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Working With Sexual Issues in Systemic Therapy Australian and New Zealand Journal of Family

Therapy / Volume 28 / Issue 04 / December 2007, pp 200-209

Desa Markovic
Desa Markovic is a systemic therapist and former assistant director at the Institute of Family Therapy
London.
This study investigates ways in which systemic psychotherapists address sexual issues. Qualitative
data were collected through semi-structured group and individual interviews and analysed using
discourse analysis. Particular attention was paid to participants accounts of the resources they draw on
and of perceived constraints when approaching the subject of sex. Main findings indicate that systemic
training and practice would benefit from greater inclusion of sexual issues to overcome current
deficiencies in the field.
Key Words: sexual issues, systemic therapy, Foucauldian, discourse analysis
My interest in this topic stemmed from my observation and concern that within systemic literature
and training there was an apparent gap in the area of sex and sexual relationships. This research aimed to
deconstruct ways in which systemic therapists have been addressing sexual issues and to gain
understanding of what helps and what hinders them in doing so. I have deliberately used a nonspecific
phrase sexual issues to allow the participants own meaning to emerge.

Literature Review
The Place of Sexual Issues in the Systemic Literature: An Overview
Since the 1950s a significant body of texts have shaped the systemic/family therapy field, without
mention of the subject of sex or sexual relationships. In contrast, the Handbook of Family Therapy
(Gurman & Kniskern, 1981; 1991) includes contributions from psychologists, family therapists and
sexologists who provided an historical explanation for the split between couple therapy and sex therapy,
and argued for reintegration and overcoming theoretical, practical and organisational fragmentation of
these separated fields. Reintegration was also proposed by Sanders (1988), Weeks and Hof (1987), and
Kantor and Okun (1989), who created models for treating sexual concerns, encompassing systemic and
sex therapy frameworks.
Most of the literature on couples listed on family therapy courses does not include sexual
relationships. Papp (in Walters et al., 1988) noted that sex was, like money, considered a peripheral issue
(p. 217). Byng-Hall (2000) argued couple and sex therapy are divorced from family therapy.
The subject of sex is markedly absent from the literature on systemic training and supervision.
Dissertations by family therapy trainees confirm this (Kavanagh, 1997; Wynn, 2001). Gorell Barnes et al.
(2000) advocate the benefits of a proactive approach to discussing sex and sexuality in supervision.

Sexual Issues in Different Family Therapy Schools: A Historical Perspective


Ackerman (1958) and Skynner (1976), from psychodynamic family therapy, regarded exploring
sexuality as fundamental to therapeutic work with individuals, couples and families. Within the
transgenerational approach, Lieberman (1979) argued family therapists should be skilled in working with
sexual dysfunction. Sexual Genogram (Hof & Berman, cited in Kantor & Okun, 1989) provides a tool to
explore intergenerational stories of sexuality. From the communicational approach perspective, Satir
(1972) held that parental accord and validation were the key to a healthy development of sexual identity.
Within the structural, strategic, Milan and solution-focused schools, sex and sexual relationships have
been regarded as content issues, therefore of secondary importance. From a constructivist framework,
Zumaya et al. (1999) critiqued the supremacy of normative paradigms and an emphasis on functioning in
sex therapy, while feminist perspectives highlighted gender imbalance as most likely to be acted out in
the domain of sex. Hare-Mustin (1994) and Dallos and Dallos (1997), from a social constructionist
perspective, researched discourses on sexuality that disguise gender inequality. McGoldrick et al. (1996)
and Carter and McGoldrick (1999) offered comprehensive descriptions of the views on sexual practices
and expression of a variety of ethnic groups.
A broader history of therapeutic approaches to sexuality seems repeated in the systemic literature in
that the most influential discourses about sex are still individualistic and scientific. Foucault (1978)
argued that in the 20 th century one of the most dominant discourses on sexuality has been that of
science. This was reflected in the dominance of behavioural interventions and medicalisation of sexual
concerns.

Method
The study investigated the following research questions:
1. What are systemic therapists_ ways of working with sexual issues?
2. What resources do systemic therapists draw on when working with sexual issues?
3. What constraints do systemic therapists experience / construe in working with sex?
I chose qualitative methodology, using semistructured interviews, as coherent with the aims of the
study to gain a deeper understanding and develop a context-rich description of the researched subject.
Social constructionism (Pearce, 1994) informed the theoretical framework, allowing for multiplicity of
meanings in the communication with participants. Ten white British male and female systemic therapists
from diverse cultural heritages were interviewed, five in a group and five individually. Their post-
qualifying clinical experience ranged from 10 to 25 years. Some also had experience as systemic trainers,
supervisors and managers.

