps clients feel understood, but ensures that therapists don’t rely on clients to educate them—an all-too-familiar experience for cultural minorities.

The following list presents a very general overview of how we come to understand the meaning of sex, gender/gender identity, gender roles, and sexuality for our gender diverse clients and ourselves. It’s important to remember that these terms are constantly evolving within the gender nonconforming, transgender, queer or transsexual communities, as well as by the practitioners who intend to help them. Gender nonconforming and transgender identities include but are not limited to: Transgender (TG), female-to-male (FTM), male-to-female (MTF), transgirl or transboy, girl/woman (natal boy), boy/man (natal girl), they/them, bigender, gender fluid, agender, drag king or queen, gender queer, transqueer, queer, two-spirit, cross-dresser, androgynous. The terms FTM (female-to-male) and MTF (male-to-female) encompass a spectrum or continuum from those who identify as primarily female or male, to those who identify somewhere in the middle or both (e.g., queer). Between these two posts or “extremes” (female and male) lie most gender nonconforming individuals.

The sexual orientation of gender nonconforming and transgender clients is a separate identity and should never be presumed or assumed. It refers to the gender one is typically romantically and sexuality attracted to (e.g., homosexual, heterosexual, bisexual/pansexual, polysexual, asexual etc).

Becoming Gendered

It’s important to think about how we become “gendered.” In part we do this by the way we organize and construct language. Most of the English language is “gendered,” constructed in a way that makes it difficult to deviate from strictly binary conceptions of male and female. We tend to acknowledge and refer to one another through pronouns, and consequently become gendered in our relational experiences. For example, when we frequent our local coffee shop, “Excuse me, Sir…Mam…May I have a large coffee?” Here is a simple example of how we have already ascribed gender to a complete stranger.

As clinicians, we need to learn to ask and address our clients appropriately. More importantly, we need to develop the capacity to become conscious of our own gendered ways. Specifically, we need to ask all our clients about their gender identity and development as well as their gender pronoun preferences. The youth that show up in my office often challenge this binary model most of us are so accustomed to, and request to be referred to as: ze, hir, one, or the plural “they” “their,” “them.” Interestingly, I often find myself arguing with my cisgender colleagues, who get caught up in grammar policing, about the importance of honoring the self-identification of these clients. The English language is constantly evolving, after all, and human and civil rights struggles play an important part in its evolution. At the same time, it’s important to not make any assumptions about people’s identification preferences. Plenty of gender nonconforming or transgender clients prefer to be referenced by conventional pronouns such as “him” or “her” because it feels congruent with their internal identity.

People tend to be preoccupied with gender long before a child is born. “Do you know your baby’s sex?” is a constant question for pregnant parents. Sex, in this case, refers strictly to the external genitalia of the child rather than their potential internal gendered self. “Gender is assigned prenatally and from that moment it determines—and severely limits—acceptable gender expressions and desires.” Our early training begins with our parents’ color selection for our nurseries, the names we are given, and the activities we are encouraged to enjoy, and because we want their love and approval, we emulate what is desired of us. We internalize the societal roles, behaviors and beliefs ascribed to us by the culture around us (including that of our family) and may not know that any other way of being is possible. Boys get blue items, are given toy trucks and guns, and are prompted to be assertive and confident. Girls wear pink, are given dolls to play with, and are encouraged to be empathic and compromising. These behaviors, beliefs and customs are socially constructed—situated in the context of historical time, social class, ethnicity, culture, power, politics, physiology, and psychology—but they are deeply entrenched in our psyches and ways of being.

Clinical Practice

As the presence and experience of transgender people has entered both public consciousness and mental health facilities, clinicians are now beginning to think about transgender/gender issues. However most clinicians are not trained to identify clinical themes prevalent for transgender and gender nonconforming individuals, and consequently misunderstand their mental health and their global treatment needs. Our traditional training fails to address gender and sexuality development for transgender persons from a nonpathological perspective. In addition, negative countertransference from providers and institutions is common and lends itself to discriminatory practices or, worse yet, thoughtless analysis of clients’ needs that may lead to irreversible medical interventions. Common feelings and attitudes for inexperienced clinicians toward these clients may include anxiety, fear, disgust, anger, confusion, morbid curiosity, and rejection, all of which can severely compromise the therapeutic relationship, our ability to help, and an individual’s identity development and transition process.

The journey of self-discovery for gender nonconforming and transgender individuals is laborious and often lonely because, simply put, the desire to become more congruent with their “True-Self” in body and mind may require a shift in physical identity. Children tend to be the most disadvantaged in this phase of life as they may be required to repress their desires to play with “cross” gendered toys and are left feeling ashamed to admit their favorite colors and activities (e.g., the boy who is prohibited from playing with dolls and having a pink bedroom).

As gender nonconforming individuals become more psychologically distressed they often feel the need to have a more congruent experience of their internal and external selves. They may need to first embrace a social transition—choosing an alternative name that reinforces their internal identified gender, dressing in a stereotypical fashion that supports their gender identification and engaging in “cross” gendered behaviors. In my clinical experience, when given the permission and support, gender nonconforming children and adults tend to become less anxious, depressed and gender dysphoric as a result.

However, some gender nonconforming and transgender individuals have a persistent need to modify or transition the physical attributes of their body to the opposite of their ascribed birth gender. This process is often too confusing for most people to comprehend, and is especially difficult because one’s gender expression and behaviors are typically the initial identifying marker for organizing one’s relational experiences among others. The clients with whom I work often desire bodily change not only to feel more congruent with their internal self, but with the hope of being experienced relationally as they truly are. For example, my transgender FTM clients use heavy-duty binders to flatten and contain their breasts so that they will not be mis-recognized as tomboys or lesbians. This experience of congruence tends to reduce gender dysphoric intrapersonal and interpersonal experiences. Our transgender clients need additional support around the use of physical and medical interventions, so it’s all the more important that we be well-educated and sensitive to these issues.

Gender Dysphoria

The new addition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), released in May of 2013, has removed the diagnosis of Gender Identity Disorder and has re-classified Gender Dysphoria as a clinical condition that gender nonconforming, transgender and transsexual clients may experience. Gender dysphoric symptoms arise when one’s self-concept and expressed gender in relation to their ascribed gender is “incongruent.” The psychological distress that results from these internal and external conflicts can lead to dysphoria, depression and a host of other conditions commonly experienced by transgender or gender nonconforming individuals. This turmoil is often created by internalizing the “gaze” of the world around them, i.e., they experience a great deal of psychological discomfort due to being publicly misgendered. Yet, it is also important to note that many gender nonconforming and transgender clients do not experience Gender Dsyphoria. They tend not to make it to our consulting rooms.

What of the clients who do end up in our offices? If a gender nonconforming or a transgender client and his or her family seek our support, are we available to console them, educate and advocate on their behalf, and offer culturally informed and sensitive treatment to the client and the family without getting caught up in our own agendas? How do we determine whether a child is an appropriate candidate for social transition, hormone blockers or even cross-hormone interventions? How do we determine whether the child is an appropriate candidate for genital reassignment surgery, which is often irreversible? How do we think about their fertility options and future family plans? How do we help a transgender child assigned female at birth who is in distress after his first menstrual period? Some of these interventions may seem radical, but if we fail to educate and train ourselves adequately around these issues, we can actively cause harm to our clients. Self-harm (body mutilation), substance abuse, homelessness, suicidal ideation or even suicide attempts can result.

