Case study—Tom

Tom was a divorced, heterosexual male around age 40 with a long history of relapse to alcohol and cocaine use. He also had bipolar I disorder and was quite familiar with his mood swings. He had been in many detoxes and several jails, and presented to our outpatient clinic for mental health counseling services while he was living in sober housing.

Because Tom had a strong personality, his male counselor worked hard at creating a bond, to the point of allowing Tom to consider his counselor more as a friend than a therapist. This approach seemed to be working, inasmuch as Tom kept his appointments, took his meds, and maintained his sobriety.

But the therapeutic relationship, although pleasant, never triggered honest, revealing, intimate discussions. Tom was unable to address his fears, secrets, or regrets in counseling. He was willing to “chat,” but resisted dialogue in more sensitive areas. He couldn't drop his guard.

When asked about previous therapeutic relationships (as the counselor tried to get an idea of what was currently missing), Tom mentioned a female therapist with whom he once shared everything. Tom guessed it was her gender, not her counseling style, that allowed him to be more forthcoming.

Perhaps his male therapist's successful “bonding” got in the way of more open dialogue. Maybe Tom's father had been emotionally unavailable to him. Maybe jail had fortified his hardened exterior.

Tom did not request a transfer to a female clinician, but his work schedule required that we assign a new therapist. Not surprisingly, we selected a woman.

Case study—Sarah

Sarah was in her 30s, a white, single, heterosexual mother of two presenting with a history of substance dependence as well as post-traumatic stress disorder (PTSD) resulting from her bullying father and abusive boyfriends.

Our knee-jerk reaction was to connect her with a female clinician. We feared that a male counselor might trigger the PTSD or that we would be reinforcing her past reliance upon males by putting her in the hands of a male authority figure. Also, we thought that Sarah might have an easier time sharing her sexual history with another female.

On the other hand, we wondered if it might be helpful to expose her to a caring male who wanted nothing from her—a man who does not hit or yell. We asked Sarah if she had a preference regarding the gender of her counselor. To our surprise, she was completely ambivalent.

Sarah was a success story. We connected her with a male clinician who moved very slowly in establishing and strengthening the therapeutic relationship. He allowed her to set the agenda and he gently explored the discrepancies between her words and her actions. He had children and was empathic in discussing her parenting issues, which were considerable. He was sincere in focusing on her strengths and accomplishments, and we believe he helped her to fortify her self-efficacy.

Conclusion

Addiction professionals must be sensitive to gender issues, being aware that men and women approach communication, listening, and problem solving differently. We must be comfortable discussing a client's sexual experiences and orientation candidly, without awkwardness or judgment. And we must be able to demonstrate the maturity, respect, and openness we wish to see in our clients.

Although “guys with guys, gals with gals” works well in AA, it has limitations in a clinical setting. If a client prefers a counselor of a particular gender, we should explore the thoughts behind the preference—and then assign the most appropriate clinician.