Interviews
The main reasons for deciding on the group interview format were to enable discussion and possible
debate, and allow access to social processes through which the meaning of the experience is constructed
and reconstructed (Farquhar & Das, cited in Barbour & Kitzinger, 1999). A frequent restraint of group
interview, the phenomenon that personal narratives are less likely to emerge in groups, was compensated
by the one-to-one interviewing, which provided opportunities for more individualised and detailed
accounts.

Research Methodology: Rationale for Discourse Analysis


Discourse analysis seemed the most appropriate research method, being concerned with the social and
cultural assumptions people are drawing on in their thinking and practice. This method is also coherent
with the research aims to explore what resources therapists perceived as available; how they used them
and what constraints they construed for working with sexual issues. Analysing discourse can be
described as searching for patterns that connect (Bateson, 1972) and form larger discourses that become
part of common sense (Foucault, 1980). While acknowledging there are many ways to describe what a
discourse is, I chose to define it as a socially constructed network of meanings that shape peoples
aspirations, beliefs and practice. Discourse analysis requires that discourses and their effects be
understood within the contexts in which they arise. For the purposes of my research, this meant
appreciating the societal, cultural, and professional discourses people are drawing on in their accounts,
originating from their families, religious and cultural upbringing, education and other networks of
conversations. Foucauldian discourse analysis (Willig, 2003) was chosen, as it is concerned with the
role of discourse in social processes of legitimation and power and draws attention to the power of
discourse to construct moral stance and practice and to legitimise and justify certain forms of behaviour.

Analytic Procedure
Interviews were audio recorded and transcribed. Throughout the project I was aware of bringing a set
of personal and professional stories to the research. This alerted me to my responsibility to reflect on my
biases and question my involvement at each stage, particularly my investment in the subject, so I kept a
diary in which to reflect on my own values, assumptions, and the relationship with participants (Potter &
Wetherell, 1987). It served as a reminder of my hopes, expectations, frustrations, surprises and
disappointments, and assisted me in monitoring them while making sense of the data.
There is variety in the process of undertaking discourse analysis; Parker (1992) proposes 20 stages;
Kendall and Wickham (1999) rely on fewer steps while Potter and Wetherell (1987) suggest the use of a
more flowing methodological approach. I chose Willigs (2003) six stages model of Foucauldian
discourse analysis as a guideline for exploring various aspects of the research material, rather than as a
stage-by-stage procedure. It provided me with the clarity of the analytic process and allowed me to map
some of the discursive resources named in the participants accounts and examine their implications.
At the first step, Discursive Constructions, I identified the different ways systemic therapists work
with sexual issues. The range of clustered discursive constructions is presented in table format below.
The stage called discourses located the participants discursive constructions within wider discourses
surrounding the topic of sexual issues such as a spectrum of personal and professional resources and
constraints. Action Orientation involved closer examination of the moral order guiding the participants
accounts. Positioning suggests that discourses offer subject positions in terms of the participants_ rights
and duties from which to speak and act. For example, the analysis of the research material in this study
discussed the therapists construction of their roles and responsibilities in relation to talking about sex in
therapy. The practice stage explored the relationship between discourse and practice, and subjectivity
traced the consequences of taking up various subject positions for the participants feelings, thoughts and
experiences.

TABLE 1
Question 1: What are the Systemic Therapists_ Ways of Working With Sexual Issues?
Ways of working with sex Discursive constructions
Importance of discussing sex Group interview
with clients Sex is a very important subject

Sexuality is part of everyday life of adults and children

Sex is part of being human


Individual interviews
Sex is an important and a difficult subject to discuss, like death
and money
Sex is an integral part of the relationship

Sexual issues can underlie what is talked about in therapy

Sex should not be divorced from other relationship aspects

Therapy is a safe and respectful place to talk about sex

Frequency of discussing sex with Group interview


clients Sex is not discussed enough with individuals

Sex is almost never discussed in therapy

Pushing the subject of sex in therapy can be damaging


Individual interviews
Sex is not that often discussed in therapy
Sex is more likely to be discussed with individuals than
couples
Sex is discussed very rarely with individuals
It is easier to talk about sex with couples, as you have both
sides of the story
Sex should not be discussed when working with families and
children
Self-description of therapeutic Group interview
styles of addressing sex with The subject is approached at arms length
clients Sex should not be discussed unless it was a key issue brought
by clients
Individual interviews
The subject is approached in: circumspect, remote, roundabout,
over cautious ways
Therapists should be led by what clients want to talk about
Sexual issues should be regularly checked for health and safety
reasons
Techniques applied Group and Individual Interviews
Helpful systemic techniques in addressing sex are: questions,
tasks, strategies, suggestions, normalising, metaphor.

