With few exceptions, most mental health clinic managers have encountered the patient or parents of a patient who make the demand indicating whether they want either a female or male therapist. The reason for this request is likely associated with the very reason they are seeking therapy. The request is difficult for the manager or supervisor to ignore. Indeed, human service professionals have been trained to listen to patients and want to deliver services conducive to their expectations. However, by complying with what a client wants, we may be helping that person avoid what he or she actually needs.
Therapy Can be Uncomfortable
There is a common misconception about therapy with laypeople, in that they believe therapy is going to be soothing and relieve symptoms immediately upon initial contact with the therapist.
In fact, facing psychological stressors that have been suppressed and avoided for extended periods of time can initially be very uncomfortable for the patient. This discomfort is analogous to the physical discomfort experienced when physical therapy is initiated after a surgery or injury. The client needs to understand that therapy can sometimes be painful in the beginning but will be become less painful as issues are addressed and resolved.. Many of these distressing issues often involve members of the opposite sex, with avoidance being the primary motivation.
Avoidance Because of Trauma and Exposure Therapy
One of the primary symptoms of trauma related disorders such as Post-Traumatic Stress Disorder (PTSD) is avoidance. If this avoidance is because of sexual assault or physical abuse by a male, it is quite understandable why a female or parent of a child victimized by a male would request a female therapist. Furthermore, this avoidance is generally coupled with the client’s complaint of being fearful of males. The fearful response is operantly negatively reinforced , when the female or child client is removed or removes self from the presence of a male and the fear subsides, exacerbating the behavior of avoidance.
Research has indicated that exposure therapy has demonstrated efficacy in the treatment of trauma related disorders. Therefore, in the aforementioned examples, the presence of a male in the therapy room, however uncomfortable at first, may be helpful in assisting the client to begin desensitizing themselves to the feared stimulus.
In addition, a male therapist with whom the client can develop a trusting relationship may also in itself, begin to dispute and challenge the maladaptive thoughts the client has in regards to males. Reisck et al., (1988), found that after initial suspicion and apprehension, women in their study which compared the treatment efficacy of different treatment modalities for sexual assault, expressed appreciation for the presence of a male co-therapist. The women indicated the presence of a non-violent male who was sensitive to their issues and reactions was appreciated.
Becker, Zayfert, and Anderson (2004) found in their survey of 207 practicing psychologists, exposure treatment for PTSD is being used by only a minority of clinicians. The primary reasons given for exposure not being utilized in therapy are lack of training, fear of exacerbating symptoms and client dropout.
In addition, the interaction of factors such as therapist discomfort with the exposure imagery and patient avoidance may contribute to under-utilization of exposure therapy for trauma related disorders. Although exposure is an empirically supported treatment for trauma, its lack of use by therapists appears to be analogous to the avoidance concerning therapist/client assignment, in regards to the client’s preference for a therapist opposite of that by whom they were victimized (Becker, Zafert, & Anderson, 2004).
A key component to exposure therapy is psychoeducation regarding the rationale for the exposure and the displacement of the feared stimulus. Assisting the client to understand that gradual and optimal activation of the fear channels is necessary for effective processing and treatment (Rauch & Foe, 2006). Educating the female patient or parent of a child during the initial intake process concerning these factors, could well diminish inhibitions concerning the avoidance of the male therapist and may well reduce client early dropout.
Interpersonal Discomfort and Dysfunction
According to Weissman, Markowitz, and Klerman (2007), one of the two major goals of interpersonal psychotherapy is to help clients resolve issues related to life situations and individuals responsible for the manifestation of their symptoms. If for instance, a male client is having difficulty relating to women, he may be inclined to request a male therapist at intake. In this example, the patient would be demonstrating avoidance of his interpersonal deficits and likely the very life situations with which he is struggling.
In this scenario, a female therapist may be able to more readily identify problem areas in his area of interpersonal dysfunction and more directly assist the client to resolve these issues.
Alliance and Outcomes Based on Mixed and Matched Dyads
The common belief in psychotherapy is client/therapist dyads matched on gender demonstrate higher levels of therapeutic alliance, resulting in more efficacious outcomes.
However, the research on this premise appears to be mixed. Cottone, Drucker, and Javier (2002) reported in their study on therapist gender and its effect on treatment outcomes for mixed and matched therapeutic dyads based on sex, suggested no significant influence on outcome.
Wintersteen, Mensinger, and Diamond (2005) found in their study of 600 adolescent boys and girls, there was no significant difference in feelings of alliance between female clients matched with a female therapist and those matched with a male therapist.
However, the male patients indicated stronger feelings of alliance with the male therapist than with female therapists. Furthermore, male therapists reported higher levels of alliance with their male clients than their female clients. The authors postulated the male therapists may have felt discomfort interacting with their female clients and failed to assess their need for affiliation.
The results indicate the male therapist’s comfort level of working with a female client may be as relevant to the decision of therapist assignment as the client’s expressed preference.
A collaborative working therapeutic alliance between therapist and client is perhaps the most important aspect of psychological treatment. I’m not saying that the client should not have a say in his choice of a therapist. However, an enlightening discussion regarding the client’s rationale for avoiding or preferring a male or female therapist may reveal important issues the patient may not have considered in the proper context. Assisting the client to better understand his/her reasons for avoidance or preference for a therapist of a specific gender may expedite the therapeutic process and help provide the client with what they need in lieu of what they initially want.