Online Counselling or Face to Face Consultations in Sydney, Australia

Ash Rehn QindsmI’m Ash Rehn, counsellor, coach and Medicare Provider. Take a look around to find out more about my in-person and online services.

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Healthy Sexuality and Sexual Addiction: Two Ideas Worth Exploring

Unhappy couple in bedroomI was recently contacted by a student who was writing a paper about ‘sexual addiction’ for a college course on sexuality. As a counsellor and therapist in private practice, I’m not usually in a position to offer so much assistance to students (I receive many requests and my time with people is my livelihood) but my curiosity was drawn to the theme of his particular course: Healthy Sexuality.

Sexual Addiction and ‘Healthiness’

To date there has not been so much written about the idea of sexual addiction from a narrative therapy perspective. When I saw the course title, what immediately struck me was the lens of healthiness through which sexuality was being judged. I know this is a very common way to consider sexuality because I hear it all the time. And I began my career working in the field of sexuality as a ‘health educator‘. In a state, culture and era when public dialogue about sex was largely taboo, health (and specifically HIV) provided an entry point to talk more openly. The rules were that our sex talk had to be the interests of public health.

When people consult me about sex addiction, they are often describing their actions in terms of whether they are ‘healthy’ or not. These days the concept of healthy human sexuality has become such a norm it is a cliche. It seems to me that, particularly since the onset of AIDS, ‘healthiness’ is the primary lens through which we tend to view sexuality. It is taken for granted that sex and sexuality must be ‘healthy’ first and foremost. And this makes me curious about the division that is made between ‘healthy’ and ‘unhealthy’ sexuality. How useful is this binary? And who determines what is ‘healthy’ and what is not?

It also has me wondering about what happened to other perspectives or lenses through which we might view sexuality. What does sexuality look like, for instance, through a lens of Pleasure? Or a lens of Community? Or a lens of Power? Or – dare I say it – ‘Fun’?! What does your sexuality look like if you view it through those lenses instead? Or how about through the lens of Self-Knowledge, finding out about yourself?

Exploring Sexualities and Alternatives to ‘Addiction’

It does strike me that when we start looking at sexuality through a lens of ‘healthiness’ we might also be standing firmly within the disease model. It’s no wonder these fears about addiction figure so strongly when we are viewing ourselves with the presumption of a deficiency or possible health disorder. We lose the context. In the stories I hear, people tell me about the steps they are taking in exploring desire. They describe themselves acting on urges they have had for 30 years but done nothing about due to shame or fear of ridicule. Others tell me about strategies of using pornography for stress relief, or to relieve boredom or to escape from grief that has overwhelmed them. Some people tell me how good they feel when they have sex but say they can’t share this with others because of taboos around discussing sex. I find myself engaged and interested in the courage, skills and abilities of those who consult with me and we draw on all of these in our work together.

The French philosopher Michel Foucault claimed that the concept of Sexuality itself was developed to ensure power remained with certain people. Sexualities are proscribed in the same way that particular activities or behaviour might be regarded as disordered or pathological or unhealthy. In narrative therapy there is an idea that people can be experts in their own lives. This certainly challenges the standard model supporting doctors, psychologists and psychotherapists as the experts, but it is a way of thinking I personally find exciting and empowering.

Contact me to make an appointment or receive my latest articles for free

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Inspiration in Treatment: The Rewards of Working as a Therapist in 2013

Celebrating 2014How was 2013 for you? What does 2014 have in store? Do you have any New Years Resolutions?

When out socially, I’m regularly told that my work must be demanding, difficult and depressing. It must take its toll on you, people say.

I don’t want to pretend that being a therapist isn’t challenging and personally tough at times. It is. But it is also a vocation full of inspiration and motivation. I thought I would take the time in this post to appreciate and reflect on the meaning and fulfilment I gain from therapeutic consultations and to share some of the most rewarding aspects of my work from 2013.

Therapy as an ‘In Treatment’ Journey

This year, I have met and continued to work with some wonderful people, journeying with them through confusion, uncertainty and change. An ongoing therapeutic relationship is like travelling with someone. You get to know them over time and through different moods and experiences. You see their ups and downs, are privy to their fears and share their relief.

Some of these are short journeys, for example, adjusting to separation or the breakdown of a long term relationship. Others have been over longer periods or are ongoing: helping guys who are coming out later in life; assisting adults responding to memories of childhood physical or sexual abuse; supporting those in grief around the death of their partner or a loss of direction in life.

In both my short term and long term work, I admire the preparedness of those who consult me in treatment. I notice and call attention to their courage or their skills, their abilities. I’m curious about the sense they are making of their circumstances. I hear their stories and draw out the meaning they make of what is happening to and for them.