Data Analysis
Data from group and individual interviews are presented together within the tables, summarising the
material obtained via two methods of data collection in the form of discursive constructions.
Question 1 explored the ways in which systemic therapists described working with sex, including
frequency and use of systemic techniques. Therapists_ ideas on the importance of discussing sex with
clients were explored, to enhance understanding of their attitude to this subject. What emerged confirmed
the importance that therapists attributed to the subject of sex; however, reported frequency of discussing
it with clients did not match the acknowledged importance, as the table below shows.
Within Question 2 participants named a spectrum of resources constructed as helping them address
sexual issues. Most of those, however, were suggested as being underused.

TABLE 2
Question 2: What Resources do Systemic Therapists Draw on Working With Sex?
Resources Discursive constructions
Therapists personal Group interview
experience/age Therapists life experience helps in working with sex
Being old makes it easier to talk about sex with clients of
different ages
Individual interviews
Therapists comfort with own sexual experience enables
talking about sex in therapy
Open partner conversations about sex enable therapists to talk
about sex with clients
Therapists personal difficulty with talking about sex helps their
understanding of clients difficulty
Clinical experience Group and individual interviews
Clinical experience helps therapists in working with sex

Working context Individual interview


Specialised clinical contexts impose the necessity to address
sexual issues, for example, working with sexually transmitted
diseases
Systemic perspective Individual interviews
Systemic perspective is a limited resource for working with
sex
Helpful systemic ideas in addressing sex are self awareness,
neutrality and circularity in relationships
Systemic techniques Group and individual interviews
Systemic questions are the most helpful therapeutic techniques
when working with sex
Drawing on other approaches Individual interviews
Systemic ideas are insufficient; psychoanalytic understanding
and the knowledge about child development are necessary for
working with sex
Therapists use of self Individual interviews
Gender similarity facilitates talking about sex

This research interview Group and individual interviews


Talking about this subject raises awareness of therapists
responsibility to address it
Changing social realities Individual interviews
Change in social prejudices enables thinking about sexuality in
a more inclusive way
Workshops and further training Individual interviews
Post-qualifying training courses can help thinking about the
subject
Learning from difficult past Individual interviews
experience In order to be able to work with sexual issues ethically, one
needs to learn how to manage personal/professional boundaries
effectively
Therapists professional skills Individual interviews
Necessary therapeutic skills to work with sex are: ability to be
playfully provocative; nonjudgmental; form a trusting
therapeutic relationship
Observing other therapists Group and individual interviews
Observing more experienced colleagues working with sensitive
issues is a necessary learning tool

In Question 3 a wide range of constraints was constructed. Hypothetical situations introduced by


therapists indicated anticipation of undesired consequences if discussing sex in therapy. Participants
unanimously agreed on certain constraints, such as lack of systemic training and literature, therapists
personal barriers, and the lack of therapists expertise in the area of sexual relationships. In relation to
other factors, the contradictory discourses emerged; for example, some regarded cultural practices as a
constraint, while others expressed views that cultural norms helpfully determine the appropriateness of
raising the subject with clients. An interesting debate evolved in the group discussion as to whether the
working context was limiting or supporting therapeutic practice.

Discussion
Group and Individual Interviews: Comparison
Group and individual interviews results are discussed together as they largely overlapped; differences
were mainly at process level the group interview contained more challenge, debate and diversity of
views juxtaposed, while individual interviews involved further personal processing, thinking time and
detailed deconstruction of clinical episodes. Personal constraints were shared more in individual
interviews. Individually, therapists related confessional narratives about their family background,
parental messages and cultural upbringing, and the impact of those throughout their personal and
professional lives. On the one hand, the dynamic quality of group interaction provided a range of
different perspectives, contributing to the richness of the material. Participants confirmed they found the
discussion thought provoking. Three group members subsequently reported the group discussion having
enabled them to initiate conversations about sex more directly and confidently. Thus group discussion
demonstrated possibilities for negotiating new forms of public knowledge (Farquhar & Das, 1999). On
the other hand, I observed how the group process reflected ways in which talk about sex is regulated in
Western society where sex is a taboo, and highlighted ways in which deviant experiences are silenced or
incorporated in the existing views and practices. The group process that emerged demonstrated the
contested nature of sexual issues, by the strength with which some views are held, and the ways in which
those are rationalised and defended.

