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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.
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.
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
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
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
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.
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.
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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