Sexual Attraction in Therapy E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 496

Veröffentlichungsjahr: 2013

Beschreibung

Sexual Attraction in Therapy presents new findings from multiple perspectives into the complex phenomenon of sexual attraction in therapy. Detailed clinical examples and strategies from expert contributors demonstrate how therapists can engage with sexual attraction, when it arises, in positive ways that facilitate client progress and ensure appropriate professional conduct. 

• Challenges practitioners to think about sexual attraction as a normal dynamic developing through the unique intimacy of the therapy encounter
• Presents new findings from research to enrich understanding of the lived experience of therapists and how they confront, avoid, make use of the process of sexual attraction
• Provides clinical examples to highlight common challenges faced by practitioners, the strategies they use to overcome them and how they normalize the ‘taboo’ of sexual attraction to make positive use of it in therapy
• Makes an important contribution to current literature on professional practice, an area of increasing importance as more emphasis is placed on issues of ethics, ongoing supervision and appropriate professional conduct
• Expert contributors include Doris McIlwain, Michael Worrell, John Sommers-Flanagan and Martin Milton

Leseprobe

Table of Contents

Title page

Copyright page

Dedication

Notes on Contributors

Acknowledgements

Editorial Introduction: An Encounter with Erotic Desire in Therapy

An Entry from My Therapeutic Diary

Part I: Relational Perspectives on Sexual Attraction in Therapy

1: ‘Hot Cognition in Sexual Attraction’: Clarifying, Using and Defusing the Dionysian in Cognitive Behavioural Psychotherapies

What Is CBT?

Brief Encounters: Does Sexual Attraction Show Up in CBT?

Developments in CBT: Integration and Expansion

Computer Love

Existential Insight on Sexuality

‘Emotion Schemas’ and Responding Flexibly or Inflexibly to Sexual Attraction in Therapy

CBT Training, Supervision and the ‘Person of the Therapist’

Clinical Strategies for the Management of Sexual Attraction in Therapy

2: Sexual Attraction in the Therapeutic Relationship: An Integrative Perspective

The Working Alliance

The Transferential Relationship

The Reparative or Developmentally Needed Relationship

The Person-to-Person or Real Relationship

The Transpersonal Relationship

Conclusion

3: Existential Psychotherapy and Sexual Attraction: Meaning and Authenticity in the Therapeutic Encounter

Theoretical Framework

Considerations of Technique/Clinical Approach

Discussion

Strategies for Working with Sexual Attraction

Existential Strategies for Managing Sexual Attraction

Conclusion

4: Knowing but Not Showing: Achieving Reflective Encounter with Desire – A Relational Psychoanalytic Perspective

Desire in the Therapy Room

Recognizing the Relevance of Sexual Desire to Psychotherapy

Desire Doesn't Happen to Good Therapists

Shame

Allowing Desire to Form

The Sublimation of Facework: Knowing but Not Showing

Handling Desire in the Moment: Being Prepared to Be Found Wanting

Clinical Strategies

5: The Role of Psychological Proximity and Sexual Feelings in Negotiating Relatedness in the Consulting Room: A Phenomenological Perspective

Introduction

Theoretical Framework

Considerations of Clinical Approach

Discussion

Strategies for Working with Sexual Attraction

Conclusion

6: An Acceptance Commitment Therapy Approach to Sexual Attraction

Introduction

What Is ACT?

Accepting What Can't Be Controlled

Committing to Values-Congruent Action

The Importance of Words and Thoughts in ACT

Sexual Fantasy and ACT

The ACT Model of Psychopathology

Getting Unstuck

Clinical Strategy for Managing Sexual Attraction

7: Addressing Sexual Attraction in Supervision

Sexual Attraction in the Supervisee–Client Relationship

Strategies for Training and Supervision

Training

Supervision

Considerations within the Supervisory Relationship

Role Induction and Establishing Norms

Facilitating Supervisee Disclosure and the Art of Broaching

Conceptual Framework

Case Example: Therapist Discomfort and Sexual Attraction

Parallel Process and Concluding Comments

8: Sexual Attraction in Conjoint Couple Therapy

Lack of Training

Self of the Therapist Issues

More Difficult because the Partner Is There Too

Ambiguous Presentation

How Attraction Can Happen in Conjoint Therapy

Too Hot to Handle

How to Handle Sexual Attraction in Conjoint Therapy

Conclusion

9: Bound to the Mast: Reflections on Analytic Abstinence

10: Why Can't We Be Lovers? The Love-Obsessed Clients Who Stalk Their Therapist

A Dashing Therapist

Intimacy Stalkers

Conclusions

Part II: Research-Informed Theoretical and Clinical Perspectives on Sexual Attraction in Therapy

11: Skilled Handling of Sexual Attraction in Therapy: A Grounded Theory of What Makes the Difference

Arriving at Theory

Vulnerability to Attraction? The Psychotherapist's Characteristics

Appraisal of the Sexual Attraction and Its Manageability

Handling the Sexual Attraction: Evaluating Options

Therapeutic Use of the Sexual Attraction

Guidance Seeking

Privileging the Sexual Attraction: Seeking Personal Rather Than Therapeutic Benefit

Discontinuation of Psychotherapy

Implementation and Consequences

Clinical Strategies to Manage Sexual Attraction

Optimal Supervision and Training Conditions

12: The Self-Preservation Society: A Discourse Analysis of Male Heterosexual Therapists and Discourses of Sexual Attraction

The Context

How Therapists Manage Sexual Attraction: Using Discourses of Masculinity

Concluding Thoughts

13: An Elephant in the Room: A Grounded Theory of Experienced Psychotherapists' Reactions and Attitudes to Sexual Attraction

Methodology

Findings

Clinical Strategies in Handling Sexual Attraction

Concluding Thoughts

14: Therapists' Disclosures of Their Sexual Feelings to Their Clients: The Importance of Honesty – An Interpretative Phenomenological Approach

Sexual Feelings

Self-Disclosure

The Study

Findings

Discussion

Strategies to Manage Sexual Feelings

Conclusion

15: Systemic Family Therapists' Narratives on Sexual Attraction in Their Clinical Practice: A Narrative Analysis

Introduction

Research Method

Discursive Themes: A Spectrum

Sexual Attraction Does Not Occur in Systemic Therapy

Attraction in Therapy Is Not Sexual and Forms Part of Therapy

Internal Management of Sexual Attraction Is Sometimes the Best Option

Sexual Attraction Can Positively Contribute to Therapy

Sexual Attraction in Therapy Is an Indication of a Problem

Movement in Boundaries Should Be Ethics Led

Plentiful Resources within the Systemic Approach Are Underused

Discussion

Clinical Strategies in Working Systemically with Sexual Attraction

Epilogue

Index

This edition first published 2014

© 2014 John Wiley & Sons, Ltd.

