When Art Therapy Meets Sex Therapy

Creative Explorations of Sex, Gender, and Relationships

Einat S. Metzl

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9781138913127
• eBook ISBN: 9781317426851
• Topic: Psychology
• Subtopic: Human Sexuality in Psychology
• Index: Psychology

Appropriate for both sex therapists and art therapists, When Art Therapy Meets Sex Therapy explores sexuality and gender through the use of art making, connecting relevant theories and research from both fields. It begins with a historical review of how explorations of anatomy, physiology, and sexual identity manifested in art making in different cultures and discusses why a clinician must take these spiritual, medical, and socioeconomic factors in account to offer effective and culturally competent therapy. The second part of the book discusses clinically effective treatments in art and sex therapy, and contains numerous case illustrations. Included are interventions for important issues in therapy, such as exploring gender identity, sexual health and shame, processing sexual abuse, couples' intimacy, parenting concerns regarding their children's sexuality, and treating sex addiction.

Part 1

Why Should We Explore Sexuality Creatively?

one

Where Art Therapy and Sex Therapy Intertwine

This chapter discusses what the book is hoping to accomplish and how integrating creative explorations of sexual issues is helpful to both art therapists and sex therapists. Specifically, this first chapter examines the main premises in current sex therapy theories and how art therapy can serve as a useful tool given our current understanding of communication, meaning making, and brain processing. Then, I explore recent research evidence of how effective art therapy is and suggest that using the intuitively reflective process of art making might be particularly helpful in uncovering intimate and emotionally charged topics, while exploring current knowledge gaps and limitations of art therapy research.

The World Health Organization (WHO) defines sexual health as:

a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (WHO, 2006, p. 3)

This widely used definition of sexual health of the WHO therefore identifies four components: “physical, emotional, mental and social well-being in relation to sexuality,” not merely the nonexistence of disease, dysfunction, or infirmity, as might be understood by juxtaposing health to psychiatric definitions of sexual challenges (for example, as described in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5: American Psychiatric Association, 2013)). Specifically:

When viewed holistically and positively: Sexual health is about well-being, not merely the absence of disease; Sexual health involves respect, safety and freedom from discrimination and violence; Sexual health depends on the fulfillment of certain human rights; Sexual health is relevant throughout the individual’s lifespan, not only to those in the reproductive years, but also to both the young and the elderly; Sexual health is expressed through diverse sexualities and forms of sexual expression; Sexual health is critically influenced by gender norms, roles, expectations and power dynamics; Sexual health needs to be understood within specific social, economic and political contexts. (WHO, Department of Reproductive Health and Research, 2010, p. 1)

On that same subject, the WHO identified the foci of sexual health as: (a) consequences or conditions such as: infections with human immunodeficiency virus (HIV), sexually transmitted infections, and reproductive tract infections; (b) unintended pregnancy and abortion; (c) sexual dysfunction; (d) sexual violence; and (e) harmful practices (such as female genital mutilation).

Understanding that sexual health and sexual concerns are multidimensional and multilayered, almost all sex therapy models—from the most behaviorally based models (such as sensate focus) to the most relational (such as emotionally focused couple’s therapy)—necessitate a thorough assessment, which would explore medical problems related to a client’s sexual health, and an assessment for depression, trauma, learning disabilities, anxiety, and other mental health issues possibly impacted and/or impacting sexual concerns both emotionally and cognitively, and, finally, the client’s social environment(s), evaluating degree of safety and freedom of sexual exploration and identification,