A number of other conditions emerge in gender nonconforming children, particularly when their families aren’t able to provide the support and unconditional love that is necessary for them to thrive. These include adjustment issues, depression and anxiety disorders, trauma, substance dependency, and characterological pathology. Clinicians must be aware that families, too, must be educated about transgender issues, learn skills for coping with the child’s gender change, and be able to mourn and seek social and emotional support for themselves. And, of course, many clients may have co-occurring conditions, such as Autism spectrum disorders, that are beyond the scope of this article.

When treating a client with a gender nonconforming or transgender identity, clinicians may find themselves involved in a few situations unique to these clients. They may be asked to assess and substantiate a client’s preparedness for various biomedical interventions—usually involving the Real-Life Test/ Real Life Experience or a Gender Readiness Assessment—which involves encouraging a gender nonconforming client to begin living in their self-determined gender role and then assessing the impact of that experience. For example, some clients might experience a reduction in gender dysphoric distress, while others—say those whose family or community context is hostile to their nonconformity—may experience an increase in symptoms. Though this assessment is no longer required by the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People published by The World Professional Association for Transgender Health, many medical providers and insurance agencies require it for coverage.

Bridging the Gap

A transgender or gender nonconforming individual’s psyche and the issues they face are very complex—and at times, convoluted—with complications in the psychological, medical, legal, and social realms. Because of this complexity, and the severity of their suffering, it should not be left solely in the hands of clients to educate their clinicians, nor should these clients be put in the vulnerable position of relying on their clinician’s empathy to determine whether they will receive the care they require. An ignorant clinician who responds negatively to such clients—even if only at an unconscious level—can cause untold harm and make it that much more difficult for clients to seek the help they so desperately need. We need to take responsibility for becoming educated and seek guidance from gender specialists—trained providers who can inform clinicians about transgender history and integrate traditional psychoanalytic and psychodynamic perspectives with queer theory.

Diane Ehrensaft, PhD, director of Mental Health at the Child and Adolescent Gender Center in San Francisco, and her colleagues are doing groundbreaking work in this area, bridging the gap between developmental, biological, queer and psychoanalytic theory using what she calls a “Gender Affirmative Model.” She draws upon Winnicott’s ideas of “true gender self” and “false gender self” in formulating her notion of gender creativity to better understand gender nonconforming and transgender children and adults. Turning prevailing wisdom on its head, she argues against labeling gender nonconforming invidividuals as dysphoric and instead views their varied gender expressions as fluid, dynamically intertwined between biology, development, socialization, and cultural context in time. Gender is not binary and may change over lifespan.

Understanding the issues that gender nonconforming clients face creates the possibility of an authentic and empathically attuned treatment that can be a true corrective emotional experience. Having the competence and confidence to administer a Real-Life/Gender Readiness Assessment can make all the difference in our patients’ lives, allowing them to socially transition and integrate their gender identity with other aspects of themselves. Thinking of the client as whole is instrumental to their overall well-being.

Not until we as clinicians grapple with our own gender identity, behaviors, and attitudes can we begin to utilize our assessment skills in developing diagnostic impressions, identify and observe our countertransference feelings, and implement treatment interventions that will lead to a balanced internal and external sense of self that improves a client’s overall quality of life. I encourage all my fellow colleagues to become more cognizant of the their own identities, values, and beliefs, and particularly to confront their fears and prejudices when working with transgender individuals. We must become mindful of what we ask—and do not ask—in our clinical interviews.

We also mustn’t assume that gender nonconforming clients are coming to us because of their gender or sexual identity and be open in creating our hypthotheses about our clients’ needs and desires. Let us accurately reflect the true clinical condition with which our client’s struggle. As I noted at the beginning of this article: imagine making your way in the world where your very sense of being makes others anxious, confused, and uncertain of themselves. By becoming culturally competent, we will be better able to provide an empathic approach to treatment that considers a range of gender nonconforming expressions and behaviors as healthy, as an authentic gender identity and bodily presentation, albeit variant from societal expectations. Gender deviation is not pathological, and if you think it is, you’ve got some work to do. On the other hand, it’s important to not be reflexively “progressive” and mindlessly support a transition that is not first deeply understood clinically.

Reflections on the theory of gender development, diagnostic conditions, and clinical treatment implications must include the role of the clinician as a gatekeeper to another’s self-determined gendered body, heart, and mind. The exploration of the transference-countertransference relationship is paramount, regardless of whether you are a case manager, a medical doctor, or a psychotherapist. Let us play with gender, and in our journey, discover the kaleidoscope of possibilities for clients as well as for ourselves. As providers, it is our social responsibility to change the role of the clinician from a gatekeeper to one who can form a therapeutic relationship that offers a way for clients to integrate their sense of self in relationship to the other that can hopefully be emulated in the outside world. A solid sense of self is likely to build confidence and self-esteem that will foster healthier relationships and diminish uncertainty and fear, decreasing the risk of self-harm and—hopefully—violence toward gender nonconforming and transgendered individuals.

Recommendations for Clinical Practice

  • Ask your clients about their gender identity and preferred pronoun. Explore their internal experience and how it impacts them interpersonally.
  • Foster multiple and integrated identity development: race, ethnicity, gender, class, sexuality, profession etc.
  • Educate parents about the importance of not pathologizing the gender expression of their children.
  • Treatment interventions should include allowing children the space to explore their gender expression, family education and support, as well as parental support to mourn the loss of their fantasies about their birth child's ascribed gender.
  • Collaborate treatment efforts with the providers involved, e.g., social workers, endocrinologist for hormone blockers and hormone treatment, family therapist, and treatment team staff.
  • Remember: Gender nonconformity is a natural expression of human development and experience.
  • Do No Harm: Seek consultation from a gender specialist. Monitor countertransference and refer out if you are not able to act fully in the best interest of your client.

Clinical Resources

  1. Report of the APA Task Force on Gender Identity and Gender Variance.
  2. Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, Version 7.
  3. Achieving Optimal Gender Identity Integration For Transgender Female-to-Male Adult Patients: An Unconventional Psychoanalytic Guide For Treatment (2008), Karisa Barrow.
  4. Gender Born, Gender Made: Raising Healthy Gender-nonconforming Children (2011), Diane Ehrensaft.
  5. The Transgender Child: A Handbook for Families and Professionals (2008), Stephanie Brill & Rachel Pepper.

Deconstructing Gender: Self-Exploration Exercise

  • What is your own gender identity?
  • How old were you when realized you were a “girl” or a “boy?”
  • Who and what made this clear to you?
  • Did you agree with your parents clothing choices for you as a child?
  • What activities did/do you enjoy?
  • Have you expressed your own gender identity differently over the course of your life?
  • How do you feel about your body? Your genitalia?
  • What messages have you received about your gender and from whom (e.g. parents, media, religion etc.)? Were you “policed” by others around your identity, gender roles and social practices or body?
  • How has your gender shaped your beliefs, social engagements and practices?
  • What have you been allowed/encouraged to do because of your gender identity and what limitations have you faced (e.g. social sanctions/promotions)?

Treating a Couple After an Affair

Posted on by Psychotherapy.net Team

The couple in my office is connected mostly by the spaces they hold between them. Sitting on the loveseat in my office, they do not touch, although their arms, legs, and elbows and hands shift in an unconscious echo of each other’s movements. They are not so much mirroring each other as performing an elaborate dance of avoidance and retreat, their bodies’ dialogue spoken even through their many silences. On a larger scale, the same thing happens where they live: he comes home, she goes upstairs; she comes downstairs, he goes up; he enters a room, she leaves. They know if one of them tries to bridge the gap, something even worse will happen. There will be a wordless rejection, a sharp reminder of loneliness like a slap, or there will be a spark that will catch, flaring up hot and mean between them.