Sex, Sexuality and Relationships: Inspiration through Counselling

One of the areas in which I specialise is depression experienced by gay men. In these conversations, we often find ourselves pulling apart the way in which their identities as gay men have been constructed and taking a closer look at what might have contributed to depressed feelings. I’m very conscious that most of us seem to develop our identity against the backdrop of heteronormativity (and homonormativity). Many men feel constrained by the way sexuality has been defined in the last 50 or so years, by the prevailing assumptions about sexuality being fixed. For some of my clients, the only word that comes close to their experience of themselves is ‘bisexual‘, but they say this does not really work for them for a number of reasons.

There are also questions of masculinity to be explored and I always find these conversations stimulating because, as quite a few guys have pointed out to me, the representation of masculinity in popular media is quite limited. This year, I intend to develop my site www.GayCounsellor.com.au with short blogs and articles that will be of interested to all men.

Something else that has been on the radar this year has been the return to dating or relationships by both men and women who are in what they might describe as ‘middle age’. It might be that a long term partner has passed away, or that the person is beginning a new life post-separation. I might be speaking with a man who has lived most of his adult life with a woman, raised children together with her, but decided now to take a new direction, one that feels more comfortable and in keeping with his sense of sexual orientation. Or it could be someone who has spent the last 20 years having casual sex, who has decided they want to experience something different.

These new directions can be quite scary and also take some time. People often feel they have ‘messed up’ or ‘failed’ when trying to establish a new relationship. Sometimes they tell me that it is about learning to date again. They say they feel like a clumsy teenager trying to get a boyfriend or girlfriend. Often they end up finding themselves in treatment, recovering a sense of connection with something quite important about themselves they had lost.

Developing Professionally as a Therapist: Some Reflections

Through this year, I’ve also changed and grown from my experiences. I was fortunate to attend an international social work conference in Kochi, India and present a workshop to an international HIV conference in Paris, France. I lived across 2 continents and worked with individuals and couples across the world. Due to my masters studies commitments, many of these conversation have been online over webcam. Colleagues are usually surprised when they hear I have conversations with individuals in cities as far spread as Moscow, Bangkok, Dublin, Stockholm, Baghdad, Perth, Capetown and Tokyo. But online clients continue to tell me that they feel more at ease working this way online. I’m convinced online counselling and therapy has a big future and can exist alongside ‘face to face’ therapy as another option for accessing help and support.

I’m now working in-person in Sydney Australia again, as a Medicare provider while I continue with my online clients. The Australian healthcare system is one of the best in the world, up there with the NHS in Britain and the public health system in Sweden. Each has its limitations but I feel quite privileged to work in cooperation with GPs to improve mental health outcomes for individuals. I am grateful to the AASW for representing my interests as a mental health practitioner.

My hope for the year ahead is to continue as a counsellor-therapist both online and in-person in this rewarding work with people and their stories. Specifically, I’ll keep pursing my professional interest in concerns about pornography ‘addiction’, ‘sex addiction‘ and mental health services for gay men. I plan to continue some supervision of social workers and complete my dissertation on community work with men who have sex with men. I’ll also be returning to my creative writing. I believe we make sense of our lives through telling stories, to ourselves and to others. This is also the therapeutic nature of narratives.

I look forward to more conversations with those currently consulting me and with new people who contact me. They are doctors, nurses, paramedics, software developers, IT engineers, mechanical engineers, teachers, academics, students, lawyers, journalists, artists, musicians, actors, sportspeople, business owners, business consultants, tradespeople and sales professionals. I find inspiration in their different experiences, stories and meanings, their different lives.

I’m grateful for the opportunity I have to journey with people through the toughest times in their lives. Regardless of whether you are in difficult circumstances right now, or you are travelling fine, I wish you well for 2014 and hope that you find peace and contentment in the year ahead.

For appointments and questions: Contact me

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Can I see a Medicare Provider for Porn Addiction? Do You Accept Health Insurance?

Man on computer next to a swimming poolAs a counsellor and therapist specialising in pornography use problems, these are questions I am asked often. Both men and women contact me seeking help, either for themselves or their partners, around use of pornography and dating websites. Sometimes they are concerned or convinced there is a mental health or medical condition involved and want to take advantage of the Australian Medicare rebate for psychology consultations. So I thought I should explain how the Medicare rebate works and under what circumstances this and other forms of health insurance are available.

The Better Access to Mental Health Care initiative was introduced to improve outcomes for people with a clinically-diagnosed mental disorder through evidence-based treatment. As a Mental Health Social Worker, I have been assessed and accredited as having specialist mental health expertise to provide this treatment (selected psychiatrists, GPs, psychologists and occupational therapists work are also working in similar ways under the same programme). Medicare has specific criteria used to determine who is eligible to receive these sessions. You need to first be diagnosed as having a mental health disorder and generally this diagnosis is done by a GP or occasionally a psychiatrist. Your GP will complete a ‘mental health care plan’ for you and you can then access up to 10 sessions of focussed psychological strategies (individual therapy sessions) per calendar year meeting me in-person or with another mental health professional*.