There are many wonderful models available for therapists to support clients as they increase their sexual health. For example, Metz and McCarthy (2010), in their book Enduring Desire, suggested a “good enough sex” model, whereby couples learn to have more realistic expectations of what great sex looks like, integrate sex into their daily living, emphasize pleasure over performance, demonstrate multidimensional approaches to sexual satisfaction, and create a positive, creative approach to sexual problems. The multidimensional approach to sexual satisfaction includes cognitive aspects (positive attitudes, preparation for relaxation, realistic expectations of sexual development informed by trial and error), emotional components (such as inviting each other’s full range of emotions), and a behavioral component (such as prioritizing sex, self-discipline, cooperation, learning sensual triggers for each, and the concept that sex is important). Metz and McCarthy (2010) aimed to create an “intimate team,” working together toward a “good enough sex.” Specifically, they identified the following elements as necessary frames for the intimate team to agree on or at least strive toward: Sex is an activity worth pursuing, sex is relational, the couple is grounded in realistic and age-appropriate expectations, good health is required for good sex, relaxation is important for good sex, sensual touch and pleasure are a priority, gender differences (if relevant to the couple) are respected, and sex can be experienced on a variety of levels (playful, spiritual, physical, etc.).

Kleinplatz and Menard (2007), in “Building Blocks toward Optimal Sexuality,” interviewed 1,000 people who reported they were having “great sex” and created a model based on six core themes. The building blocks they identified included: (a) being present (flow, arousal overcomes thinking—sex as a state of being); (b) authenticity (being true to one’s sexual self, ability to bring yourself to the partner); (c) intense emotional connection (I–thou, understanding one another fully by being separate); (d) sexual and erotic intimacy (feeling aroused and “safe” when kissing, for example); (e) communication (verbally being able to say what works and doesn’t work and being able to deliver and receive emotions nonverbally); (f) transcendence (perhaps like Maslow’s peak experience, a god-like state, spirituality, as found by Ogden (2013)). All in all, they suggested we move past attempting to eliminate pathology and work toward creating sexual knowledge through exploration.

Recent theories of sex therapy call for the expansion of sex therapy practice (Ogden, 2013), specifically identifying the need to add spirituality and existential frames, understanding that sexual experiences are multidimensional. Specifically, Ogden (2013) stressed that sexuality can manifest the ways our physical, emotional, mental, and spiritual experiences throughout our lives have informed us and how, dialectically, our sexual choices further formulate our beliefs, core identities, and the possibility of stagnation or change. Ogden (2013) suggested the use of integrative and expressive tools for assessment (see Chapter 2) and treatment of sexuality-related issues through shamanic practices and the ISIS Wheel,¹ which helps clients move between processing the physical, emotional, cognitive, and spiritual intuitive wisdom so that all can heal and support a healthy sexual core identity. Although not an art therapist, Ogden (2013) suggested the need for interventions that are ritual-based, visceral, sensual, and audio-perceptual. Specifically, she identified using “drawing activities” such as “creating yourself on paper” (p. 103), in which clients create a body-size outline of themselves and embellish it through words and colors to reflect stories held in the physical body. While this is but one example from the current sex therapy literature, it certainly reflects not only the possibility and usefulness of art making for such expanded exploration of sexuality, but also the need to consider how expressive tools can and should be used. Although the present book is by no means intended to train sex therapists as art therapists (that requires a full graduate degree!), it nevertheless can inform sex therapists who are currently using expressive techniques in considering different aspects and possibilities of art. Perhaps more importantly, these expansions to sex therapy practice suggest that art therapists who are already trained in using expressive tools might find a specialization in sex therapy a profound and unique way to contribute to both respective fields. In fact, it suggests that even art therapists who do not wish to operate as sex therapists or specialize in this topic can and should consider the ways that the art interventions they already use might support clients’ wellbeing while they more directly acknowledge their clients’ sexuality.

In her most recent edited book, Extraordinary Sex Therapy: Creative Approaches for Clinicians, Ogden (2015) collated the work of renowned sex therapists who practiced from a more holistic and expressive approach. Specifically, she illustrated the need to ask our clients questions that support healing beyond the technicality of their sex lives, helping clients understand their experiences of sexuality as layered and central to their relationships, personal goals, and desires. According to Extraordinary Sex Therapy, interventions related to the use of imagination, sensory-perceptual expressions, connection to ritual and nature, writing, touch, and playfully working with archetypes are all illustrations of current sex therapy practices that seem particularly connected to current art therapy practices.