She can’t imagine how she is going to get over the affair. She is all the things anyone would expect: angry, hurt, shamed, frightened. He is torn between the grief of losing his wife and the grief of losing his lover. He has given up his lover in that he no longer sees her, and hasn’t for months, but he still has this backwards kind of feeling that if he re-engages with his wife—has fun with her, makes love to her, creates pleasant memories with her—that he is somehow being unfaithful to the lover he has renounced and, most importantly, all that she represented to him. To maintain what remains of his honor and fidelity he feels he must remain distant from his lover, his wife, and himself.

Today she is angry, but instead of the usual sullen acceptance on his part, he flares up in anger, and then, just as suddenly, bursts into tears. They are both startled by his emotion.

He gasps out the words, “I can’t believe how much I miss her” and I think, oh boy, she is going to explode.

I take a breath, preparing to intervene, but I hesitate when I see her face. There is anger there, but also something more like confusion or doubt. I wait.

“I don’t know what to do,” she says, “I want to kill him, but my heart goes out to him at the same time. What am I supposed to do?” In other circumstances, the bewilderment in her expression would be comical.

I would have said, if he had given me the opportunity to offer advice, that it would not be helpful for him to share this grief with her, that it would only inflame her anger and hurt and sense of betrayal, but there is no going back now. His grief is intense and visceral. He is holding his head in his hands and almost wailing.

Still looking at me, she holds her palms up and shrugs her shoulders in a mute gesture of helplessness, then turns to look at him. I have no idea what will happen next.

Slowly, she reaches across the couch for his hand and twines her fingers through his. He grasps her hand like a lifeline and clings to her as he sobs.

He chokes out his guilt—“I’m so sorry, so sorry”—but at the same time his relief is palpable. He seems more present than he has at any time since they started coming for sessions. There is no sense of anything secret or held back. He gathers her closer to him and they lean into each other in a tight embrace, both crying.

They leave, and I find I am near tears myself. What I am feeling is mostly the kind of surprised awe I feel sometimes in nature—what I feel in those rare moments, a dawn, or a sunset, when I am completely outside myself, bearing witness to beauty. His unvarnished honesty, her generosity, their mutual capacity to express love in what has been an atmosphere of despair and anger were acts of tremendous courage. Certainly it may have been, like a particular sunset, a fleeting moment, perhaps unrecoverable. But I hope—and I realize that I don’t need to go much further than that one word: hope. I hope, and I believe they will hope, that this moment of meeting holds a promise that other such meetings are possible.

Esther Perel on Mating in Captivity

Posted on by rezendevknowfully.com
Lori Schwanbeck: You are widely known around the world for your unique and thought-provoking stance on what makes marriage work. Can you tell us a little bit about your perspective and what makes it unique?
Esther Perel: I was originally trained in psychodynamic psychotherapy, but my real home for many years has been in family systems theory—I trained with Salvador Minuchin, and then in psychodrama, expressive arts therapies, and bioenergetics. And for many years, I worked extensively as a cross-cultural psychologist with couples and families in cultural transition, primarily refugees, internationals, and mixed marriages—interracial, interreligious, and intercultural couples.
LS: So you saw a lot of different people’s lives.
EP: Yes, I'm interested in difference. I'm interested in the relationship between the individual and the larger context, looking specifically at gender relations and childbearing practices. I then added my interest in sexuality, so that I'm now working at the intersection between culture, couples, and sexuality.

I also like to work with clinicians, be they physicians or mental health professionals, to promote the integration of sexuality within the couples therapy world, and to integrate relational thinking within the sexuality world.
LS: What do you think is missing in most clinicians’ approaches to working with sexuality and intimacy in the Western world?
EP: I just read a whole review article by Eli Coleman about sexuality training in medical schools, and it has undergone yet another major decline since 2010. We would have thought we were finally creating comprehensive training in sexuality for physicians, but we are not. So what is missing? First and foremost, for mental health professionals as well as for all health professionals, is training: the acknowledgment of sexual health as an integrated part of general mental and physical health. The vast majority of couples therapists have had no training in sexuality whatsoever—maybe an hour here and there. Couples therapy has become, over the years, a desexualized practice. Sex is the elephant in the room.
Couples therapy has become a desexualized practice. Sex is the elephant in the room.
Most therapists do not talk about it, don't know how to talk about it, and often wait for a couple to bring it up. And the couple themselves are often uncomfortable talking about it, so it remains the unaddressed subject, though it's often hardly insignificant.

A Better Sexual Relation

LS: You see our sexuality, our erotic life, as vital in the health of a couple.
EP: I see a couple's erotic life as an important dimension of their relationship because it is an integral part of the romantic ideal that is the dominant model of modern love. We took love and brought it to marriage or committed relationships. We then sexualized love. Then with the democratization of contraception, we liberated women from the mortal dangers that were associated with sex, and sex got separated from its sole reproduction function—as Anthony Giddens says, it became a reflexive project of the self, an ongoing process of self-definition. We have, for the first time in history, a sexuality within long-term relationships that isn't about having ten kids or a woman's marital duty, but that is rooted in desire, i.e., in the sovereign free will of individuals to engage sexually with their partners. And in the process, we have linked sexual satisfaction with marital happiness; that is what has made sexuality an important element of modern marriages.

I realized in writing Mating in Captivity that I was not interested only in sexuality, per se. And I certainly was not so interested in, "Are people having sex? How often? How hard? How many? How long? Are you a sexless couple because you have less than 11 sexual interactions a year?" and so forth. My interests lie not in the statistics of sex or the perfect performance industry that pervade our society.

Instead, I found I was really interested in what makes a couple feel a sense of aliveness, vibrancy, vitality—of Eros as a life force. When couples complain about the listlessness of their sex lives, they sometimes may want to have more sex, but they will always want a better sexual relation. And they will invoke the experience of renewal, of connectedness, of playfulness, of mystery, of regeneration, of power.

My distinction between sex and eroticism actually came out of my work in trauma. My husband directs the International Trauma Studies Program at Columbia, and he works a lot with torture survivors. I would wonder, "When do you know that you have reconnected with life after a traumatic experience?" It's when people are once again able to be creative and playful, to go back into the world and into the parts of them that invite discovery, exploration, and expansiveness—when they're once again able to claim the free elements of themselves and not only the security-oriented parts of themselves.

In the community of Holocaust concentration camp survivors in Antwerp, Belgium where I grew up, there were two groups: those who didn't die, and those who came back to life. And those who didn't die were people who lived tethered to the ground, afraid, untrusting. The world was dangerous, and pleasure was not an option. You cannot play, take risks, or be creative when you don't have a minimum of safety, because you need a level of unself-consciousness to be able to experience excitement and pleasure. Those who came back to life were those who understood eroticism as an antidote to death.
LS: That’s a very powerful statement. Do you find many couples that come to you dead in their relationships?
EP: Yes, but it's not always in their relationships. Sometimes they feel deadened inside of themselves as individuals.
I think that one of the prime motives for transgression is trying to beat back a feeling of deadness.
I think that one of the prime motives for transgression is trying to beat back a feeling of deadness. And the deadness isn't the fault of the other person at all. It may be a slow progression of an atrophy that has taken place inside themselves. I think that when people miss a sexual connection, there's often one partner who misses it more than the other. That longing, that yearning for that feeling of aliveness, of connection, of transcendence, of vitality, of energy, of rush is what people talk about. And on the other side of that, they will talk about feeling flat, feeling numb, feeling shut down, feeling dead.
LS: It sounds like you’re really talking about eroticism as an expression of libido, of life energy. How do you support couples in reinvigorating the passion in their lives?
EP: There’s a little exercise that I like to do, which I borrowed from the work of Gina Ogden. I ask the each partner in the couple to complete the statement, “I shut myself down when… I turn myself off when…”

We tend to talk about “what shuts me off” and “what turns me off”; we say, “You turn me off,” but we don’t often ask the question, “When do I turn myself off?” “I turn myself off when I look at an email just before going to bed. I turn myself off when I am disinterested in what you’re talking about. I turn myself off when I worry about the kids. I turn myself off when I remember my childhood.” What do I do to shut myself down? “I turn myself off when I don’t take time for myself.”
LS: It’s really about personal responsibility.
EP: That's exactly it. So the partners go back and forth, and they can come up with a list of 10 or 15 each. And then we come to, "I turn myself on when…I become alive when…"—not just sexually. Because if you're feeling dead, the other person can wear the nicest Victoria's Secret lingerie (and there is no Victor's Secret, you know), and it's not going to do anything because there's nobody at the reception desk.