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Library of Congress Cataloging-in-Publication Data

Sexual attraction in therapy : clinical perspectives on moving beyond the taboo : a guide for training and practice / edited by Maria Luca.

pages cm

Includes bibliographical references and index.

ISBN 978-1-118-67434-5 (cloth) – ISBN 978-1-118-67433-8 (pbk.) 1. Psychotherapy–Practice. 2. Clinical psychologists–Training of 3. Psychotherapists–Sexual behavior. 4. Psychotherapist and patient. I. Luca, Maria, 1956– editor of compilation.

RC465.5.S48 2014

616.89'14–dc23

2013036259

A catalogue record for this book is available from the British Library.

Cover image: Kazimir Severinovich Malevich, Torso, 1928-32, oil on canvas (detail). State Russian Museum, St. Petersburg, Russia / The Bridgeman Art Library.

Cover design by Simon Levy Associates

Dedication

To Stefanos, Andreas, Marianna and Maria

Notes on Contributors

Anthony Arcuri, DPsy, is a Counselling and Clinical Psychologist who has completed Doctoral studies in Counselling Psychology and has practised psychotherapy, conducted research and taught across various settings. He currently operates a private practice in Sydney, Australia.

Michael D. Berry is a PhD candidate and counselling trainee, working in the Department of Clinical, Educational and Health Psychology at University College London. His work examines the use of dynamic psychotherapies in treating sexual and relationship issues, and appears in sex therapy journals, psychology journals and psychoanalytic publications. His research is supported by a grant from the American Psychoanalytic Association.

Richard Blonna, EdD, is a university professor with over 30 years of experience teaching human sexuality. He is a Board Certified Coach (BCC), Counselor (NCC) and Health Education Specialist (CHES) and the author of the best-selling college textbook, Blonna, R., & Cook-Carter, L. (2013). Healthy sexuality (2nd ed.). Dubuque, IA: Kendall-Hunt Publishers. His groundbreaking new book, Blonna, R. (2012). SEX-ACT: Unleash the power of your sexual mind with acceptance and commitment therapy. Charleston, SC: CreateSpace Publishers, is the only book devoted entirely to applying acceptance commitment therapy (ACT) to improving one's sex life.

Mark Boyden, MBA, Dip (Marketing), MA (Psychotherapy), MBACP & UKCP Accredited Psychotherapist. He completed his MBA at Oxford Brookes, and the advanced management programme from Templeton College at Oxford University. He followed a series of psychotherapy trainings, including cognitive analytic therapy (CAT), and worked as a psychotherapist at Guys Hospital for 3 years. His clinical experience includes work with teenagers and young adults and psychotherapy through new media. Prior to training in psychotherapy, he ran complex departments in both private and voluntary organizations as well as two businesses. He is an Associate Member of the Institute of Management Consultants. Mark spent 7 years in France working for the Aga Khan Development Network. He maintains a private practice based at various London locations and in Dorset.

Malcolm Cross, PhD, was formally Dean of Students and a Reader in Psychology at City University London. He was elected Chair of the Division of Counselling Psychology of the British Psychological Society (BPS) Division in 2007–2009. He has worked as a senior manager in the higher education and not-for-profit sectors and served in a voluntary capacity on a range of BPS committees over the past decade. He is also a council member of the Health Professions Council. He has authored and edited three books and numerous chapters and peer-reviewed publications. He is regular contributor to print and broadcast media in the area of gender and masculinity.

Steven M. Harris, PhD, LMFT, is Director of the Couple and Family Therapy Programme at the University of Minnesota. He has also been practising as a marriage and family therapist for over 23 years. He has conducted research and presented on the topic of sexual attraction in therapy throughout his career. One focus of his research agenda is on the ethical delivery of mental health services with particular attention to the dynamics of sexual attraction.

Maria Luca, PhD, is Reader in Psychotherapy and Counselling Psychology and the Head of the Reflections Research Centre at Regent's University London. She teaches modules on sexual dynamics in therapy, assessment and formulation, and grounded theory. She has extensive clinical experience as a psychotherapist in the British National Health Service and has a small private practice in London. Maria gained her PhD from the University of Kent at Canterbury and is a registered psychotherapist with the United Kingdom Council for Psychotherapy and an accredited supervisor with the British Association for Counselling & Psychotherapy. She is editor of the book The therapeutic frame in the clinical context – Integrative perspectives. (2004). London: Brunner-Routledge, and author of book chapters and articles in journals. Among other publications on the subject, she is author of (2003) ‘Containment of the Sexualized and Erotized Transference’, Journal of Clinical Psychoanalysis, Vol. 11 No. 4.

Desa Markovic, DPsy, is Programme Director of the Masters in Psychotherapy & Counselling, Regent's University, London. She is a systemic Family Therapist, supervisor and trainer for over 20 years in the United Kingdom; she also qualified as a psychosexual therapist. She has written and published, taught, presented and practised clinically in the context of integrating systemic and sex therapy and has created a model of integration of systemic and sex therapy developed through many years of working with clients presenting a wide range of sexual issues. Some of her more recent articles on the subject were published in the Australian and New Zealand Journal of Family Therapy and Sexual and Relationship Therapy Journal.

Anna Marshall, DPsy, is a counselling psychologist registered with the health professions council. Anna gained her BSc (Hons) in Psychology from Royal Holloway, University of London, her MSc in Health Psy­chology from City University, London, and her PsychD in Counselling Psychology from the University of Surrey.

Doris McIlwain, PhD, is Associate Professor in Psychology at Macquarie University, Australia, teaching personality and philosophy of psychoanalysis, supervising many postgraduate students and clinical interns alike. Researching emotion and personality, she profiles narcissism, Machiavellianism and psychopathy in terms of affective personality dispositions. She is interested in self-reflective awareness of the bodily broadcast and pursues this new interest exploring colonizing the body via participant observation and experimental research into the practice of yoga. An enduring interest is in charismatic leader–follower relations, and she has a book on that subject and an encyclopedia article in press. She has published in psychology and philosophy journals as well as literary journals like Meanjin and Artlink. She does yoga, throws pots, loves poetry and has a small private practice.

