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:

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.