Most of the time, in response to the "I turn myself on" question, people will say things like, "When I am with friends. When I go out dancing. When I take time in nature. When I take time for myself. When I've accomplished something that I'm proud of"—things that have to do with our sense of self-worth, our connection to meaning, and our sense of pleasure—things that make us feel alive.

Then you ask a person, "You tell me you like to dance. When's the last time you went to dance?" And if they tell you, "It's been months," or, "It's been years," then, before you start to work on anything connected to sexuality, you say to them, "I think it's high time you went dancing, since it seems to be something you really love to do."
LS: When you say that modern couples therapy has become a desexualized profession, it really sounds like you’re talking about more than just sex, but really about tracking and supporting aliveness in people.
EP: I think that there are a few forces that desexualize couples therapy today. One is the notion that sexual problems are the consequence of relational problems. Then it follows that, if you fix the relationship, the sex will follow. Therefore, if all sexual problems are relational problems of complicity, of intimacy, of communication, of trust, and all of that, then there are no sexual problems. So we don’t talk about sex because sex is just a consequence of something else.
LS: And you’re saying it stands alone as a phenomenon in a relationship.
EP: I don't think that sexuality is only a metaphor: "Tell me about the state of the union and I know by extension what happens in the bedroom." I think that sexuality is a parallel narrative. I think, in fact, that when you change a couple's sexual relationship, it has an effect on every other part of their lives.
When you change people's relationships to their own sexual selves and their ability to connect with others, you have touched them at the core.
When you change people's relationships to their own sexual selves and their ability to connect with others, you have touched them at the core, because it's everything: mind, body, spirit, breath.

Love and desire both relate and conflict. Looking at the way people connect and their emotional history is very important, but it gets translated into the physicality of self, and then it inhabits its own narrative. They are parallel stories and they need to be looked at as such. So that's one.

Another element of the desexualization, which is, I would say, stronger here in the United States, is related to the fact that the focus over the last decades has been on security, attachment theory, the need for safety, and much less on the need for freedom, sovereignty, and self-determination. This is because we are working within a context that is among the more egalitarian contexts of the West, and one where people are often so individual and so alone that all the theories that have proliferated have been theories of connection. In the few decades before, they were all theories of individuation. It's like in art: you have one wave succeeding another. This is not a time when, in this country, people are very interested in investigating the need for freedom. That happens in environments where people are a lot more oppressed, and where they are overly connected in layers of extended family. That is not the dominant concern here, existentially or socially. And sexuality plays itself in both realms. You need a certain security for sex, for some people—not for everybody. But you certainly need a lot of freedom for sex.

Balancing Security and Freedom

LS: Tell us more about how that need for security and need for freedom can coexist.
EP: For me, the reference person is Stephen Mitchell, who in his work in Can Love Last? looked at how modern love and romanticism have brought us to try to reconcile within one relationship, within one person, fundamentally sets of opposing human needs.

In every epic story—in The Odyssey, for example—there is the home and the journey, the travel and the base. Today we want our needs for security, predictability, stability, reliability, dependability—all the anchoring, grounding elements of our lives—to be met in the same relationship with the person from whom we also expect adventure, novelty, mystery, and all of that. We still want what marriage always gave us, which was about economic support, companionship, family life, and social respectability, and on top of it, we want our partner to want us, to cherish us, to be our trusted confidant and our best friend. In effect, we are asking one person to give us what once an entire community used to provide.
LS: It’s a lot to ask for.
EP: We've never tried to experience both like that at that level in the history of human relationships. We also live twice as long—a hundred years ago, we died seven years after we were done raising children. So the longevity of what we expect from a monogamous, committed relationship is also unprecedented.

There is something about the enshrinement of the modern couple that has basically made it this hermetic unit where we have get all our needs met, rather than understand that there are certain things you're going to get from your sister, your aunt, your grandmother, your best friend, your colleague. I think that we can have multiple intimacies that are friendships and deep relationships with other people.

The model for me is really seeing the movement between freedom and security, which are the two pillars of development—connection and autonomy, independence and dependence. I think they are the two main pillars of growing up. And it is the same as any system. Every system needs to balance homeostasis and growth. It isn't just on an individual level. And every system regulates change and stability. So do individuals regulate connection and separateness.

The image that I often use in my work with couples is little kids: if everything is nice and going accordingly, you will have your child sit on your lap very cozy, nested, at ease, comfortable. And at some point, the child needs to jump out and go into the world to meet what are called the exploratory needs: freedom, independence, separateness, autonomy, all of that. If the little kid turns around, which kids always do, and looks to see what's going on with the adult, and the adult says, "Kiddo, the world's a beautiful place. Go for it. Enjoy it. I'm here," often the child will turn around and go further, and experience at the same time connection and independence, freedom and security. At some point, she has enough, and comes back to base and plops herself into your lap again, happily returning as an act of freedom to a place where she feels welcome because it offers security as well as the respect for freedom.

But if, on the other hand, the little child turns around and the adult says, "I need you. I'm alone. I miss you. I'm depressed. I'm anxious. I'm worried. What is so great out there? Why don't you want to be with me? My partner hasn't paid any attention to me"—any of the messages that basically say to the child, without ever saying it in words, "Come back"—then there are a number of dominant responses. One common one is that the child comes back, because we'll do anything not to lose the connection, since that's the primary need.

But we will sometimes lose a part of ourselves in order not to lose the other. We will forgo our need for freedom and space and separateness in order not to lose the other and the connection. And we will learn a way of loving that will have a certain excess emotional burden, responsibility, worry, that is beyond the normal elements of love that have to do with mutuality, reciprocity, care, and responsibility—so much so that once I love you, I can no longer leave you enough to be able to experience the freedom and the unself-consciousness that are necessary for sexual excitement and sexual pleasure. The adult makes that motion into sex: the ability to be inside myself while I am with another. If, when I am with another, I have to leave myself, stay outside of myself, basically, I can't even culminate. Physiologically, we cannot come if we don't have a moment where we can be completely with ourselves and inside ourselves in the presence of another.
LS: So it’s really holding that dialectic of being both within yourself while also connected.
EP: Yes. But when you talk about intimacy, you need attachment as a precondition for connection. In the realm of desire, separateness is a precondition for connection.
Love needs closeness. Desire needs space.
Love needs closeness. Desire needs space.
LS: Could you give us a practical example from a couple that you’ve worked with of how someone can have both connection and separateness? And what does separateness mean within a relationship?
EP: Imagine the person says, "I turn myself on when I go to the movies alone." Not sexually, right? "I come to life. I connect to my desires in the realm of pleasure"—that broad sense of the word "sex."
Sex isn't something you do. It's a place you go, inside yourself and with another or others. It's a space you enter.
Sex isn't something you do. It's a place you go, inside yourself and with another or others. It's a space you enter. I work in the erotic space, if you want. It's not an act. People have had sex for generations and felt nothing. I am not into promoting people having sex, but having a certain relationship with a certain dimension of your life.