TABLE 3
Question 3: What Constraints do Systemic Therapists Experience/Construe for Working With Sexual
Issues?
Constraints Discursive constructions
Therapists personal barriers Group interview
Talking about sex causes discomfort
Lack of conversations about sex in therapists personal lives
makes it difficult to address the subject in therapy
Therapists personal curiosity about clients sexuality can
present ethical professional dilemmas
Therapists lack of confidence prevents dealing with sex
Individual interviews
Therapists personal inhibitions, embarrassment and reticence
prevent them from approaching the subject of sex
Therapists religious, cultural, class, and familial context of
upbringing constrain them from working with sexual issues
Therapists lack of comfort with own sexual experiences is a
constraint to discuss sex in therapy
Risks to the therapeutic Group interview
relationship The subject of sex is titillating
Discussing sex in therapy would make a therapist become a
voyeur
Individual interviews
Discussing sex with couples will lead to seeing therapist as
seduced by the opposite gender partner
Talking about sex in therapy is likely to be offensive and intrusive
Lack of personal therapy Group and individual interviews
Lack of personal therapy renders therapists vulnerable to
approach a sensitive subject like sex
Therapists current life stage Individual interviews
Being a parent of teenage children makes a therapist vulnerable
to discussing sex

Therapists professional Group interview


insecurity High severity of the sexual problem is a counter indication for
systemic work
Individual interviews
Discussing sex in therapy can make it more difficult to manage
boundaries between intimacy and working relationship
Working with sex requires knowledge and skills which systemic
therapists are lacking
Therapists construction of their Group interview
professional role Sex is an area of expertise of individual psychotherapy

Therapists protect clients privacy by not discussing sex


Individual interviews
Therapists should not dig in the area beyond their professional
expertise
Systemic therapists should not act as if they are sex therapists
Therapists might get bad reputation if they get overboard mentioning
sex
Lack of systemic literature Group and individual interviews
There is no systemic literature on sex
There is lack of evidence based research to prove positive outcomes
Insufficiencies in systemic Group and individual interviews
training Systemic training is deficient in providing an input on the
subject of sex
Cultural practices Group and individual interviews
The absence of the subject of sex from clinical practice is
mirroring social conversations
Ways of sexuality being treated Group and individual interviews
in the wider culture Societal double standards are preventing therapists dealing
with sexual issues effectively
Societal narrow views such as seeing sex as separate, distinct
and belonging to adults only, limits therapeutic practices
Therapists should respect clients_ cultural norms and, within that,
what is OK/not OK to talk about in public
Context of work Group and individual interviews
Finance driven agency policies and the power of money and
hierarchy determine the therapists role
Adult mental health labels desexualise a person and create an
unhelpful split between sexual and mental health difficulties
The subject of sex does not fit with working with children and
families
Lack of professional support Group and individual interviews
There is no forum for systemic therapists to discuss working
with sex, during or post training
Lack of sense of positive reasons Individual interviews
Therapists are not convinced about the positive outcomes of
addressing sex
Legal risks/child protection Individual interviews
For therapists own legal protection it is safer not to discuss sex
with children
Theoretical constraints Individual interviews
There is no coherent systemic theory on sexual development
and sexual relationships
The nature of sexuality Individual interviews
The subject of sex is exposing, complicated, confusing and
risky and is bound to make therapist feel vulnerable
The nature of couple work Individual interviews
It can be complicated to decide whether to talk about the
couples intimate relationship if one person wants to and the
other does not
Therapists public image Individual interviews
Public expectations put therapists under pressure to prove
successful treatment so they avoid the subject of sex as too
risky

Research Questions Discussion Using Foucauldian Analysis


How Systemic Therapists Work With Sexual Issues in Clinical Practice
Data analysis revealed ways in which discursive constructions and therapists_ positioning within
them open up or close down opportunities for action (Practice). Sexual issues were constructed as very
important; however, the resulting infrequency of such discussions in practice is overridden by a powerful
discourse that sex is a difficult subject. In the context of constructing conversations about sex as
dangerous, inappropriate, titillating, self exposing, and unsafe, therapists positioned themselves
(Subject positioning) as experiencing inhibition, reticence, and anxiety (Subjectivity). In addition, it
could be argued the contradictory discourses from the interviews (Figure 1) create dilemmas and
uncertainties regarding the subject, which then contributes to it being treated with avoidance and
apprehension (Action orientation).
The above dominant discourse (Sex is a difficult/inappropriate subject to discuss) and the subject
positions contained within it, located therapists within the structure of rights, duties and responsibilities
from which to speak and act (Action orientation). Discursive constructions about the inappropriateness
of discussing sex in therapy became bound up with a cultural discourse which constructs talking about
sex as offensive, intrusive, and incompatible with cultural respect (Discourse). These discourses then
formed a legitimate basis for making decisions about not addressing it in clinical practice (Practice).
Constructions of therapists role and therapeutic relationship as protecting privacy, following the
clients lead and respecting the clients cultural context allow therapists to justify and continue existing
practice. Foucauldian discourse analysis thus demonstrated the power of discourses to facilitate and
limit, enable and constrain what can be said, by whom, where and when (Parker, 1992).