Martin Milton, DPsych, CPsychol, CSci, AFBPsS, UKCP Reg, is Director of Counselling Psychology programmes at Regents University London. He also runs an independent practice in psychotherapy and supervision. He is a counselling psychologist chartered with the BPS, a BPS registered psychologist specializing in psychotherapy and a UKCP registered psychotherapist. Martin gained his BA from the University of Natal (Durban), his BA (Hons) from the University of South Africa, his MA (Antioch) from the School of Psychotherapy and Counselling Psychology at Regents College and his DPsych from City University (London). He is author of several articles, chapters and books.

Kirsten W. Murray, PhD, is an associate professor in The Department of Counsellor Education at The University of Montana. Her interests include supervisory practices and sexuality competencies for counsellor training. She has taught graduate-level courses in subjects of supervi­­sion and sexuality for counselors and has been a clinical supervisor since 2002.

John Nuttall, PhD, is Head of the School Psychotherapy and Psychology at Regent's University London and also lectures at the University of Greenwich. He is an honorary psychotherapist and Chair of West London Centre for Counselling, and is a UKCP and BACP accredited psychotherapist, a Certified Management Consultant, and Chartered Marketer. He has written widely on management and psychotherapy and his PhD focused on the process of personal psychotherapy integration. His special interests include psychotherapy integration, organization theory and the provision of psychotherapy in the community.

John Penny, DPsych, is a chartered psychologist. Following a successful career in teaching and educational management, and having achieved his Chartership as a Counselling Psychologist, John worked in the prison service and in the British National Health Service before establishing a successful private practice. He now divides his time between psychotherapy, psychological assessments, supervision work and writing.

Andrea Sabbadini, C. Psychol., is a Fellow of the British Psychoanalytical Society, its former Honorary Secretary and its current Director of Publications. He works in private practice in London. A former director of the Arbours Training Programme in Psychotherapy, he also taught at Regent's University London for 20 years. He is currently a Senior Lecturer at University College London, a trustee of the Freud Museum, a member of the IPA Committee on Psychoanalysis and Culture, the director of the European Psychoanalytic Film Festival and the chairman of a programme of films and discussions at the Institute of Contemporary Arts (ICA). He was the founder editor of Psychoanalysis and History and is currently the Film Section editor of The International Journal of Psychoanalysis. He has published in the major psychoanalytic journals, and has edited Il tempo in psicoanalisi (1979), Even Paranoids Have Enemies (1998), The Couch and the Silver Screen (2003), Projected Shadows (2007) and Psychoanalytic Visions of Cinema (2007).

Paul Smith-Pickard, DPsych, is an existential psychotherapist in private practice. He is a former chair of the society for existential analysis. His interest in embodiment, sexuality, addiction and radical approaches to therapeutic practice are reflected in various book chapters, journal articles and conference papers he has written and delivered. He spends his time between his home in Dorset and his home in Greece, where he is a visiting lecturer in existential thought and practice at Gignesthai in Athens.

John Sommers-Flanagan, PhD, is Professor at the Department of Coun­sellor Education at the University of Montana. He is a Psychologist, Counsellor Educator, author of ‘How to Listen So Parents Will Talk’, ‘Clinical Interviewing’ and ‘Tough Kids and Cool Counselling’.

Juliet Soskice, MA, graduated from Oxford University and worked in advertising and the civil service before training at the School of Psychotherapy and Psychology. She now has a psychotherapy practice in central London.

Tina M. Timm, PhD, is an associate professor in the School of Social Work at Michigan State University. Licensed as both a marriage and family therapist and a clinical social worker, she has spent her 20-year career focusing on clinical issues related to sexuality. Her training as a sex therapist provides a unique perspective on sexual attraction in conjoint therapy.

Michael Worrell, PhD, is Programme Director and Consultant Clinical Psychologist, Royal Holloway University of London & Central and North West London Foundation NHS Trust, Postgraduate Training Programmes in Cognitive Behavioural Therapy; responsible for overall management, Academic and Clinical Standards across the full range of Postgraduate Programmes including the Postgraduate Diploma/MSc in CBT, The IAPT High Intensity training programme and the Development of Post Graduate Certificate courses in CBT Supervision Skills. Both diploma programmes are Level 2 Accredited programmes with the British Association for Behavioural and Cognitive Psychotherapies (BABCP). He is author of several articles and chapters.

Acknowledgements

All anthologies are collaborative enterprises, including this one. All contributors have worked diligently to make this project viable, and I feel incredibly fortunate to have worked with such erudite scholars. My deep thanks go to my family, friends and colleagues for supporting my work on this volume. I would like to say a special thank you to Michael D. Berry for his assistance in formatting the manuscript and to John Nuttall and Stelios Gkouskos for their comments on my co-authored chapters. Thank you to my students, my clients and supervisees who are always important sources of inspiration. Finally, I would like to extend my thanks to Darren Reed (Senior Commissioning Editor), Karen Shield (Senior Project Editor), Olivia Evans (Editorial Assistant), and the rest of the publishing team for seeing the manuscript through to publication.

Editorial Introduction

An Encounter with Erotic Desire in Therapy

Maria Luca

This book is a study of sexual attraction. Anyone who studies sexual attraction will know that no particular discipline has claim over the subject. Hence, philosophers, anthropologists, sociologists, psychologists and psychotherapists all have much to reveal about the topic. We all in our own ways attempt to reduce such an irreducible human experience and give it the substance our intellect hungers for. This book has no intention of embarking on reductions. This book is situated in the various ways it seeks to begin with the therapy subjects, as they relate to each other in ordinary therapeutic relationships, that is, as involved in particular sexual attraction situations. It is within this space that erotic desire appears demanding a response.

The present collection was inspired by my experience as a supervisor, clinician and teacher of psychotherapy. Having witnessed the unsettling journeys of clinicians in their attempts to grapple with their own sexual attraction to a client or know how to handle a client's sexual desire, I decided it was time to give it the unique place it deserves. As Giles (2008) states:

It does not take particularly great powers of observation to see that sexual matters are everywhere, that sexual meanings infiltrate and imbue our daily interactions, that sexual glances are forever being made, that sexual fantasies quietly attend our dealings with numerous people, that a person's gender and sexual attractiveness fundamentally determine how we react to him or her … (p. 2)

To this it could be said that the therapy consulting room actors would not be immune. After all, therapy is a microcosm of the wider world and human actors are subjects who relate to each other with the agency characterizing their existence as a whole. The chapters included here offer different perspectives on the handling of sexual attraction in therapy. Despite differences in theoretical approach, style, angle and methodology, these perspectives share a common thread that binds them together in their attempt to move beyond the taboo and reveal the consequences on therapy of the neglect surrounding this subject.