So, if they say, "I like to go to the movies," then the next question will be, "Do you go?" And you will listen to the degree to which they tell you, "It's hard for me to leave," or, "It's hard for my partner when I leave," or, "No, it's just a matter of circumstances. Lately, I haven't had a chance to go, but it's never been an issue for me," or, "When I come back, I'm always worried." The third child I didn't describe is the one who does go, but is constantly looking over his shoulder, making sure that the adult here isn't going to punish him, reject him, become depressed, or collapse on him when he returns.

So the person says, "I don't go often to the movies alone, or listen to music, or play my music for that matter"—or whatever it is—"because when I come home, I experience that anxiety, that knot in my stomach that I'm not going to be told, 'How was it? How wonderful,' or I'm not going to be told, 'Stay out as long as you want. Everything's fine. Enjoy yourself.' I'm going to be told when I leave, 'Again you have to go? When are you coming back? Why are you staying out so late? Why do you not want to go with me?' I'm going to hear comments that basically say, 'Give up your freedom so that I can feel secure.'"

That is a classic transaction in the couple, versus, "I'm happy for whatever it is that you are experiencing elsewhere, even when it has nothing to do with me, because you bring this back, and that makes you a more interesting and alive person that maintains a certain vitality between us."
LS: If we use attachment language, it sounds like you’re trying to cultivate secure attachment.
EP: Yes, and a secure attachment for me isn't a singular experience: there is not always just one person to whom we turn. And I think it's a difference in culture. There are loads of places in the world that are more likely to think that your partner is the person with whom you experience parts of your life, while friends and family provide the existence of multiple safe harbors.
LS: So secure attachment for you is about feeling securely attached in the world, in your life, but not exclusively attached to one person. That’s a big difference.
EP: Right. The enshrinement of the modern couple is connected to the exclusiveness. I don't think we are more insecure today than we were before, but I think
We bring all our security needs to one person, and then we blame them for whatever is missing in our lives.
we bring all our security needs to one person, and then we blame them for whatever is missing in our lives. God forbid you have conversations with others that you should be having with your partner, because that becomes an emotional infidelity. The system is rigged with injunctions against leaving the relationship in any way possible—not just in sexual terms.

A Vibrant Field Has Multiple Voices

LS: How are you finding your ideas are holding up in our Western culture? Are other therapists embracing them, or is there a push back that you’re finding when you teach?
EP: I think that a vibrant field is a field that has multiple voices. When I wrote my book, it wasn't written for professionals. I did not think that it was going to become one of those voices—that it would be embraced in the couples and sexuality fields, as it has by some. I'm happy that it is one of the many voices. One of the things that you get when you work cross-culturally, as I do, is that every time you hear a truth in one place, you know that another place is thinking of it completely differently. The pacifier, the baby's bed, the baby's crying don't mean the same thing in every culture. And it's very refreshing to be located in a much more multicultural, nuanced, nonjudgmental, relative way of thinking. It works for me.

I think that there are people who have difficulty with what I talk about, and there are people who find a tremendous sense of affirmation in what I talk about—this is how they have been thinking, and they've been looking for that approach. I'm glad to be part of the conversation, and I'm glad to be a stimulant in the conversation.
LS: You're certainly that, and it is very refreshing. It's almost like you're bringing that multicultural perspective of relationships into a multicultural perspective of how to do therapy, as well—how to hold and look at a relationship and embrace different perspectives
EP: I think that romanticism has appeared in every part of the world, even in very traditional cultures. And wherever romanticism has appeared, people are investing more in love than ever before, and divorcing more in the name of love—or the disillusions of love—than ever before. And
I think that wherever romanticism has appeared, there's a crisis of desire.
I think that wherever romanticism has appeared, there's a crisis of desire.

Originally, I wrote my book from the perspective of a European therapist observing American sexuality. I started the original article during the Clinton and Lewinsky scandal because I was very intrigued as to why this society was so tolerant towards divorce—you can divorce three, four times without much stigma these days—but it was very intransigent towards any transgression or infidelity, whereas the more traditional family-oriented world had always compromised towards infidelity (a burden carried primarily by women, I should add), in the name of preserving the family, and separated the well-being of the couple from the well-being of the family.

I had no idea that I would be going to 20 countries on book tour. In the process, I began to realize that a crisis of desire was nothing unique to this country. It is really part of the romantic model and the changing meanings of sexuality in modern committed relationship.

But there are some unique features to this culture that have to do certainly with its relationship to sexuality. First, it's a society that often relates to sexuality as smut or sanctimony, titillation on the one side, and condemnation on the other side. It vacillates between extremes.

Second, it's a society that has certain views about transparency, and about transparency as essential to intimacy: wholesale sharing, telling it all, being explicit, not beating around the bush. I think that this is a society that looks at honesty from the point of view of a confession. Minimal tolerance for ambiguity and the imponderables is what makes American business great, but it's not necessarily what other cultures bring into the private sphere.

Keeping Secrets

LS: You’re saying that the emphasis on complete transparency and honesty actually gets in the way of creating a vital relationship?
EP: I think that one should know that, while it is obvious in some cultures, like here, that if I can tell you everything then we are closer, there are other cultures—sometimes your own neighbors—who actually think that the ability to maintain privacy is what enhances intimacy, and not necessarily transparency.
LS: It’s a big difference.
EP: It’s a difference. And I think each one evolves in its own context. But it’s very refreshing to know that there is a whole other way of looking and thinking out there that totally throws off what you take for granted. Working in New York City, I get people from 15 countries coming into my office. I practice in many languages. I cannot assume that that a couple who came at nine o’clock and wants to tell each other everything is the same as the couple who comes at ten o’clock with a completely different notion of boundaries, individual space, the mandate for sharing, the hegemony of the word as a form of intimacy, gender structures, power dynamics, and so forth.
LS: The policy of not keeping secrets within the couple is also widely held among therapists here. I’m wondering if you have a different perspective. As a therapist, do you have the same policy that many therapists have of not holding secrets?
EP: There is a clear hierarchy of secrets. There is only one particular secret that therapists really grapple with in terms of credibility, ethics, and mode of working. If you tell your therapist that you have had a miserable sexual relationship with your partner for years, that you’ve been faking it forever, that you can’t stand his smell, or her looks, or whatever it is, you rarely will hear a therapist say, “Either you need to tell your spouse, or you have to go to individual therapy.” That’s also a big sexual secret. I cannot imagine a partner one day after 27 years finding out that their wife or their husband has been lying and faking to them all these years. They’d be no less crushed. But somehow that one doesn’t do it. It is really any one of the secrets in the range of the infidelity spectrum. And even if you raided your bank account, a therapist would not usually say, “If you don’t tell, I can’t start working with you.”
LS: So you have more of a subjective stance to the issue of whether or not full transparency between your clients is ultimately serving them.
EP: I think it needs to be examined. Sometimes it's dangerous. In the field of infidelity, I would align myself very much with the work of Janis Spring, Michele Scheinkman, Tammy Nelson, or Stephen Levine, who are examining the concept of keeping a secret. Today, in the first session with any couple, I will say, "I will see you as sometimes together and sometimes apart—I don't know how much of each. When I will meet you apart, it's because I think that there's certain conversations that may be better held alone, because you will be less defensive. You will take more responsibility. You will be more able to examine yourself quietly. You won't be in the reactive stance. And those will be confidential conversations, which means that each of you will probably tell me things that your partner may not know. And you will decide at what point you want to share that."