Resources That Systemic Therapists Draw on When Working With Sexual Issues
A range of personal and professional resources was constructed (Discursive constructions), from
therapists personal background and life experience to the clinical experience and learning from
colleagues (Discourses). However, these were frequently described as being underused in systemic
practice (Practice). The study material pointed to strong views about a lack of resources and support
systems, from systemic therapy training through to post-qualifying levels. Within the research data,
therapists seemed unaware of a useful and informative, albeit modest, systemic writings on sexual issues.
This can be understood in the context of the reported lack of support, through which the existing
literature could be made available. Equally, systemic ideas and techniques were constructed as limited
resources in the reported absence of opportunities to discuss applying them to the area of sexuality.
FIGURE 1 Discourses on ways of working with sex in systemic therapy.
FIGURE 2 Constraints that systemic therapists experience/construe for themselves in dealing with
sexual issues.

Constraints that Systemic Therapists Experience/Construe in Working With Sexual Issues


Figure 2 shows numerous constraints; some were depicted as unhelpfully limiting clinical practice,
others as justifiable reasons not to address sex. Conversely, no participant reported any negative
experiences from discussing sex with clients; moreover, when discussed, the results were described as
therapeutically beneficial. Thus, the numerous hypothetical obstacles introduced by therapists far
outweighed the stated resources.
The therapists self as a constraint dominated the data directly, through their admission of lack of
confidence and personal inhibitions, and indirectly, through apprehension, justifications for not
addressing sex and by presenting numerous hypothetical scenarios where addressing it would damage the
therapeutic relationship. Figure 3 shows contextual influences from therapists past and present lives that
constrained them.

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

FIGURE 3 Therapists self as a constraint to working with sex.


Discourse analysis showed how therapists anxieties about sex talk reflect some of the tensions and
ambiguities in the wider systems, located particularly within child protection and legal discourses,
exacerbated by the new legislation regarding sexual abuse of children. These attitudes contradict
systemic discourses defining the tasks of therapy as opening up conversations, bringing the unsaid into
focus and encouraging active exploratory curiosity. Therapists seem to be drawn into a double bind
(Bateson, 1972) whereby they are set up to fulfill an impossible task, to be all inclusive and yet left with
no guidance as to how to perform it. In addition, therapists are caught in the contemporary postmodern
world with its radically pluralistic, radically changing structures and values (OHara and Anderson,
1991), which brings new uncertainties and dilemmas and opens up layers of anxieties in personal and
professional relationships. In this climate, professionals may feel they could be thought of as abusive or
harassing others by discussing sexual matters.
Findings indicate a need for systemic training institutions to enable future therapists to develop
confidence, knowledge and skills in this area, covering both all training levels and post-qualifying
practice. Given the delicate and sensitive nature of the subject, systemic training courses have the
responsibility to encourage a self-reflexive approach to sexual issues.
Data analysis also confirmed the potential for systemic conversations to promote new thinking and
practice in the area of sexual relationships. It showed systemic therapists place a significant value on
systemic conversations about sexual issues. In research interviews alternative constructions began to
emerge, such as counter-discourses, that it is anti-systemic to separate sex out; that sex should be
integrated in individual, couple and family work; that adult mental health labels desexualise a person and
that cultural norms are constraining therapists in addressing sex. The study also demonstrated systemic
therapists would welcome more opportunities to share ideas and learn to include this area as a topic
integral to their practice.
This research experience reminded me of the provocativeness of the subject; the vulnerabilities it can
trigger; judgments and prejudices it can spark off, and the pervasiveness of deeply embedded inhibitions
and anxieties with regards to topic of sex. At this point the research has further consolidated my
impression that systemic resources are undervalued and underused in addressing sexual issues and at the
same time of the great potential of systemic conversations in this area. Further research could bring more
valuable insight into this area, employing different methods, and might also include clients views.

Acknowledgments
I would like to thank all the participants in the study and to Teresa Wilson for her helpful reading of
the final draft.

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