Can I be Diagnosed with Addiction to Pornography or Dating Websites?

According to the World Health Organisation, ‘disorder’ is not an exact term…

…but used to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder…

(source: http://www.who.int/classifications/icd/en/bluebook.pdf)

Despite popular ideas about the existence of ‘porn addiction’, there is no such diagnosis of pornography addiction in the current International Classification of Mental and Behavioural Disorders (within the ICD-10) used by Australian medical practitioners and the British NHS*. This is the manual Australian doctors use to determine their diagnosis under Medicare’s Better Access programme. There is also no diagnosis of ‘pornography addiction’ or ‘sex addiction‘ in the DSM V – the Diagnostic and Statistical Manual of Mental Disorders used by American Psychiatric Association. So technically a GP cannot give you a diagnosis of ‘addiction to pornography’ that will permit you access to Medicare rebates or health insurance for psychological services.

However, my own professional experience is that many people presenting with concerns about what they believe is excessive use of pornography or dating sites will eventually be diagnosed with a particular mental health condition provided they see a GP. Often the diagnosis they receive will be a form of depression or anxiety (or a combination of both), diagnoses related to grief or loss, mood disorders (e.g. bipolar), post-traumatic stress (e.g. PTSD) or adjustment disorders. Very occasionally it could be a form of sexual dysfunction not caused by organic disorder or disease. These kinds of conditions are often present alongside relationship difficulties, work stress, sleep difficulties, domestic violence or a particular physical illness or health condition.

In other words, it’s important to remember that your access to the Medicare rebate may hinge on whether the doctor considers you have an underlying mental health condition rather than how often you are using dating websites or what kinds of pornography you are using and when. Some people look at pornography regularly and do not report any disturbance to their mental well-being. But patterns around the use of sexual images and even sex itself can be a response to psychological difficulties a person is experiencing. Men, particularly, talk to me about their use of the Internet as a way to escape from anger, stress, boredom, shameful feelings or thoughts of inadequacy. People can use sex as a way to avoid sadness or distract from the emotional pain of separation or even a coping strategy when work, a relationship or loneliness is overwhelming them. Some build up a reliance on the Internet or using sexually explicit adult websites which ends up in sleepless nights, arguments with partners, downloading banned material or many wasted hours and time lost at the expense of other priorities. If internet dating or porn websites have started causing you problems, it can be a sign that all is not well with your mental health.

Getting Help for Depression, Anxiety or Other Problems Associated with Using Dating Sites or Porn Addiction

If you are in Sydney, or can travel from other parts of Australia, you can meet with me in person to discuss your concerns. The first step is to contact me, and sending an email is best although you are welcome to call and leave a message. If you think you might have depression or anxiety, an adjustment disorder or another mental health condition, you can either meet with your own GP or I can refer you to competent local medical practitioners in inner Sydney. If you are an Australian resident and meeting with your regular GP, ask for referral to me under the ‘Better Access’ programme. The doctor will generally ask you some questions to ensure your symptoms are appropriate for the referral and then complete what is called a ‘mental health care plan’ for you. What I require at the first appointment is a letter of referral from your GP. This can either be addressed to me or ‘The Mental Health Professional’. Some GPs have existing relationships with other mental health social workers or psychologists, but it is your choice who you see. Unfortunately I cannot meet with you without a referral letter so it is best to ask for it to be addressed to me personally or the generic ‘Mental Health Professional’. Ask the doctor to give you the letter (don’t mail it to me, give it to me in person at the first session). My address for the referral letter is:

Ash Rehn (private and confidential)
PO Box 7798
Bondi Beach NSW 2026

Provided you meet the criteria for the Better Access programme, have been referred and not used all your 10 sessions for the calendar year, Medicare will provide you a rebate that will cover part of the cost of the consultation. To find out more about my fees, please contact me and let me know you are interested in an in-person appointment in Sydney.

If you don’t live in Sydney, cannot travel or simply prefer to meet online over webcam, telephone or through email counselling, we can meet online. Unfortunately, at this stage Medicare does not offer rebates for online counselling or therapy appointments. But many people prefer the privacy and convenience of meeting online. And of course for some people it can feel a lot easier to discuss these kinds of sexual problems online. Take a look at my online counselling and therapy options for more information about the services I offer.

