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Exploring Evolving Clinical Models for Sex Therapy

Exploring Evolving Clinical Models for Sex Therapy

By Steph Auteri | From the June 2014 Issue

Last week, over 550 sexuality professionals attended the 46th annual AASECT conference. It was a chance for sexologists to further their education; to trade tips and concerns, swap information, and engage in industry-specific dialogue; and to meet in person colleagues with whom they may previously have only communicated via phone, email, or listserv.

Events like AASECT's annual conference also provide opportunities to evaluate the industry itself... to take stock of how the field is doing and to ask: Is there more we should be doing? How can we more effectively serve those we're licensed to serve? How can AASECT continue to be a distinct voice among sexual health practitioners and educators?

And then there is the question of how effectively we maintain a continuing dialogue about evolving clinical models for sex therapy. AASECT has a tradition of questioning how to do better and how to continue challenging what we think and how we practice. How do we continue promoting this type of dialogue, and when do we take a stand?

One highly visible example of this dichotomy in action is the continuing controversy over the sex addiction industry, covered in a pre-conference workshop earlier this month by Richard Siegel, MS, LMHC, CST, CSSP and Lawrence Siegel, MA. In their workshop — A Sexological Approach to Treating Problematic Sexual Behavior — Richard and Lawrence set out to explore sexual addiction treatment and the mental health professionals who broadly apply the term "addict"  to their clients. Through their presentation, they aimed to help clinicians develop a more sexological — versus "addictionological" — approach to the diagnosis and treatment of problematic sexual behaviors, forcing therapists to take a closer look at a treatment methodology that was already in wide use.

"This program came about as a reaction to the burgeoning sex addiction treatment industry, in which sex is treated in the same way they treat every other addiction," says Richard Siegel, who has a private sex therapy practice, co-directs two sex therapy institutes, and teaches as an adjunct at the undergraduate level. "The fact that these [addiction professionals] are not sex therapists further adds to the frustration," he says, stressing that if one were to seek out professional help for problems related to sexuality, they should see someone actually trained in those issues.

Lawrence Siegel — who teaches at several universities and also does professional training — elaborates on his and his brother's general view of the sex addiction industry: "It's pretty much a moralistic ideology that's masquerading as science," he says. "We want sex therapists to be sex therapists and do the work they're trained to do. And we want addiction people to get better trained in sexual health and sexuality rather than making the behavior the disease. We encourage people to have enough professional curiosity to know what the behavior is a symptom of. Is it an anxiety disorder? Depression? Something else? That's what we're trained to treat."

Organizations like the International Institute for Trauma and Addiction Professionals (IITAP), meanwhile, train and certify licensed professional health care providers to approach sex addiction as a trauma-related disorder, integrating emerging brain-based neurophysiological drug addiction research, claiming these brain studies demonstrate similar consequences stemming from sexually addictive behavior.

In fact, ITTAP training does not cover human sexuality at all, instead focusing on a one-size-fits-all 30-task model. The task model is the "standard of care" expected to be universally provided by all 1,700 Certified Sex Addiction Therapists (CSATs). 

It gives one pause to contrast the training of certified sex therapists with that of certified sex addiction therapists, especially when one considers the fact that IITAP is a for-profit entity, tied to a particular theory of treatment, rather than a non-profit organization like AASECT that does not find itself beholden to any specific treatment methodology.

In considering a stance on the efficacy of the sex addiction model — and on other treatment methodologies in general — what should AASECT and, by extension, all sexuality professionals be taking into consideration?  

Beyond one controversy:  licensing, research, and evolving clinical models for sex therapy

For one thing (as has already been alluded to above) we can start taking a closer look at the discrepancies in licensing standards that can sometimes emerge across various disciplines. 

While, for the most part, certified sexologists do seem committed to continually furthering their education, we must confront the unfortunate reality that not all certifications and training programs are made equal, especially among non-sexologists whose work only bumps up against sexuality peripherally.

As Peggy J. Kleinplatz, PhD, writes in New Directions in Sex Therapy: Innovations and Alternatives (which earned AASECT's 2013 Book Award): 

"Training in human sexuality and in dealing with sexual problems is not typically integrated into the training of most clinicians, e.g., physicians, nurses, clinical psychologists, clinical social workers (Maurice, 1999). ... It is rather disturbing that while advertisements in the media are telling consumers to talk with their physicians about sexual concerns, the teaching in medical schools surrounding human sexuality continues to be reduced or eliminated. The majority of medical students in the U.S. and Canada feel uncomfortable talking about sex with patients, unprepared to do so, inadequately trained to do so or in most cases, all of the above (Frank, Coughlin, & Elon, 2008; Malhotra, Khurshid, Hendricks, & Mann, 2008; Shindel, Ando, Nelson, Breyer, Lue, & Smith, 2010; Wittenberg & Gerber, 2009)."