I'm often asked, "What do I do with the secret of infidelity?" I sit with it, because sometimes the secret is the therapy. Or, as Janis Spring says, "Giving up on the secret is the therapy." Then the question is, is revelation mandatory? It is often seen as mandatory here. The concept that intimacy needs to be rebuilt through transparency and revelation doesn't take into account that for some people, revelation may be more traumatic, which then is answered by other people who say, "But, somehow experiencing the trauma is part of rebuilding the relationship." But that's one view.

So I work with secrets. If I agree to work with the couple, I take the couple as it comes to me. It's not for me to decide what risks people need to take in terms of revealing their secrets. There are major power imbalances in society—major risks involved for women to reveal certain secrets, for instance. I very carefully assess with them what is safe. I've learned that when I go to Cuba, Mexico, and other places, I can't just take transparency as a norm without looking at the political and social implications of gender politics. In that sense, the dominant theories and trends du jour are not as contextual as systemic thinking used to be.
LS: What advice would you give to therapists in looking at their own erotic lives, in terms of how that’s going to affect the way they show up with clients?
EP: There are two levels: the professional and the personal. On the professional level, I think you want to continue to learn, renew yourself, grow. I think it's particularly important for experienced therapists to not stop growing, to not stop listening to other people.

Every time I go to a workshop or a conference, I know that I work differently the week that follows. I am filled up. I am renewed. I'm trying out new things, stepping outside of my own comfort zone. Every time I go and I lecture some place, I ask people, "Has my work grown? Has it changed? Have the ideas matured? I hope I'm not repeating the same thing." At this moment in my work, I have made new choices, different choices than the ones I certainly was trained with—or indoctrinated with, we could say, because they were never questioned.

I also think that it's very important for me, anyway, as a therapist, to read anthropology, history, poetry. The arts are a lot more able to deal with the complexities of love, sex, desire, and transgression than psychotherapy is. The greatest novels, movies, and poems capture the complexities and the contradictions of our life. I strive towards the embrace of the contradictions, or the dialectic, and not necessarily towards the dogma. I tend to work more on the side of art than on the side of science. And to work in the realm of art is to work with the unknown, rather than to want to simplify the known and to make it predictable and organized. I don't have a set model in that sense.

Maybe what people have appreciated about my work is the fact that I am questioning our assumptions. I really don't think I have the truth on things, even though I sometimes sound very confident. But I am willing to ask myself, "Is this the only way? And who says? And must it be this way? And for whom?" The people who come to study with me do so because I'm out of the box, not because they're going to get a nicely structured framework. There are a lot of other important elements to couples' lives, but it happens to be that this existential dimension is the one I have become very interested in. So I write about that.

And personally, make sure you stay alive. Make sure you stay in touch with your own experience of pleasure, of receiving, of giving, of sexuality, of your body. Don't disconnect, or you will bring that into your work, and it doesn't benefit anybody.

Lonnie Barbach on Sex Therapy

Posted on by rezendevknowfully.com

Early Years of The Human Sexuality Program

David Bullard: Lonnie, as we start this interview I should acknowledge that we’ve known each other a long time as friends and colleagues.
Lonnie Barbach: Well, we met in late 1974 at the Human Sexuality Program at the University of California at San Francisco—that is a while ago!
DB: Yes, and you were one of my post-doctoral instructors, along with Jay Mann, Bernie Zilbergeld, Harvey Caplan, and Rebecca Black. Actually, you all were more important therapist role models to me than anyone I had encountered in graduate school.  And it was an exciting time to see how you all were bringing a kind of San Francisco humanism to sex therapy.
LB: That was an incredibly exciting time in human sexuality research and therapy and it led me to write my first book.
DB: Yes, For Yourself  was your timely and incredibly successful book that empowered women to take charge of their own sexual pleasure.  Not to linger too much in the past, but are there any impressions you can share when you think back to those days of the UCSF Human Sexuality Program, which for awhile was the largest training program in the country for psychotherapists, physicians and nurses in the newly-emerging field of sex therapy, post-Masters and Johnson.
LB: Well, for me, it changed my life; it was a pretty formative and important time. I didn't fully appreciate its significance at the time, but I knew that it was exciting.

DB: You graduated with a doctorate in psychology from the Wright Institute.
LB: I had done everything but my dissertation when I began at UCSF. I ended up designing this format for pre-orgasmic women's groups at UC, Berkeley where I worked with a small group of UC students in women's consciousness-raising groups using masturbation as a learning technique, but no one believed this form of therapy could work with middle-class housewives! So I was challenged and had to find a different environment in which to do my dissertation research.  Jay Mann was a psychologist and director of the HSP at UCSF and he said, “Well, if you pay us rent to use the space, you can run your research groups out of here and be under the umbrella of UCSF.” Then, as part of recruiting subjects, I was a guest on Don Chamberlin’s radio talk show called “California Girls.”  Thereafter, whenever someone mentioned having an orgasm problem, he would refer them to me. Within a few months, I had hundreds of women on a waiting list at UCSF.

Women’s Preorgasmic Groups

DB: So his show really jump-started your work with women’s preorgasmic groups.  Prior to your contributions, the professional diagnostic terms for a woman who had never or rarely had orgasm were “nonorgasmic” or “frigid.” Your use of “preorgasmic” instantly re-set more hopeful expectations and dropped the pejorative labels that almost all women had been oppressed by one way or another.
LB: Yes.  The semantics were oppressive, and we had to push over several years to get the medical and psychological establishment to drop those old labels. 
There was a great need in our society for people to drop shame about their sexuality in order to enjoy it….
There was a great need in our society for people to drop shame about their sexuality in order to enjoy it and for general self-acceptance. I learned a lot from the women in the groups–they were my teachers also. After completing three research groups with great results, I suddenly had this large number of women wanting help, so Jay Mann suggested we do a large group educational program. By then he realized that UCSF would earn more if they hired me and directly took in the money the women were being charged rather than my just paying them rent.  So I was brought on as co-director of clinical training in charge of their first women's program; later they added a men's program that Bernie Zilbergeld headed.
DB: You and I were both in graduate school in that era and I can remember what a powerful idea this was: empowering women to learn to take charge of and enjoy their own sexuality.  
LB: And I didn't realize that at first! All I knew was that I needed a job. It was actually a fluke that I even got into the field of sexuality. A woman came to a volunteer educational program I was leading for Planned Parenthood. At the end she said “you really should apply for my job because I'm leaving a position at UC, Berkeley as a sex therapist.” I was trying to finish my education at that point and really needed to earn some income. Two male colleagues of mine, Jim Purcell and Bob Cantor, both agreed they would do Masters and Johnson couples therapy counseling with me.  In that format, you needed both a female and male therapist for one couple. We got the job and I read the few books that were out and talked to everyone who knew anything about sex therapy, although there weren’t many of them at that time.  Shortly, Jim and Bob told me that they were too involved with their other jobs and graduate work and had no time to do the couples sex therapy. So I had a job I could not do as a single female. 
 