Health Insurance Rebates for Pornography ‘Addiction’ or ‘Sex Addiction’

Once again, as neither Pornography Addiction nor Sex Addiction are officially acknowledged as mental health disorders, health insurers will generally not pay for treatment specifically for these concerns. However they may be satisfied if the appointment was ‘psychology services’. Whether or not your health insurer will pay towards the sessions depends on the insurer. I generally do not mind who pays for the sessions but require payment at the time of the appointment. You will need to discuss payment with your health insurer in advance if you want to be sure. I can provide you a receipt to show you have paid for the sessions but cannot guarantee that your insurer will pay. Some of my clients – both online and in-person consultation – prefer to keep their sessions ‘off the record’. The advantages of not requiring a rebate for private therapy and counselling include:

  1. It’s much easier to get an appointment. You don’t need a doctor’s referral or to meet the eligibility criteria;
  2. I will work collaboratively with you and can be flexible to your circumstances. If you go through the healthcare system, the system determines how many sessions you receive and when your treatment is over;
  3. Funding through both Medicare and health insurers is limited to certain psychological approaches and strategies. You may not find these meet your needs or take your preferences into account. For example, Medicare does not fund relationship counselling, yet many of my clients seek assistance for their relationships and this may require a course of sessions in itself.

How Can a Medicare Provider Help Someone who is Using Porn or Sex as a Response to Mental Health Problems?

Once again, it’s important to stress that using pornography or sexual activity is not necessarily a mental health issue in itself. But if you are having severe mood problems, suicidal thoughts or destructive thoughts, chronic depression or disabling anxiety, and your porn-watching or sexual behaviour is making these worse, it is time to get help.

The focussed psychological strategies that Medicare Providers use include,

  • Psycho-education, including Motivational Interviewing
  • Cognitive behaviour therapy (CBT) including: behavioural intervention, behaviour modification, exposure techniques, activity scheduling
  • Cognitive interventions and cognitive therapy
  • Relaxation Strategies (such as progressive muscle relaxation and controlled breathing)
  • Skills training and
  • Narrative Therapy

Taking the first step is often the hardest and it gets easier after that. The people who consult with me tell me they are glad they made the decision to get help and the first session was much easier than they imagined. So if you have been thinking about doing something positive for your mental health, stop delaying and make contact now. It is the first step towards feeling better.

For more information get in touch with me either by email or phone.

*This information is correct at the time of posting this article.

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Is this Sex Addiction? Questioning ‘Sex Addiction’ in Therapy and Counselling Conversations

Tastatur, SEXThis paper examines the concept of ‘sex addiction’, and its increasing popularity since the emergence of AIDS in gay communities in the 1980s. Adopting narrative therapy’s ethical orientations of decentred yet influential positioning, and being in a ‘lifelong apprenticeship’, the author worked with a number of men to renegotiate their relationship with ‘sex addiction’ in their lives. This work included various maps of narrative practice, including the Statement of Position Map / externalising conversations, re-membering conversations, the absent but implicit, and deconstructive conversations.

What is ‘sex addiction’? The concept of ‘sex addiction’ seems to have grown rapidly in popularity in the last couple of decades. Some people are now convinced they are ‘addicts’ who, while perhaps being able to mitigate some of the effects of this on their lives, will never be able to change this ‘truth’ about their identity. This paper explores some of my attempts to understand both the phenomenon of ‘sex addiction’ and the affects of this idea on people, as well as work with clients to find ways to revise their relationship with this idea.

I come to this subject through a career working primarily with gay men. My first professional role was as a sexual health educator with the Queensland AIDS Council (QuAC) and I later went on to work for the AIDS Council of New South Wales in Sydney. The advent of AIDS in Australia triggered a great deal of fear towards and violence against homosexual men. In the mid 1980s, groups of concerned gay men came together to start a number of non-profit organisations to address the increasing stigmatisation and welfare needs of themselves and their peers. By 1989, some state health departments had made funding available for the purpose of educating so called ‘high-risk populations’ about HIV transmission. The AIDS councils took the position that a ‘sex-positive’ approach was critical to the engagement of gay and bisexual men in education strategies.

As is often the case when marginalised people join together, there was much opposition and hostility. Politicians, religious leaders, and media columnists fuelled calls for monogamy, an end to premarital sex, and prohibitions against homosexuality. There are, of course, documented histories of attempts to regulate sexual behaviour that well precede AIDS just as there are histories of opposition to these attempts to regulate. Gay men have been involved in aspects of both and during my employment with the AIDS councils, I met and worked with many men who favoured an approach to the prevention of HIV transmission that involved increased policing of sexual behaviour at a state and personal level. With respect to the latter, there were many instances of gay men criticising and even pathologising their peers for the frequency or type of sex they were having and calling for monogamy and celibacy in response to dominant discourses about gay men and their behaviour.

At this point, I think it is fair that I declare my concerns about approaches that pathologise individuals. I have found that when individuals are labelled as ‘disordered’ or ‘sick’, it makes it very difficult for them to move forward or develop a sense of personal agency about a problem. As a gay man who is also a counsellor and therapist, I am deeply committed to finding ways that free myself and others from such restrictive understandings and to working towards understandings that are empowering and affirming of who we are. When I started my private practice, I had a sense of the kinds of problems and difficulties I would be encountering. I was marketing my services to gay men because this seemed a good place to start for a therapist who had worked with gay men in organisations for a number of years. In some ways, it was not a surprise to find people were approaching me wanting solutions to the problem they were calling ‘sex addiction’. However, I did not realise how much I would have to consider how to approach this subject.