During the course of our conversation, Kleinplatz adds: "All of the different professions indicate that it's unethical to treat someone outside the scope of one's training and expertise, and yet very few programs in medical or mental health training provide what is required to deal with sexuality in practice."

Daniel N. Watter, EdD, who has written on the topic of ethics as they relate to sex therapy, and who has served on the Ethics Committee for the New Jersey Psychological Association, expands upon this, highlighting the importance of supervision and referrals in cases where training has not left one sufficiently prepared for the issue at hand. "Individual clinicians have an ethical obligation to not take on cases they're not trained to treat," he says. "You shouldn't be treating sexual addiction if your training was in alcohol addiction. All of us are expected professionally to get supervision if we come across something we're unfamiliar with."

This exploration of how various service providers can better educate themselves — and collaborate with each other — is undertaken in greater depth in another one of our articles this month. But non-sexuality-based programs aren't the only issue. Even within programs that purport to serve those who might handle issues of sexuality, some programs are more or less rigorous than others.

Returning to the area of trauma and addiction as just one example, sex addiction therapist training courses don't tend to offer even a basic course in human sexuality. As a result, problematic sexual behavior is treated in the same way as every other addiction.

Says Watter, "I think people need to be wary of those organizations who will offer you a certification too easily. Sometimes people shy away from the hard ones, even though those are the ones more likely to be substantial." 

When asked to comment on certification inconsistencies, he says, "I'm pleased that AASECT's certification process has become much more stringent over the years. But there are still plenty of organizations that if you send them a check, they'll send you a certificate."

Richard Siegel hones in on this particular distinction, explaining the difference between certification and certificate-ion. He mentions how organizations like AASECT follow a national standard in their credentialing procedures. "But when someone goes to a Patrick Carnes sex addiction workshop," he says, "they receive a certificate... not a certification. That's not the same as a certifying body holding a standard and maintaining a level of competence. Part of the problem and frustration is that the public doesn't know the difference."

Which is something sexologists can't necessarily control. "AASECT does not have the power to mandate training outside its own membership," says Kleinplatz, "but in doing that for our own members, we can at least provide an assurance to the public that AASECT credentialing means the consumer is in the hands of someone who does have the required training and knowledge of human sexuality; skill and competence in individual and couples therapy; and, beyond that, specialty training at the post-graduate level in dealing with sexual problems in counseling and therapy."

To that end, those like Virginia Sadock, MD, continue to create new opportunities for those interested in strengthening their knowledge base in the area of human sexuality. Sadock brought her own program in human sexuality to NYU Langone Medical Center's Department of Psychiatry in 1980, and it has since become an AASECT-affiliated program, imparting AASECT CEs.

"I was on several exam committees," says Sadock, a clinical professor and the director of her program, "and I saw there were very few questions about sexuality. Also, there was not much teaching about sexuality." 

When Sadock first brought her training program to NYU, it was a two-year program that devoted one full year to didactic teachings, and one to clinical hours. "They've packed in a lot more information since then," says Sadock. As detailed on the program website, participants meet with patients on a weekly basis for a 45-minute session and receive hour-for-hour supervision for each treatment session. In addition to their own cases, trainees are also exposed to other treatment issues during clinical case conferences. Weekly seminars of one hour are also offered that cover a broad range of material on sexual dysfunctions and clinical case discussion.

In highlighting the competitiveness of the program, Sadock says they only accept state-licensed mental health professionals who have had at least two years of clinical experience in their own field. When asked if most students are sexologists-in-training or other clinicians looking to further their understanding of human sexuality, she says she sees both. "It's marvelous to have people from different disciplines," says Sadock. "Everyone brings in something different."

But beyond training standard discrepancies — and only adding to the difficulties of being able to effectively evaluate various treatment models — are the varying qualities of research being presented to both professionals and the public. How can sexologists discern a reliable source from an unreliable source?

Watter points out that we should first take a look at the organization behind the research. "Whenever you talk about a for-profit situation," he says, "there's always the potential for an inherent conflict of interest. Their intent could be for the good, but the for-profit mission of those sponsoring the research means that the bottom line is going to drive a lot of the decision-making."  

Lawrence Siegel provides even more guidelines we can follow in critically reading various types of research. "We need to evaluate whether or not something has been peer-reviewed," he says. "We need to ask ourselves what a research sponsor's agenda may be. What are they basing this information on? Is this an academic site or just a blog? Is there some kind of professional organization behind it? Where are they getting their info? Was this researched? We have to do our homework, too." 