At the same time six women who also had no partners applied for sex therapy at the student health service. Some were single, some had partners but the partner wasn’t willing to come into therapy.  And one woman was faking orgasm and didn’t want her partner to know. Women’s consciousness-raising was really big at the time.  It seemed to me that Lo Piccolo and Lobitz's nine-step masturbation program could be used in a consciousness-raising group format.  So I tried it and led the first group with Nancy Carlson. Our first group was ten sessions long and we only had five weeks in order to fit it in between midterm and final exams! They were all “primary pre-orgasmic” women (never having experienced an orgasm by any means); by the end of this group they were all orgasmic by themselves and most of them were also orgasmic during sex with a partner. That was the beginning…. and if I had been on the East Coast, I probably never would have done anything more because, as I learned later, other professionals couldn't believe what I was doing out here–there was really a negative, critical reaction to working with women in groups and teaching them masturbation. But I was in California! So it all grew and developed.
DB: LoPiccolo and Lobitz had used this behavioral approach only in individual therapy?
LB: Yes. And then Jay Mann said I should write a book about this approach.  “But this stuff is so basic,” I said, and while he agreed, he believed that women needed permission to approach it so simply. So he was entirely responsible for my writing career. 
DB: Well, many therapists have ideas and talk about writing books, but actualizing it is quite a different matter!
LB: The power of the book is that it gives permission to women and to their partners to explore themselves. I did not realize that this was so needed because I did not come from a particularly sex negative or repressive family or religious background, so sex seemed natural and normal to me.
DB: And you were a couple of years ahead of the publication of Jack Annon’s book, in which he spoke about the PLISSIT (Permission, Limited Information, Specific Suggestions, and Intensive Therapy) model. 
LB: Yes, his wonderful book, The Behavioral Treatment of Sexual Problems, came out in 1976.
DB: How many copies of For Yourself have sold and in how many languages?
LB: It has been translated into 8 languages and a couple of million copies have been sold worldwide. I don't keep track of the numbers, but I do know that I’ve sold over 4 million copies of the total of my books in the United States.

A Career in Human Sexuality

DB:  I hope you don’t mind if I repeat a comment made at a professional meeting, when you were introduced as the person who has been responsible for more female orgasms than anyone else in human history!
LB: Yes that was either Bernie Zilbergeld or Jay Mann; it was very funny.
DB: That has led to a long career and interest in couples and sexuality, as well as in individual therapy. You do everything in your private practice.
LB: You can't separate out sex from a person’s life context. So we go into the psychological issues, the relationship issues, and perhaps the medical or physiological and neurophysiological issues.  Half the time it's not just a sexual issue but also a relationship issue. So that is the majority of my work.
DB: I don't imagine you've done a women's group in a long time.
LB: Probably not for 25 years. Group therapy is not as popular as it used to be and it's difficult to get a group together around one particular sexual issue. And it is not as needed. More basic information and permission about sexuality is now out there in every Cosmopolitan issue and in many books and the media in general. The culture is more open to the topic of sex.
DB: It's interesting to see how psychological issues evolve over time as a result of the culture changing, not just from research findings and technical changes.
LB:  
Yes, for example, trans-gendered, gay and lesbian issues are being discussed in high schools and now most people have a friend or cousin in one of these sexual minority groups because people are more open about it so it has become more natural. Look at the opportunities given to all of us to learn about other ways of being human that television and the internet have brought to us.  The culture is more accepting and it's infiltrating into the job market and the military.
DB: You wear several hats that I know of:  you have a partner and colleague of 26 years in David Geisinger, you are a mother of a wonderful daughter, you are a therapist with a private practice, you are a lecturer and workshop leader, and are an author and writer….
LB: And I used to be a producer of educational as well as erotic films.  I was a consultant for K-Y [a manufacturer of personal lubricants]. And a teacher at UCSF and at Antioch West.
DB: You then focused on male sexuality and couples sexuality as well.
LB: One thing just naturally led to another.

Couples Therapy

DB: Switching to your couples work and sexuality, are there any particular influences other than your own ongoing work with clients?
LB: I’m process oriented. For example, there can be a negative kind of power or withholding.
Not wanting sex and/or not having orgasms can be powerful ways of impacting the relationship, especially if there is a power imbalance in the relationship.
Not wanting sex and/or not having orgasms can be powerful ways of impacting the relationship, especially if there is a power imbalance in the relationship. If the man seems more powerful and has a larger personality, this negative withholding may be a way for her to balance out the power. So I tend to look at and work with the system in a relationship although power may be only one aspect of it. If one person is more forward, talking a lot, I may have them talk less and have the partner talk more. You have to move the process of the relationship in therapy. David and I wrote a book together called Going the Distance, Finding and Keeping Lifelong Love and in that we described our theory of working with couples and it has deepened over the years. Since then, other therapists have come up with similar approaches, such as Sue Johnson’s Emotionally Focused Therapy. The main premise is that intimacy is no better than the dialogue between two people and the dialogue has to be one based on vulnerability, so an important task is to help couples learn to be vulnerable and to make it safe to be vulnerable in their relationship. You look underneath anger for the more vulnerable feelings and help them express what's going on at that level so that people can hear each other and really respond without being pushed away and without getting defensive. It works really well.
DB: When you give a talk to graduate students who are interested in couples therapy, what particular ideas do you suggest, especially for dealing with any sexuality component their clients may be struggling with?
LB: One reason I think couples therapy is fascinating is that there are so many parts: each partner has his or her relationship history, each has their own personality issues, and then there are the ways they fit together. This is true for all aspects of their relationship including their sexual relationship. So I would suggest dealing with sex in the same way you deal with other issues: talk about it directly and specifically. See how early history may be contributing; how their relationship dynamics such as power struggles or just plain chemistry may be contributing, in addition to taking in real-life practical constraints such as job stress, children, medical issues etc. So it's wonderfully complicated and you play with that in order to get change and that’s all fascinating to me.
DB: Your enthusiasm and passion for working with couples is evident. I'm glad you also use the word “complicated” to describe couples work.   I have another very successful psychotherapy colleague who has written several books on therapy but doesn’t do couples therapy, saying “They are too complicated.” And you're now saying couples are “wonderfully complicated”!
LB: I have a road map in my head when I'm working with a couple and it’s a lot like writing a book. I know where I’m headed and I’m trying to figure out best how to work with them to get there. I believe that an intimate relationship is really the place where people can be healed most effectively–where emotional wounds are healed. So you are involved in a process where each partner is able to heal the other.
DB: Does that mean you've seen instances where you see an individual as part of a couple who might've been somewhat or completely resistant to individual therapy, but within the couples therapy format, that person was healed and got what they needed? Perhaps they could not have gone to or been successful in individual therapy.
LB: Absolutely! And sometimes with couples I also like to see them individually for a session here or there if there are individual issues that are contributing and both partners are very reactive to each other, and they take the other’s feelings too personally. So the couple dynamic comes into play when the reactivity keeps us from going deeper in the couples work. An individual session with that person may bring some clarity so they may be less reactive to their partner’s words.
 
If I were to speak with graduate students, I would suggest that they not start out with couples. As we’ve discussed, it is very complicated. One of my first internships was working at a Synanon-type program at Oak Knoll Naval Base in Oakland. I was working with drug users who were pretty hardcore. I had standard intern responsibilities and was the only female on the ward. I was also leading a couples group for the men and their wives or girlfriends. I was so lost that the guys kept having to explain to me what was going on! I was so over my head. I loved working with the guys and actually signed up for a second go around–the learning was amazing.  However, I would recommend you learn psychotherapy with individuals first and get comfortable with that before attempting work with couples.
 
When I do individual work, I’m always thinking about what is going on with my client’s partner, presuming innocence about them and not just seeing things from my client’s point of view. Also if you're not comfortable talking about sex, you are really limited in the kind of help that you can give couples because so many couples with relationship problems have sexual problems. I've had people come to see me who say, “I went and saw a couples therapist but when I talked about sexual stuff he said, ‘I don't do that’" and they were referred to me.
You're very limited in the kind of intimacy work you can do if you are not comfortable dealing with sex.
You're very limited in the kind of intimacy work you can do if you are not comfortable dealing with sex. The more depth and breath in your skills, the more you can be of assistance to the people you work with.