James’s Story

Soon after I started my practice, I was approached by James. James lived abroad in a country where he was considered quite wealthy by local standards. He described a deterioration in his mood and a history of a number of years struggling with what he was, for want of a better word, calling ‘depression’. He described it being like pieces of a puzzle he was unable to put together. He told me that despite having a male partner of 15 years who he loved, having a wonderful and privileged life abroad, he could not stop having sex with different men. He had not discussed this with his partner and he knew his partner would not approve. He told me that many of his sex partners were younger married men and the exposure of these liaisons could have devastating effects for many people.

James had begun to go through his life to find a cause for his behaviour, assuming that if he could find a ‘source’, perhaps he could do something about it. Was it because he was no longer attracted to his partner? Was he just being selfish? Was it something to do with his relationship to his father who had died many years earlier? James had heard something about ‘sex addiction’ and wondered if he too suffered from it, and whether it was something that he could not control. He had started thinking perhaps he was a ‘sex addict’. If this was the case, he believed there was nothing he could do but accept it. But he felt he had to at least seek treatment first. He asked to see me every couple of months when he would be visiting Sydney so that we could try to establish whether control was possible.

Meeting James started me thinking: What was my perspective on ‘sex addiction’? Was it something that really existed or was it just an idea? If I was going to help James, what did I need to know about this problem? How was I going to approach the issue with people? This article is the story of how I found myself questioning sex addiction.

The Landscape of Sex Addiction

Many of the ideas presented in narrative therapy have influenced my thinking about the subject of ‘sex addiction’. To begin with, I felt I needed to know a bit more about its origins. I did some Internet searches and came across recent media articles on the subject in relation to a couple of Hollywood personalities who had sought treatment. There were also a lot of web pages devoted to the subject and written from a Christian perspective. There were 12-step programs dealing with sex like they deal with alcohol and drug addiction. And I also found and read a couple of textbooks about it. Finally, there were quite a few practitioners in Sydney who were willing to work with sex addiction. It seemed there were plenty of professional people and services claiming to know the truth of its existence!

Yet I was sceptical. I have always been concerned about diagnoses or claims that behaviour can be categorised. A diagnosis carries an idea about measuring normality and even the worth of a person. A diagnosis carries an implication that there is an order that the person does not fit. Could the rapid rise of not only the popularity, but also the ‘reality’ of ‘sex addiction’ be an example of reification, where the idea has become a reality? Did the naming of ‘sex addiction’ infer its existence? What might it mean for someone to hear about ‘sex addiction’ and try to fit their life into these ideas? In terms of how to work with people experiencing – or being diagnosed with –‘sex addiction’, I pondered further questions such as: Who decides what is too much sex or when sex is ‘addiction’? How is it that certain people are able to make such truth claims? If someone was able to abrogate the responsibility for their actions on account of having an ‘incurable’ disease or disorder, what did this do to their sense of personal agency? How might this conclusion support a person to act towards others?

Mark’s Story

During this time that I was exploring these ideas around sex addiction, a man named Mark asked if he could see me about problems he was having associated with looking at pornography and dating sites on the internet. He was concerned that he might be experiencing ‘sex addiction’ and wanted help. Mark told me how his studies were suffering as a result of so much time spent on the Internet. He also attributed the demise of his relationship with his girlfriend, a committed Christian woman, to his viewing dating sites as this had compromised the trust she had for him.

As our conversations continued, Mark told me some history about his being excluded from activities and events in life and the effect this had had on him. Our dialogue quickly progressed to talking about inclusion and what gave rise to inclusion. Mark told me of his more recent efforts to be included, particularly in his family, and how he had been revising his relationship with his mother despite her death and their 20-year estrangement. I saw this as an opportunity to engage in some re-membering conversations about his family members that helped him come to a new understanding of how he had been bringing about inclusion (Russell & Carey, 2004; White, 2007).

Mark also told me about the emails he and his girlfriend exchanged and the realisation of how important it was for her that he acknowledge the expression of her feelings. He told me of how this continued contact was a new thing for him as he had previously always excluded ex-partners from his life rather than try to maintain a friendship with them. These alternative stories stood out for me as acts of resistance similar to those we hear if we listen carefully to stories of trauma. In his attempts to overcome the ‘waste’ and ‘broken relationships’ of his life, Mark had started making significant connections. By ‘talking’ relationships with others into ‘continuity’ he had started to experience greater inclusion and forgiveness.