Therapists' encounter with erotic desire is never quite one of clear recognition, but more a play at the edges of knowing. As Oliver (2005) puts it, ‘our part is not knowing, but looking, and touching, and loving’ (p. 72). When we stumble upon the novel territory of desire, we may become blinded by its forcefulness and intensity, thus fear it and run as far away from it as possible. Despite the increasing proliferation of therapy modalities, there is a wide gap in the much-needed multimodal discourse on the topic. The book provides such discourse through giving supremacy to embodied and relational theoretical constructions of sexual attraction, illustrating through clinical material what clinicians of different modalities make of a phenomenon surrounded by much taboo. Thus, the book is about an embodied encounter and handling of desire for therapeutic means. As intimated by Mann (1997), ‘The purpose of the erotic bond is that it deepens the individual's capacity for connection and relatedness to others as well as to him or herself’ (p. 2).

Recent literature makes it known that ‘therapists lack the language to engage with sexual material. Thus, instead of working with such issues, therapists responded to patients in ways that were rejecting, judgemental, condescending or moralistic, thereby bringing the therapy to a premature end’ (Lichtenberg, 2008, p. 141). To this end, this collection, attempts to provide a way of talking about sexual desire that harmonizes with actual therapy experience, seeking to overcome the practical limitations and consequences of a common therapeutic avoidance, connected with this subject. Recent literature (Celenza, 2010; Mann, 1997) has notable exceptions in the recognition that the erotic in therapy can be transformational.

In the words of Jeanrond:

Human desire for the other arises out of the experience of difference or radical otherness. No experience of love can ever remove from us our individuality and our personal journey towards death, but it can make that journey through life, toward our individual and personal deaths, different. Love has the potential to transform our lives (Jeanrond, 2007, p. 254).

In this introduction, I begin by giving an example from my own journey in recognizing and handling desire for the benefits of a client. This is intended to give a flavour of how the book opens the therapy consulting room space to the gaze of you, the reader, inviting you to encounter desire through the contributors' unique perspectives.

An Entry from My Therapeutic Diary

Albert, a man in his late 30s, in the fourth year of his psychotherapy, who was suicidal, had a systematic mistrust of the world; in fact, he hated it and wished he had not been born. He provided numerous rationalizations of the world he constructed in his mind, full of egoistic people that should be dead rather than ‘on the loose, causing misery around them’. There was nothing in his life that had meaning except Ginger, his cat. Although he was successful in his job, his narrative revolved around conflicts with others and his sessions were populated by descriptions of nasty, selfish, greedy, disgusting ‘bastards’ who had no interest in others. Albert waged a war against the world. I worried sometimes that one day someone out there might attack him, especially during one of the ‘road rage’ incidents where he would get out of his car screaming abuse at a driver who attempted to overtake him from the inside lane. He admitted hating himself too and hating the mother he had not seen for many years through his own choice. Albert's mother tortured him emotionally and often disappeared, leaving him to fend for himself from as far back as he could remember. She told him that he was conceived in an act of rape, the impact of which was evident in Albert's hatred of the world and of himself. His sense of aloneness and a feeling of not belonging to the human race were key presenting concerns, but he mostly feared that his murderous rage would land him in prison, and he'd much rather be dead than trapped.

Albert waited with indifference for his death. In fact, this was his only consolation in life: that his rage and hatred for the world would one day come to an end; in his mind, ‘the sooner the better’. His suffering tormented me and his dismissal of my tenderness for him, was disconcerting. He had no love for anyone and expected no love. For him, love was an alien concept; he was on the outside of it. The space he inhabited demolished hope for human empathy and understanding. There was no one coming towards him, no one interested, only silence and a dark void. Whenever he made telephone contact with me to cancel a session, something he rarely did, he would pre-empt the conversation with ‘It is Albert, your client’. He believed I had not held him in mind and that he was just a name on my psychotherapy list.

When sufficient meaning had been made of Albert's predicament, particularly his coming to terms with a cold, rejecting mother, and much cathartic work was out of the way, he confronted the cold, rejecting internalized mother and the rage associated with her he became accessible. I felt more connected with him. He no longer fought to keep me at a distance. In fact, he arrived for sessions with a warm, big smile on his face, telling me how much the sessions meant to him. He could hardly wait to come to his sessions. I also enjoyed sessions with him. He was endearing and my tenderness for him had increased enormously. I listened out for the whispers that revealed the presence of self-worth, to prepare Albert for a self-validating life, a life without the constant shadow cast upon it by death. In one of his sessions, Albert announced that each time he walked out the consulting room door, he no longer felt he went straight over a cliff. The world inside the therapy room and the world outside were not so vastly different anymore.

Albert began to share his feelings about me more openly. His statement to me, ‘I like to rest myself in your thoughts’, resonated with a sense that he had achieved the emotional connection he so craved for. The arrival of sexual dreams where the woman he so desired scorned and ridiculed him did not surprise me. Although Albert allowed himself to feel loved by me, developmentally he was not ready to own his potency as a man. For him, potency was equated with violence and intimacy with rejection. He recognized that he was anxious that women would reject him or worse, he might harm them. In his fourth year of therapy, as he was leaving his session, Albert accidentally brushed himself against me and apologized profusely. I was able to acknowledge his need for warmth through touch and did not reject him. On another occasion, again as he was leaving his session, he kissed me on the cheek and said, ‘I've been wanting to do that for a long time’. While Albert previously kept his erotic desires for women and for his therapist at bay, both to protect himself and his therapist, through a process of differentiating himself from a hateful mother, he could get in touch with his sadness. This paved the way for deeper work, where Albert's loving sentiment accompanied by sexual desire manifested in his openly flirtatious and seductive behaviour towards me. During this phase of the work, I, too, felt Albert as an attractive and desirable man and took this to be an indication of a transformational therapy experience, where his previous absence or lack of a loving and lovable self was now more fully embodied in a mutual encounter with desire. Albert's aggression and rage captured in his wish to be dead had softened and his self-hatred transformed into feeling worthy of another's love. He soon met a young woman with whom he formed an intimate relationship.