"Unfortunately," he continues, "there's no easy way around it anymore. We have to slog through a lot of crap to find that rich nugget. We have to have a more critical eye for recognizing the integrity of the information being presented."

"I subscribe to 20 journals and I read them every month," says Kleinplatz. "I really do think it's important that we be on top of the research. Things change. We're going to be inadequately trained if we don't stay on top of reading the literature. It's a professional and an ethical responsibility." But she concedes that maintaining focus on only the best resources out there can sometimes be difficult. "It's also important that students take some courses in research methods," she says, "so as to have the academic and critical reading tools to sort through the wheat from the chaff in the literature."

As Watter points out, research doesn't definitively prove anything, and new research is always furthering and transforming our understanding of things we may have assumed were already set in stone.

And so, because continuing education and up-to-date research are only two ways in which to have a continuing dialogue on clinical models, new and old, we need to consider how else we can remain open to other alternatives out there. Have we ourselves become single-minded or closed off to other treatment methodologies that could possibly be beneficial to those who seek out treatment?

In referencing IITAP's own single-mindedness, Watter points out that "It makes the assumption that there's a one-size-fits-all kind of treatment. I just don't believe that's so," he says.

He goes on to talk about the ways in which we sometimes — after a time — accept one way of treating people as the best and perhaps only way. "I see it as our ethical obligation to always question even the most widely-accepted principles," says Watter. "A lot of times, our dogma is the result of a research study that indicates something but proves nothing. Research doesn't prove anything. We walk around as if there's some certainty in all of this. We have to challenge all the time, because information and understanding become richer all the time."

"I think AASECT and other organizations do a good job of making open forums for people with different opinions to present their data and approaches," says Watter. "That keeps the dialogue going."

Kleinplatz agrees. She adds, "Some organizations or approaches claim to be 'biopsychosocial' but, in reality, one or two of the critical elements may be missing." In New Directions in Sex Therapy, Kleinplatz (2012) writes: 

"The number of clinicians who identify primarily or are trained as sex therapists has dropped dramatically, at least as indicated by the records of the American Association of Sex Educators, Counselors and Therapists (AASECT). ... It seems a shame that we are losing the critical mass of colleagues with a similar or at least complementary base of training in sex therapy and the opportunity to meet on a regular basis and cross-fertilize. We may never have had the kind of multi-disciplinary brain-trust required for our profession to develop and thrive, each benefitting from the knowledge base and perspective of the other’s home discipline; however, whatever collective, intellectual, meeting ground we shared has surely been eroded by the splintering of our field into separate, specialty domains. Many conferences are now marketed towards and attended by physicians rather than clinicians who identify as sex therapists. Similarly, conferences populated primarily by social scientists are impoverished by the absence of our medically and biologically oriented colleagues. It is to our mutual detriment when we fail to incorporate the insights and advances of our fellow professionals who deal with sexual issues and concerns (Kleinplatz, 2003). As a result of this professional fragmentation, one cannot count on seeing a clinician who has received a fundamental core of training in the biological, psychological, interpersonal and social aspects of human sexuality."

Others think it's time for certain debates to end, and for AASECT to take a stand when it comes to models like the sex addiction model. Though AASECT has taken a stand on other methodologies — you can read their position on sexual orientation and reparative therapy here — the validity of treatment models such as the sex addiction therapy model continues to be a hot button topic among members.

"I certainly appreciate AASECT's desire to have as wide a tent as possible," says Lawrence Siegel, "and to be as inclusive and welcoming as possible. But we need a focus. As an organization, we need to be able to state a clear position on the lack of clinical legitimacy of the sex addiction label. While we welcome the continued debate and discussion, we can't give it equal time. It's a false equivalency."

"We stay away from that dialogue," Richard Siegel says when asked how we can work toward having a more effective discourse on sex addiction and other contentious topics in a field rife with continuing educational and research disparities. He references Neil deGrasse Tyson's statement when comparing climate change deniers to flat-earth arguers: "We can keep on arguing," he says, "but there comes a point where you have to say that the jury is, in fact, in... and you're wrong." 

Do you agree? Do you feel the topic still carries too much complexity for AASECT to be able to take a specific stand? Do you have more to add to this discussion? We encourage all members to click over to AASECT Express and continue the conversation there. We'd love to hear what you have to say!

AASECT has a tradition of questioning how to do better and how to continue challenging what we think and how we practice. How do we continue promoting this type of dialogue, and when do we take a stand?