After a few weekly sessions, we were both surprised to acknowledge that the time Mark spent looking at pornography since the start of our appointments had been minimal and he had ceased using dating sites altogether. His relationship with his partner was improving and they were talking more with each other about what they wanted for their relationship in the future. What was also surprising was that none of our conversations had been about ‘sex addiction’, the initial name Mark gave to the problem. We both thought that this was significant. In making the counselling appointment, Mark had presumed the task ahead would be associated with ‘self-control’ and that the problem reflected a deficit or weakness in himself. In making space for Mark to speak of his values, beliefs, and preferences, I was interested in hearing alternative versions of Mark’s life. Mark’s explanations of how he had been revising and working at maintaining relationships lead to a realisation for both of us that, far from being ‘weak’, he had been influential in making changes. It also made me think about the nature of ‘sex addiction’ and offered further evidence that it might be ‘just an idea’. And if it only existed as an idea, how powerful was it? How could I respond to this idea in a way that was empowering to individuals and communities?

Inviting Stories

I decided that to find out more, I would have to talk more with people who thought they might be experiencing ‘sex addiction’. So I advertised on the Internet that I worked with this subject. I was a little uncomfortable at first as my strategy flew in the face of what dominant therapeutic discourses tell us about professionalism. To ‘profess’ means to know. What did I know about this? I found some ideas concerning therapeutic orientation in narrative practice useful in this context:

  • There is no need for me to put myself up as an ‘expert’ and centre myself in this work; it is possible to be decentred and yet still influential (White, 2007, p. 39)
  • It is possible to approach one’s work as a never-ending apprenticeship (a connected idea, that comes from my understanding of Buddhism, is that of ‘beginner’s mind’ or allowing myself to be a learner; see Suzuki, 2002)
  • Counselling practice is enhanced by uniqueness and hearing details of that which is near and familiar to people more than generalities
  • There are always opportunities to explore the absent but implicit (White, 2000)
  • There is value in questioning truth claims!

Having convinced myself that I did not need to know everything there is to know about the subject, I still had another ethical question. Was it okay to advertise that I worked with ‘sex addiction’ when I was not even sure such a thing existed except as an idea? My answer to this was simple. Mark had expressed a lot of appreciation for my assistance in helping him with his problem, so I knew this kind of decentred approach could still be influential (White, 2007, p. 39). Advertising that I worked with ‘sex addiction’ was the easiest way for people who felt under its power to find me and I could with join anyone who was themselves at this point of questioning ‘sex addiction’. So I created some advertisements on free websites to indicate to people searching for Internet information about ‘sex addiction’ that I was prepared to have conversations about the matter.

Keith’s Story

Keith, a man in his 60s, contacted me after seeing one of my advertisements. He told me that he suffered from ‘sex addiction’, that it was a hard problem, and had been going on for years. Keith had been attending SLAA (Sex and Love Addicts Anonymous) groups – a 12-step program – and wanted to know whether I was prepared to help him with this because he had not been able to find a counsellor who had the knowledge to work in this area.

Keith had been to a number of different psychologists and doctors but not found anyone who could help him. One doctor had told him, ‘Well just don’t worry about it, just enjoy having the sex’. But for Keith, there were very big problems with this approach. Not only was he feeling guilty about keeping a secret of the sex he had with men outside his relationship, but his partner of five years, Xavier, had discovered that on one occasion, Keith had taken a stranger into the bed they shared. Up until this time, there had been much affection in their relationship and Keith really loved this, as it was not something he had experienced for much of his life. Since Xavier’s discovery, however, the affection they both enjoyed had virtually ceased and Keith reported that Xavier felt betrayed by the event. Keith did not know how to repair the situation. He was concerned to ensure it did not become any worse. Keith told me that he had been attending the SLAA groups for some time and while the problem had not seemed to improve much, he felt better for going as it felt like he was at least trying to do something about it. The idea that ‘sex addiction’ might be responsible for Keith’s situation was actually proposed by Xavier who had done some research about it on the Internet.

I was concerned about Keith’s expectations that I work within the SLAA model. It seemed he had devoted a lot of his time and thought to the SLAA groups. My unease was that ‘sex addiction’ was being portrayed as a disease by SLAA. But while I was uncomfortable with this, I did not see how I could expect Keith to simply drop this framework of understanding just because of my own reservations. How were we going to proceed? In the beginning, I did not know the answer to this question but I was curious about Keith’s experience with the problem and what he might have learned and might know from his own experience. I told him I had not attended SLAA groups but I was prepared to learn and valued this opportunity to meet with someone who was prepared to explain them to me. I proposed that I could contribute some skills around asking questions that might help us both to understand the best way forward. In my mind, I was thinking about the metaphor of co-researchers (Epston, 2001; Nosworthy & Lane, 1996). I had to be careful about this, however. As I got to know Keith, I discovered that he had not experienced much formal education and often was dismissive of his own knowledge with comments like ‘I’m not very smart’. I thought the best way to proceed might be for us both to explore and acknowledge what he did know about the problem.