The man described in the above-mentioned illustration exemplifies that sexual attraction, if handled with sensitivity, can be liberating and transformational for a client. If a therapist can embrace the client's as well as her/his sexual desire and facilitate the development of intimacy in a ‘measured’, embodied fashion, with sentiment and feeling, not pure technique or avoidance, the therapy becomes a vehicle for an authentic, relational and transformational therapy experience.

Anyone who studies psychotherapy, clinical and counselling psychology will recognize something of themselves in this book. Those with curiosity about sexual attraction in a therapeutic relationship will learn that, despite the fears and anxieties such a topic may evoke, the topic is situated in the lives of clinicians; it is therefore a normal, albeit intensity-infused subject. No particular clinical discipline has exclusive claim on this topic. Hence, all clinicians of different disciplines and theoretical orientations have something to say about this pressing topic. To avoid missing out on the valuable understandings of clinicians generally, I have undertaken to be as inclusive as possible, by inviting scholars from different disciplines and perspectives to contribute chapters from their own unique theoretical, clinical and research vantage points. Almost without exception, the authors have worked diligently under the scrutiny of the editor to revise their work to bring it to its present quality. I am grateful to all contributors for their commitment to do justice to such a complex therapeutic manifestation.

My interest in the topic has been evolving for many years since my own very first experience of a seductive male client expressing sexual desire towards me when I was an honorary psychotherapist. I became worried and wondered whether I had the capacity not to make a mess of his therapy, with my anticipated anxiety that if I did, there was a risk of a premature ending to the work. Luckily, my then supervisor helped me recognize the clinical significance of the manifestation of my client's sexual desire so that I could manage the intense feelings it evoked in me. Of paramount significance was my learning that therapy involves an intersubjective connection between two people and that it should not be surprising that sexual desire may emerge as part of the intimacy continuum.

The ideas in this book have been developed through mine and my collaborators' teachings, practice and research of sexual attraction in therapy. I have personally learned a great deal from supervising students' projects, particularly those linked to sexuality and sexual attraction. My readings and writings of erotic, erotized, sexual and sexualized transference and countertransference topics have guided my understanding and practice for many years. However, I feel that the field is now in need of furthering our understanding of sexual attraction in therapy, from a new vantage point and from a variety of perspectives.

I have benefitted from discussions with friends, colleagues and students alike, and in the process, I have come to think about the experience of sexual attraction in therapy as normal and often an inevitable process of healing. So, why should it matter so much how sexual attraction in therapy is experienced and managed by therapists? Having often witnessed how such an experience evokes powerful feelings of fear, anxiety, shame and guilt in therapists, often to the detriment of the therapy process, I believe we need to give the topic the centrality it deserves to help us move beyond the taboo and learn to manage such situations more effectively.

The book's intention is to help students, researchers and those in clinical practice understand the permutations of sexual attraction and learn to embrace it as a manifestation of the human condition, not to avoid or fear it but to attempt to capture its essence as a meaningful occurrence of therapy relationships with transformational potential. The book is peppered with case vignettes and clinical examples. These are developed to help readers see how an idea translates into practice. It also raises important questions rather than answers to invite the reader into deeper reflective practice. Each chapter offers insights on what sexual attraction is, as well as clinical strategies for working with it. Together, they reveal the endless complexity and richness of perspective on sexual attraction. Rather than sum up a single perspective and widen its field, the diversity of this volume seeks to promote new perspectives on sexual attraction, new ways of thinking and new ways of working with it.

The topic of sexual desire and attraction is an existential concern as it is rooted in our everyday life. Sexuality, sexual desire and their manifestation in relation to another are givens of our existence. They are at the core of our human connectedness, no matter how difficult to define. I believe that if we accept sexual attraction as an intrinsic aspect of our fundamentally human condition, then it follows that it would naturally find its way into the consulting room. The book will provide highlights from the consulting rooms of many, while at the same time restricting the content and disguising the agents so that confidentiality and anonymity remain intact.

I hope that the book is received as a torch for further innovative and creative psychological investigations on sexual attraction in therapy.

Maria Luca

June 2013

References

Celenza, A. (2010). The guilty pleasure of erotic countertransference: Searching for radial true. Studies in Gender and Sexuality, 11, 175–183.

Giles, J. (2008). The nature of sexual desire. Plymouth: UPA.

Jeanrond, W. G. (2007). LOVE ENLIGHTENED – The promises and ambiguities of love. Retrieved from http://www.catho-theo.net 6 pp. 253–281, http://www.catho-theo.net/Love-enlightened.

Lichtenberg, J. W. (2008). Sensuality and sexuality across the divide of shame. New York: The Analytic Press.

Mann, D. (1997). Psychotherapy, an erotic relationship. London: Routledge.

Oliver, M. (2005). New and selected poems (Vol. 2). Boston: Beacon Press.

Part I

Relational Perspectives on Sexual Attraction in Therapy

1

‘Hot Cognition in Sexual Attraction’

Clarifying, Using and Defusing the Dionysian in Cognitive Behavioural Psychotherapies

Michael Worrell

A young-ish male therapist walks downstairs to meet a new client for an initial assessment session. The setting is a shabby NHS out-patient psychology department. Sitting in the waiting room is a well-dressed young female client who regards the approaching therapist with a detached look of mild curiosity. The therapist greets the client and asks her to follow him upstairs to the consulting room. The client says nothing and follows as directed. The therapist has already noted that this new client is well dressed, composed and out of place in this grey and grubby environment that the therapist has increasingly come to experience as oppressive.