Sexual Issues in Therapy

DB: Can you give any advice to graduate students and therapists who may feel they have not had enough sexual experience themselves, or somehow feel that their sexual life is not up to some standard, or are just uncomfortable and may have a taboo sense of talking about sex. Any recommendations?
LB: I would say to people to read the books that are out there to get the basic information. Read Bernie Zilbergeld’s book The New Male Sexuality – still the best male sexuality book that's out there. Read For Yourself and For Each Other. Read a book on menopause, like The Pause. Read The Sexual Healing Journey by Wendy Maltz on sexual abuse and about sex and aging so you know about the changes people experience in their sexuality. 
 
And then explore experiential exercises within a graduate program or workshop, such as sex history giving and taking. It can really help to be in a course situation where students ask each other and inquire into the specifics of someone's sexual history and life. Or just practice taking sex histories with friends or lovers. The idea is to get more comfortable talking explicitly about sex.  Most of us need to get over feelings of shame that we are different or not normal or we may be otherwise anxious because we are comparing ourselves to some mythology about others. The more information we have, the more we realize that sexuality has a huge range. It’s not about right or wrong or better or worse, but what is right for the individual person and how their body functions and how they fit with their partner.
DB: In the beginning of the sex therapy revolution in the 1960s and 70s, the focus was on the sexual dysfunctions: erection problems, orgasm problems, ejaculation problems. Over time, desire problems seem to have become preeminent for couples. Is that what you're seeing in your work?
LB: Every now and then I'll get a rapid ejaculator or someone who's not having erections or orgasms. But the vast majority of the people I see are concerned with their lack of sexual desire. There are so many causes for a lack of desire: relationship and communication problems are the most common cause, then there is menopause, lack of chemistry, poor sexual communication, interfering medications, etc. etc.  Half the problem is figuring out the cause.  For example, psychotherapy won’t work if the problem is caused by low testosterone.
DB: So much of you and your work has been showcased in the media, that I have to ask what it was like for you to be on shows like Oprah?
LB: Well, she was lovely, but the most memorable show I did was the Phil Donohue Show.  Before the show he came and said, “ Look, you're the only guest for this hour but I'll be out there with you. You’re not alone.” It was great to have a whole hour on TV with nothing but questions from the audience that I could address. At one point, Donahue started going off on something and then he stopped, looked at me, and said “Can you help me out here?” So I jumped in.  I figured, you’re going to help me, I’m going to help you. It was such a lovely relationship working with him. The questions from the audience were so real. There was one eight-month pregnant woman who asked about sex during pregnancy, “What can you do?” And I got to talk about oral sex and manual stimulation and all sorts of things on national television. So it was a great educational opportunity.
DB: On regular network television! Was anything bleeped?
LB: No nothing was bleeped at all, and a friend who had seen it called me up later to say, “I can't believe on national television you were talking about hand-jobs and blow-jobs.” Not with that language, but that's what happened. On Oprah, other guests get in the discussion and it goes in different directions so you don't get into the depth of coverage and aren’t able to educate the same way that I was able to with the Donahue show.
DB: I'm thinking of the cultural changes. In 1959 on the Jack Paar Tonight Show, they bleeped the word “pregnant!” And years later you get on television and are able to talk about hand-jobs and blow-jobs! 
LB: I have done maybe 20 book tours over the years, and I still remember that at one live local morning show in Seattle, I think, the interviewer asked me, “How do you have oral sex?” I asked her “Do you want me to describe it right now on the air?”  And she said “Yes, I think that would be educational for our viewers.” So I said,“Okay” and I explained how to have oral sex. I gave a “how to.” So that was the most startling for me. At another show the female host of the program introduced me as being responsible for her own first orgasm.
DB: Wonderful!
LB: Yes, it was very sweet.
DB: Is there a current book project that you're working on?
LB: I may have waited too long to actually put a book together, but I'm working a lot in the area of sex after 60.  Also, David [Geisinger] and I have a second book on relationships that we need to write, but haven’t had the time to get to. 
DB: Speaking in generalities, perhaps, is there one overall sense you have of what helps couples feel better about their sexuality?
LB: Self-acceptance and connection. First, you need to feel connected to your partner, to feel safe with them and cared for by them and turned on to them.  Second, the more compassion you have for yourself and the more self-acceptance, the more comfortable you are with yourself the more comfortable you are likely to be with your partner and the better your sexual relationship is likely to be. It all fits together. 
DB: Do you routinely get detailed sex histories from each person you work with?
LB: I get my own kind of sex history from a person. I don't get a formulaic one, because I think a lot of it's just not relevant. I follow my intuition, but almost always ask about the person’s first sexual experience, relevant previous sexual relationships and look for any kind of molestation or negative sexual experience or trauma. Trauma of any kind can affect a sexual relationship. I also want to know about the initial sexual experiences with their current partner. Absent a history of abuse, if the sex with this person was never good, if there was never any chemistry, I find it very difficult, if not impossible, to create it down the line.
DB: For couples therapy, do you do this sex history individually?
LB: Yes, I find it easier for people to open up completely when I meet with them alone and I may learn about other significant sexual experiences or problems within the current sexual relationship that the person might not be open about in the presence of their partner.

Buddhism and Other Influences

DB:  What aspects of Buddhist psychology and philosophy have you found helpful and intriguing?
LB: I would say that Buddhist philosophy makes sense to me. It’s fairly new to me as I've only been working in a meditation group for 3 years, so I don’t claim to be terribly knowledgeable. Certainly, the Buddhist concept of suffering has been useful in my practice; that we all have to endure suffering but that we actually create suffering through our attachment to impermanent things.  Meditation is very useful with a lot of my clients, especially those who are very reactive. So I teach my clients how to meditate and how to be more in the moment.  Also the importance of compassion for oneself and others. And the necessity of presuming your partner innocent before getting upset at them. I’m not sure this last one is specifically Buddhist in origin, but it seems that way to me. 
DB: How do you approach suggesting meditation techniques?
LB: I just say, “Try this,” then I give them a short hypnotic induction, and have them focus on their breath, especially that peaceful and spacious moment after the exhale and before the next inhale.  I explain how it can help them and work with them on incorporating it into their daily lives. I also find EMDR useful, especially with sexually abused clients
DB: You've also been interested in and studied NLP (Neuro Linguistic Programming).
LB: NLP works very well for me.  NLP and EMDR are both techniques, where as Buddhism is a philosophy and psychology.  I keep a whole store of Silly Bandz, which are these little colored rubber bands which come in different colors and shapes. I have clients put one on their wrist and use it to remind them to practice whatever we have been working on to help them stay aware of.  
DB: They don't have to snap it like the old behavioral aversive technique?
LB: No, it is just an awareness enhancement.  For example, maybe you say “yes” to the requests of others automatically; and since you may not even realize it, it can be hard to break that pattern. The Silly Bandz can help someone in between our sessions to stay conscious of what we are working on.
DB: Is there an overall sense you have of what helps people change in couples therapy?
LB: I believe we can start to move when we have compassion for ourselves, our defenses go down, we can relax, be more ourselves, and be more present in our relationship. Of course, there are also physical issues to stay aware of.  For example, since we've gotten Viagra, Cialis and Levitra, there are a lot fewer erection problems that I see. Sometimes men may have low testosterone and other medical or physical issues. And then we have relationship issues.
DB: No drug for that yet? 
LB: Not yet one for women.  Let’s end with a New Yorker cartoon I’ve seen: A couple is lying in bed, next to each other with their arms crossed. And the woman says, “I wish they would develop a pill for conversation.”
DB: I’ll trade you:  I saw a cartoon with a husband and wife where she has her arm around him, looking at him and she says, “I would agree with you Leroy, but that would make us both wrong.” Lonnie, thank you so much for allowing us to get a sense of what it is like to be doing the kind of work that you have done and are doing. 
LB: The pleasure was all mine.