Externalising ‘Sex Addiction’

I began with externalising the problem, asking questions about Keith’s relationship to it. Keith told me how he thought of it as The Compulsion and, since he was more comfortable calling it this than ‘sex addiction’, we began using this name for it. We looked at the effects of The Compulsion on Keith and what these effects meant for him, his life with Xavier, and his own sense of power. Some of this involved using the language Keith had learned from the SLAA groups. For example, he told me about ‘Intriguing’ which he explained was a kind of purposeful fantasising about someone one might see on the street or in a toilet block or elsewhere. Intriguing was something The Compulsion liked and helped make The Compulsion stronger. Keith told me he had direct experience of this.

We also spoke of what Keith wanted for his life with Xavier. Having sex with men in toilets and other places had never been a problem prior to the relationship. If he had not met Xavier he would not even be attending SLAA meetings or seeking help! This told me something more about the importance of his relationship with Xavier and we spent a whole session discussing the impact of The Compulsion on their relationship and why this was significant for Keith. In Michael White’s Statement of Position Map (White, 2007), we were at the ‘justification of the evaluation’ stage of externalising around this point, and found ourselves shuttling back and forward across Keith’s life making connections between events from the distant and more recent past. In speaking of his values and commitments, Keith shared stories from his life that explained why Xavier was so important to him, and the histories of their shared life that justified Keith’s focus on accountability. Through negotiating this experience-near and particular definition, mapping the effects of the problem, evaluating the effects, and hearing Keith’s justification of why he was taking this position in relation to The Compulsion, I was struck by his depth of knowledge of The Compulsion and I wondered how I might be able to encourage Keith to question it.

Documenting Strategies

Keith had been explicit in wanting me to ‘find resources to help’ him. Rather than externally-produced resources, I thought it might be useful to write to Keith with a summary of what we had found together, creating a therapeutic document that could serve as Keith’s own resource. I have included it here as it provides a good overview of our conversations and highlights the strategies that Keith had indicated he was already using.

Dear Keith,

We have now met on four occasions and at today’s appointment, you agreed it might be useful if I were to write and summarise some of the conversations we have had in our counselling sessions.

You have told me that in talking of The Compulsion, your hope is to find ways to live with it, manage it, and control it.

You have told me about the effect The Compulsion has had on you, on Xavier, and on the relationship you both enjoy. You and Xavier have a lot in common and like doing things together. You have told me about how in the past it has been hard for you to get close to people, because you feared they would discover your sexuality. However, you also have experiences of honestly telling people about yourself which have resulted in people trusting you. You have told me about how the picnic, Xavier’s invitation to go on holiday, and interaction with his family have contributed to your hopes that you can patch up the relationship with Xavier. What part might honesty play in regaining trust with Xavier?

You have identified a cycling that The Compulsion does. Lately, it has been a lot better as it has been staying up the back and waiting. It is sneaky. When it is not strong, life is easier as you are not fighting it. We know that The Compulsion likes:

  • Isolation and withdrawal
  • Tiredness and frustration/depression
  • Intriguing.

So together we have identified some of the resources that you have already found have an effect on The Compulsion, that have enabled you to live with it and that perhaps go some way in managing or controlling it. These are:

  • Spending time with Xavier
  • A good sleep
  • Saying your piece (which helps to avoid frustration as it results in you calming down really quickly)
  • Attending SLAA meetings and sharing (which also allows you to say your piece)
  • Accounting for how you spend your time and you have been doing this with Xavier
  • Not leaving enough time to do other things that support The Compulsion
  • Not avoiding professional appointments
  • Attending counselling.

You also have an idea that talking with Xavier about these resources might help to keep The Compulsion weak. Xavier has, in the past, expressed a willingness to hear about your efforts to deal with The Compulsion. You would like to find out Xavier’s thoughts about the ways you are trying to manage and control The Compulsion. You have also talked of the possibility of Xavier attending one of our sessions and joining us in our investigations of ways to manage and control The Compulsion.

Someone at the SLAA group has suggested that you may need support when you go on holiday with Xavier. I wonder who might be available to provide support and how you might remain in contact with this support while you are away? Keith, in deciding which direction to go, it seems you have a great deal of experience and knowledge about this Compulsion from which to make some decisions. I have really enjoyed our discussions and finding out how you have been attempting to manage, control, and live with the Compulsion. I have also learnt a lot about this subject from our discussions. Now I am wondering about how you might be able to bring some of this knowledge and experience into your relationship with Xavier and into the SLAA meetings in order to further weaken The Compulsion.

I look forward to our next appointment.