Upon sitting down in the comfortable but worn chairs, the therapist somewhat lazily starts the session with the usual enquiry “so … what is it that brings you here today?”. The client does not respond immediately with the usual rush of description regarding anxiety or low mood but instead looks into the distance in an apparently reflective manner. The therapist thinks to himself “how interesting … she seems pretty reflective … really composed … she looks a bit European … quite sophisticated.” He sits up straighter in and pays more attention. There is some sense of discomfort as well, a vague anxiety. Finally, the client responds. “You know … sometimes I think there is nothing at all going on inside my head …” instantly the spell is broken …1

Russ (1993), writing from a psychodynamic perspective, suggests that ‘Sexual Drama infuses therapy’. Is sexual attraction between a therapist and a client a phenomenon encountered in cognitive behavioural therapy (CBT)? If one were to judge this according to the amount of theoretical or research literature devoted to this topic within CBT, in comparison to the psychodynamic literature, one would conclude that it is either nonexistent or of such small significance as to not warrant attention. In fact, at the time of writing, there appear to be no substantive theoretical contributions nor research reports that specifically address sexual attraction between therapists and clients within CBT. Possibly, the domain of sexual dynamics in therapy is one that has been seen by CBT therapists as the preserve of the psychodynamically inclined, an area of enquiry that has long ago been demarcated as alien territory. In seeking to address the topic of ‘sexual attraction in CBT’, it is useful to briefly outline some of the essential aspects of CBT that will function as part of the context for how sexual attraction might be disclosed and responded to. A consideration of some of these features may also go some way towards explaining the lack of attention given to this phenomenon by CBT therapists.

What Is CBT?

The field of the cognitive and behavioural therapies has expanded considerably in recent years and it has become increasingly difficult to make generalizations that would cover all its variations of theory and practice. CBT is increasingly an umbrella term for a range of approaches that share a concern with developing an empirically grounded approach to psychotherapy. In this chapter I will primarily be concerned with discussing what might be referred to as ‘Beckian’ CBT, that approach to CBT developed by Aaron Beck and his colleagues (Beck, 1976). This seems to me to be appropriate, given that Beckian CBT is likely the most widely practised form of CBT worldwide and also the version of CBT that has been the most productive in terms of research and theory development. Beckian CBT can, in some senses, be regarded as the ‘standard version’ or ‘mainstream CBT’. Perhaps the most important feature of CBT in regard to the present topic, and the feature that has led to the most criticism and challenge from therapists of other orientations, is the relative importance placed on the therapeutic relationship. In contrast to relationally oriented forms of psychotherapy that see the relationship between client and therapist as the primary, if not sole, driver of beneficial change, CBT practitioners regard a good therapeutic relationship as necessary but not sufficient for beneficial change to occur. CBT has tended to place a strong emphasis on specific technical interventions and skills as the primary driver for therapeutic outcomes. The therapist in CBT explicitly takes up a role of collaborating with clients to identify new cognitive and behavioural skills that may be of benefit in addressing the difficulties the clients experience in their day to day lives. In contrast to approaches to psychotherapy that seek to create and subsequently manage a particular type of relationship, that for its effectiveness needs in some important senses to be seen as separate and different from the client's everyday life (a container or vessel that needs to have strong boundaries to eliminate potential contaminants from the ‘outside world’), the CBT therapist's focus is primarily upon what is happening ‘outside’ of sessions, in the client's everyday world. In fact, CBT therapists will very frequently venture into the client's world in a direct fashion, whereby therapy sessions (such as exposure work for phobias) may take place in the clients home, in a supermarket or in a crowded lift.

Therapy sessions in CBT are usually highly structured, with a clear agenda set at the beginning of sessions, and efforts made at the end of sessions to review what has been covered and to seek clear and direct feedback from clients regarding how the session was experienced. This emphasis on structured sessions and an active–directive stance of the therapist, has led some to criticize CBT therapists for apparently taking up an ‘expert position’, seeking to control clients and to teach them how to think or how to behave. In response, CBT therapists have argued that, in fact, what is sought is a highly collaborative relationship with clients where there are two experts present. The client is seen as an expert on his or her own experience, thinking and feelings, and the therapist is an expert in general patterns and strategies that have been found to be helpful. The task, as seen by CBT therapists, is to engage with the client in a joint effort to work on those areas of living identified by the client as problematic. CBT, on the whole, also tends towards a short- to medium-term intervention with sessions ranging anywhere between 6 and 24 sessions.

Brief Encounters: Does Sexual Attraction Show Up in CBT?

The previously mentioned, admittedly brief and incomplete, characterization of standard CBT serves to provide some context for understanding how sexual attraction may show up or, perhaps far more frequently, may not show up (explicitly) in CBT. It is possible that dilemmas around sexual attraction between therapist and client are far more likely to become activated in therapies that are of a long-term duration and in which the therapist takes an explicitly relational focus. It is possible that the highly focused and structured nature of CBT functions to prevent sexual attraction from coming to the awareness of the therapist or the client, or, at most, serves to keep such phenomena safely in the background. It is possible but, I suspect, highly unlikely. Any consideration of one's own experience of the vagaries of sexual attraction indicates that this can show up in a wide range of contexts and does not require a specific time context. Where would the field of romantic literature be without the concept of ‘Love at first sight’?

I am unaware of any research that reports on incidents of CBT therapists experiencing sexual attraction in therapy (either client attraction to therapist or therapist towards client) or data on how CBT therapists respond to and manage such experiences. Rodolfa et al. (1994), however, report on a survey of over 900 members of the American Psychological Association. While they obtained a typically low return rate of 43%, the findings are striking in that only 12% of respondents indicated that they had never experienced sexual attraction towards a client in therapy. These authors do not report on the theoretical orientation of the respondents; however, it is reasonable to suppose that at least some of these practising psychologists will have been working from a CBT orientation. If we assume that CBT therapists are as likely to encounter the phenomenon of sexual attraction in therapy as are other therapists, it is also reasonable to assume that this experience provokes for them the same anxieties and concerns as that which has been reported in the literature for practising therapists more generally (Pope, Sonne, & Holroyd, 1995).

The experience of anxiety (as well as a wide range of other emotions) is highly understandable when encountering phenomena of sexual attraction in therapy. There is now a very widely shared understanding among psychological therapists of all orientations that actual sexual contact between therapist and client is likely to be highly damaging to the client, is an abuse of the power relationship between therapist and client, and, in addition, is in direct violation of professional ethical codes. While CBT training in the United Kingdom will routinely cover the ethical dimension of practice, it would be unusual, in my experience, for the topic of sexual attraction in therapy to be delivered as part of formal lectures or workshops. The result, particularly for beginning CBT therapists, is likely to be the activation of anxiety when this phenomenon is encountered as it will be experienced as ‘This is not who and how I should be as a CBT therapist!’ A particularly useful concept in contemporary CBT is the notion of ‘thought–action fusion’ (Wells, 1995). This concept refers to the beliefs clients (or therapists) may hold about the operation of their own minds. This can refer, for example, to beliefs such as ‘if I experience a thought, image or feeling, this must mean something about me, it means that I must want to do this thing and am in danger of doing so’. Such beliefs have been found to be particularly important in obsessional difficulties. While it will be understandable to experience a degree of anxiety in response to sexual attraction for a client (or being the recipient of sexual attraction from a client), this anxiety is likely to be that much stronger and distressing to the degree that the therapist's reactions demonstrate thought–action fusion. Efforts to avoid or suppress thoughts have also been found to have a counterproductive effect in that this serves to increase the salience and frequency of the avoided thoughts (Wells, 1995). Of course, as will be discussed further, sexual attraction may not be reducible to thoughts.

It is likely to be beneficial for CBT therapists that the topic of sexual attraction is more frequently raised in training in order to support therapists to respond appropriately and effectively if and when this is encountered. In my view, a range of recent developments within CBT have extended the range and flexibility of this model and provide a framework that may allow for theoretical and research work to be conducted on this topic.

Developments in CBT: Integration and Expansion

As the theoretical and research base of CBT has continued to be developed, and as the approach has been extended to work with clients presenting with more complex and enduring difficulties (such as clients experiencing difficulties that result in them being diagnosed as having ‘personality disorders’), there has been significant reconsideration of some basic principles. Perhaps the most significant of these has been a deepened appreciation for the role of the therapeutic relationship and emotion.

While CBT has maintained its perspective on the therapeutic rela­tionship as being necessary but not sufficient for beneficial change, the emerging research, from within CBT, has indicated that the therapeutic relationship holds far more variance in terms of outcome than had been appreciated (Waddington, 2002). Contemporary CBT can be seen to be moving beyond a somewhat ‘black and white’ approach that contrasts technique with relationship to a perspective that acknowledges that all technical interventions can also be seen as relational interventions. There is a recognition also that the appropriate application of CBT strategies can also help to support the development of optimally supportive (and challenging) therapeutic relationships. Additionally, contemporary CBT has placed a greater emphasis on emotion in therapy such that the ‘cold and intellectual’ discussion of cognition is seen as insufficient and that, instead, the focus of work must be on ‘hot cognition’, that is, cognition that is closely tied to client emotion. A related development has been those efforts directed to integrating a more interpersonal perspective within CBT. Safran and Muran (2000), for example, have argued convincingly that the core beliefs and schemas highlighted by CBT as being implicated in forms of psychological suffering are inherently interpersonal and concern self–other relationships as much as self–self relationships. The purpose of this chapter is not to review these or a range of other equally relevant developments in depth. However, it does seem to me that theoretical and clinical developments that open the possibility for CBT therapists to consider the therapeutic relationship, emotion and interpersonal experience in more depth also open the way for a consideration of sexual attraction in therapy.

While current developments in CBT may potentially make room for thinking about the phenomena of sexual attraction in therapy, might it not also be that doing so in any depth may also provoke further challenges for CBT theory and practice? In my view, the development of a CBT perspective on sexual attraction in therapy challenges CBT to consider in greater depth its perspective on ‘embodiment’ and the relative emphasis it has placed on the ‘computer metaphor’.

Computer Love

A primary metaphor for CBT has been the ‘mind as computer’ as it has also been for cognitive science more broadly. Clark (1995), for example, asserts that a fundamental postulate of CBT is that all acts of perception, learning and knowing are the products of an active ‘information processing system’ that selectively attends to the environment, filters and then interprets the information impinging upon the organism. Such ‘processing’ of information is seen as evolutionally adaptive. In psychopathological conditions, aspects of the information processing system are seen as having become ‘distorted’, biased or maladaptive, leading to experiences of emotional, behavioural and relational distress. The role of the CBT therapist is seen as assisting the individual to clarify their current patterns of information processing and to modify this through a range of strategies that encourage individuals to take on a more ‘scientific’ stance towards their own experience. Clark further states that in CBT:

The therapist and patient collaborate to identify distorted cognitions, which are derived from maladaptive beliefs or assumptions. These cognitions and beliefs are subjected to logical analysis and empirical hypothesis testing which leads individuals to realign their thinking with reality (Clark, 1995, p. 155).

As Safran (1998) has noted, the mind-as-computer analogy has been a highly productive one in cognitive psychology; however, this should not detract from a consideration of the ways in which the mind, and interpersonal experience, is not computer-like. I would suggest that troubling or disturbing instances where a therapist encounters sexual attraction in therapy are likely to be one of those occasions where the person-as-information processing system is likely to be found seriously wanting (reports of individuals who appear to develop attachment relationships with their computer equipment and hand-held devices notwithstanding). Indeed, in situations such as this, and many others besides, the therapist is likely to be confronted with the irreducible embodied nature of human interpersonal existence. Consider the following.

Collaborative Colin (CC) has been working with an older female client on her long-term problems with recurrent depression. He has taken an evidence-based approach and emphasized behavioural activation as well as cognitive disputation strategies, all of this to good effect. The client, who has been single all her life, has responded well to the emphasis on increasing her socialization; however, this has also brought to the fore her long-term anxieties and disappointments about relationships with men. Colin has noted that, as therapy has progressed, her self-presentation has improved. He has noted her wearing perfume and has complemented her on her improved self-care. Towards the end of a particularly productive session she looks CC directly in the eye and states ‘I wish I could just take you home with me.’ This statement and the look in her eye have an immediate physical effect on him. It feels like her statement is a physical caressing of his face and he experiences himself as both attracted and repelled at the same instant and is unable to say anything. In response to the attraction he feels shock and disbelief, and to the repulsion he feels a sense of guilt and struggles not to express either emotion in his bodily gestures or gaze. He mutters something about the value of her learning to become her own therapist and the session ends.

While in the previous example there are clear indications of interpretative processes or cognitions, can the interaction or experiences described be reduced to the operations of information processing without something central being lost? Sitting with a client in CBT is not an experience of one information processing system encountering another for the purpose of some form of reprogramming, it is rather an embodied experience of being in the presence of another. The embodied nature of the therapeutic encounter is primary; the statement ‘I wish I could just take you home with me’ may indeed be offered and experienced as a caress of the face.

It is possible that a CBT perspective on sexuality and sexual attraction in therapy could be advanced by considering an integration of insights and perspectives from a wide range of sources. Some mainstream CBT practitioners, for example, have asserted the need to develop cognitive models of transference and countertransference (Guidano, 1991). Others have drawn upon insights from attachment theory and evolutionary biology and neuroscience (Gilbert, 2010). In my view, an alternative source to both challenge and develop a CBT perspective is that of existential phenomenology, and it is to a consideration of this possibility that I will now turn.