Best regards,

Ash

Writing this letter provided Keith with documentation of our sessions and a point for starting to have a conversation with Xavier. It also enabled a reference point for our future conversations. I saw Keith once more before he went on holiday and then there were almost two months before I saw him again. When we next met, Keith told me that The Compulsion had been ‘way back there’ which was ‘really good’. It had subsided a lot since our last meeting and ‘did not cause a lot of stress at the moment’. His relationship with Xavier had improved and was ‘99% back the way it was’ with Xavier ‘singing and dancing’ around him all the time. The affection in the relationship had returned as well. Keith told me that he had not been attending the SLAA meetings but intended returning. He wanted to try to start ‘sharing’ as ‘they said things started to change when you start to share’. He also found that hearing stories gave him strength and this was important to keep The Compulsion weak.

But Keith had also started to question some of the ideas of SLAA, particularly that ‘abandonment leads to sex addiction’. When I asked him about this, he referred to an earlier conversation where he told me a story of asking a family friend about his mother:

Keith: She said, ‘She was hard, but she loved you’. And that’s how I know I wasn’t abandoned. My mother loved me, and I remember that.

Ash: So this idea of abandonment doesn’t fit for you?

Keith: No. I don’t know where they get that from.

We talked about how Keith had started out trying to fit into the ideas of SLAA but now he was only using the ideas he found helpful. Up until he went on the holiday, he had been very concerned that he had not been reading enough SLAA literature. But he had gone away ‘hoping it would just be okay’ with what he was already doing. After the holiday, he realised it had been okay. Now he was questioning some of the ideas of SLAA. This was significant as it meant Keith was giving some preference to his own knowledge rather than being confused because he did not understand the SLAA teachings or had a sense of failure about not having done his homework.

Unravelling ‘Sex Addiction’

Having had these and many other conversations about ‘sex addiction’, I am more confident about asking questions of it. Looking closely, it seems like a jumble of cords that will take some unravelling. These cords are the lines of stories that have become tied and tangled and lost in a mess that is seen simply as ‘sex addiction’. Tangled together are ideas about sex and love, judgements and norms, stories about values, commitments, desires, hopes, and dreams. So it is hard to see ‘what follows from what’ or understand the connections or the continuity of those stories that are inspirational. As with other problems, people often approach me expecting I will have a kind of internal manual to work out a solution or course of treatment for them. But what has been confirmed by my investigations so far has been Harlene Anderson’s observation: we don’t need to solve the problem, the problem dissolves when we have conversations (Anderson, 1997).

I understand that, as a counsellor and therapist, I am in a privileged role within this process. Due to the nature of this subject, none of the people I have mentioned in this article were willing for me to include any information about our sessions that might identify them and it was important for me to respect that. I have consequently used pseudonyms and altered details or been general where necessary to protect the anonymity of the people who have spoken with me. However, I must express my appreciation for what they have helped me learn about questioning ‘sex addiction’. My conversations with some of these people continue and there will be other conversations with other people who join me to ask questions about ‘sex addiction’. Of course, there are so many other options for where I can take people in conversations if they are willing. For example, what possibilities might exist for an exploration of James’s association of life (White, 2007)? If Keith brings Xavier to an appointment, what might be gained from attempting some definitional ceremony practices or at least outsider-witnessing, with the couple (Russell & Carey, 2004; White, 2007)? How might the SLAA group act as a community of acknowledgement (White, 1997)?

What I think I have done here is nothing particularly grand or – dare I say it – ‘sexy’. It has been to simply start asking questions about a concept that has, in some quarters, taken on the status of a ‘truth’. In doing this, I have been listening for the alternative stories. I know these alternative stories exist wherever and whenever there is resistance to, or attempts to overcome, a problem.  These are really just the beginning attempts to unravel stories around ‘sex addiction’ so as to make it possible for people to come to new understandings about their identities and relationships with others.

References

Anderson, H (1997). Conversation, Language and Possibilities. New York, Basic Books.

Epston, D. (2001). Anthropology, archives, co-research and narrative therapy. In D. Denborough (Ed.), Family therapy: Exploring the field’s past, present and possible futures (pp. 177–182).

Nosworthy, S., & Lane, K. (1996). How we learnt that scratching can really be self-abuse: Co-research with young people. Dulwich Centre Newsletter, (4), 25–33.

Russell, S., & Carey, M. (2004). Narrative therapy: Responding to your questions. Adelaide: Dulwich Centre Publications.

Suzuki, S. (2002). Zen mind, beginner’s mind. New York: Weatherhill.

White, M. (1997). Narratives of Therapist’s Lives. Adelaide: Dulwich Centre Publications.

White, M. (2000). Re-engaging with history: The absent but implicit. In M. White, Reflections on narrative practice: Essays and interviews (pp. 35-58). Adelaide: Dulwich Centre Publications.

White, M. (2007). Maps of narrative practice. New York: W.W. Norton.

This article originally appeared in The International Journal of Narrative Therapy and Community Work 2009, no.2

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