Existential Insight on Sexuality

Why seek to draw upon the insights of existential–phenomenological thought to clarify and expand a CBT perspective? Why not draw instead upon psychoanalytic thought and practice or some other form of psychotherapeutic thinking? As Ottens and Hanna (1998) state, at first sight, existential thinking, and the existential versions of therapy inspired by such, seems at opposite ends of the therapeutic spectrum to the behavioural and cognitive psychotherapies. However, there are, in fact, many points of potential contact principally surrounding the focus on ‘meaning’ in understanding psychological distress; in fact, Clark, Beck, and Allford (1999) have suggested that CBT finds its most compatible philosophical base in the field of existential phenomenology. Thus, it seems entirely reasonable to consider what an existential–phenomenological perspective on sexuality might provide for CBT practitioners wishing to consider the phenomenon of sexual attraction in therapy.

The contribution of existential–phenomenological philosophy, and existential therapies derived from this, to CBT practitioners is, in my view, the foregrounding of the inevitable aspects of human existence itself, or the ‘givens’ of existence. This includes the inherently ‘interrelational’ basis of human existence (the centrality of context), the unavoidability and indeed centrality of anxiety for human existence and, as is most relevant for the present discussion, that human existence is always embodied and sexual (Cohn, 1997; Spinelli, 2001). Admittedly, existential therapists themselves, such as Spinelli (2001), have noted that an existential perspective on sexuality has been curiously neglected (again perhaps due to a sense that this field is somehow owned by psychoanalysis). Nevertheless, a consideration of the work of one existential philosopher, Merleau-Ponty (1982), seems to offer avenues for development. As Spinelli writes, in taking a phenomenological approach to sexuality, Merleau-Ponty is setting aside analyses that principally focus on issues of gender and socialization as well as analyses that might focus on biological imperatives such as developmental or evolutionary theory.2 The question for existential phenomenology is ‘what is the essence of human sexuality?’ Merleau-Ponty's philosophy places particular emphasis on the embodied nature of human existence. In this perspective, the body is not regarded as a ‘thing’ to which a consciousness is somehow attached or which acts as the vehicle for an encapsulated mind (or information processing system), but rather human existence is irreducibly an ‘encarnated consciousness’. The body, for Merleau-Ponty, is the configuration through which our dialogue with the world is manifested. Sexuality, in turn, rather than being something that can be reduced to the effects of physiological or biological drives, is inherently ‘intersubjective’ in nature. As Spinelli writes:

How we are, sexually, and what we enact sexually, therefore become statements not of reproductive drive but of our willingness, hesitation, delight and anxiety to explore the ‘being-with’ of self and other (2001, p. 8).

From this perspective then, sexuality and embodiment are ‘givens’ of human existence, an inevitable aspect of the context for human existence, implicitly present, if not explicitly clarified, in all psychotherapeutic encounters. Thus, ‘sexual attraction’, just as much as experiences of ‘sexual repulsion’ or ‘sexual indifference’, can be understood as a relational expression concerning, for example, ‘who one wishes to be’ in the world, and who one believes ‘one cannot or should not be’ in relation to self and other, topics discussed more fully in Chapters 3 and 5. How might such an existential perspective on sexuality inform a CBT perspective on sexual attraction in therapy?

‘Emotion Schemas’ and Responding Flexibly or Inflexibly to Sexual Attraction in Therapy

Earlier CBT models have stressed the experience of emotion as being primarily an outcome of cognitive processing. Emotion is thus seen as, in some sense, secondary to, and consequential to, interpretative processes. Contemporary cognitive models, such as the ‘metacognitive’ model of Wells (1995) and the ‘emotional schema’ model of Robert Leahy (2002), have sought to extend this perspective. Leahy's model, for example, has sought to integrate insights from emotion-focused therapy (Greenberg & Paivio, 1997), which itself draws upon insights from existential philosophy as well as the humanistic models of Rogers and Fritz Perls. In this perspective, emotional experiencing and emotional processing in therapy is prioritized as it is argued that emotions are in themselves a form of information processing in which the experiencing of emotion allows an individual to access the meaning of events. Here, emotion is regarded as a ‘prime mover’ of cognition and not just a consequence of ‘cold cognition’. Leahy's model attempts to integrate this insight into CBT and stresses various forms of cognitive and emotional processing, as well as behavioural coping styles, which come ‘online’ once an emotion becomes foreground for an individual. Emotions, including those centred on sexual attraction, thus become a ‘given’ of experience that an individual will subsequently process via ‘emotional schemas’ or beliefs, rules and action plans regarding what emotions may mean and how emotion should be responded to. Thus, once an individual experiences sexual attraction in a specific context, for example, they may then respond to this experience in accordance with a range of rules, beliefs and action tendencies. The model stresses both adaptive and maladaptive processes of emotional regulation and processing that may allow individuals either to experience their emotions as valuable, if at times distressing and disturbing, windows to insight about what is important, true or needing attention in their lives, versus anxiety- and distress-provoking experiences that are responded to with strategies of distraction, suppression and avoidance. How might such ‘emotion schemas’ and associated processes play out in instances of encountering sexual attraction in therapy? Let's consider the following.

Rational Ray (RR) has been a CBT therapist for over 10 years and comes from an impeccable academic background. He prides himself on the technical proficiency of his work and is fully convinced that therapeutic outcome is driven by the therapist's adherence with specific intervention protocols and procedures. RR has been working with a young female client presenting with a blood injury phobia. She is a postgraduate physics student. Highly verbal and intelligent, she understood the CBT model and treatment plan very quickly and was highly motivated for treatment. RR found himself looking forward to the therapy sessions as a highlight of his working week. He felt more alert and awake in sessions with her and worked in a particularly focused way to help this ‘ideal client’ overcome this one area of difficulty in her life that seemed to be holding her back. He was vaguely aware that he gave additional attention to how he dressed on her therapy days and he always managed to find the time to prepare for her session. He found himself thinking about her between sessions but quickly dismissed these thoughts other than to note ‘ah yes … maybe we should try this new CBT strategy that I read about recently’. Therapy was very successful and the client left very happily. RR also felt very pleased and yet was aware of a sense of loss at the end of therapy and experienced a depressed mood for several weeks afterwards that he found difficult to conceptualize or communicate.