These expansions to sex therapy reinforce concepts that art therapists already know well. Vija Lusebrink’s (2004) expressive therapy continuum, for example, modeled directly how the art therapist can work through the kinesthetic-sensory level, the affective-perceptual level, and the cognitive-symbolic level by offering appropriate media choices and art interventions. She asserted that the creative synthesis realized through art making provides meaning making of both conscious and subconscious processing. Our current understanding of communication and brain processing (e.g., Ellis, 2007) also illustrates the usefulness of art making in working through, clarifying, organizing, and expressing what is often felt and unnamed or named in ways that reduce the fullness of the experience (Barbee, 2002). Dissanayake (1995) presented a theory of art making and creativity as central and unique to the human race. More precisely, she addressed the unique need we have for expressing and communicating meanings, which she asserted as essential to the survival of our species.

While art therapy as a field is certainly in great need of more consistent and solid outcome research, what recent evidence-based/outcome research findings there are certainly support art therapy as an effective modality across diverse clients, settings, and mental health issues (e.g., Slayton, D’Archer, & Kaplan, 2010). Although art therapy theory and research are yet to receive the desired “evidence-based practice” imprimatur (due to limited resources for research, the small size and relative newness of the field, among other factors), psychological research has tied creativity to wellbeing through the concept of “flow” (Csikszentmihalyi, 2014), as well as to specific attributes related to creativity. Specifically, creativity seems to inherently support personal growth and wellbeing in our everyday lives (Richards, 2007) and as we consider mental health (Kaufman, 2014). Finally, researchers are forging a connection between creativity and resilience (Alayarian, 2007; Bender, Metzl, Selman, Gloger, & Moreno, 2014; Corley, 2010; Jenkins, 2005; Metzl, 2009), exploring both the cultural and contextual aspects of creativity as well as the universal way in which creativity seems to foster recovery despite adversity or trauma.

It would seem, therefore, that creativity is particularly suited to enabling client engagement that is both profound and integrative, a manner in which physical, emotional, cognitive, and spiritual aspects inherently thread together, and promote meaning making and wellbeing—a concept closely aligned with Ogden’s (2013) call for what the sex therapy field needs. Further support for the fit between art therapy and the work of exploring sexuality thoughtfully lies in the many voices within the sex therapy field urging therapists to raise clients’ mindfulness and awareness of their own experiences (e.g., Resnick, 2012). Art therapy practice has a comprehensive understanding of the ways art making enhances connections to the here and now while assisting clients in distilling their internal experiences. These premises of art therapy are in fact so common that it would be hard to cite any one source; indeed, art therapy’s capacity to foster an intuitively reflective process for uncovering intimate and emotionally charged topics has also been named and illustrated throughout the art therapy literature (e.g., Franklin, 2000; Wadeson, 2001).

So, this is how I ended up here. Informed by the above-cited trends in sex therapy and my heartfelt gratitude for having the art as a tool to offer my clients as an art therapist, encouraged by my experiences teaching art therapy students about human sexuality and sex therapists about the possibilities art holds in national conferences, this book took shape.

Note

1 The ISIS Wheel of sexual experiences denotes the integration of four experiential dimensions—that of mind, the heart, the body, and the spiritual—in coming to know one’s sexual self.

two

Creative Assessments of Sexual Needs and Wants

This chapter touches on the way current sex therapists and art therapists explore sexual needs and assess diagnostic and systemic variables, discussing how sex therapists attempt to explore the multilayered aspects of sexuality, creating priorities and goals for treatment that are as parsimonious and effective as possible. Similarly, I review basic premises of creative therapies and art therapy in particular, and then illustrate how art therapists have looked at developmental considerations of art making and applied those to assessments of sexual abuse. I also discuss potential strengths and challenges of these art therapy assessments with regard to the limited effectiveness/outcome research in our field, comparable to established assessments from the sex therapy field.

At the heart of sex therapy’s historical canon are the assessment and treatment models known as the PLISSIT model (Annon, 1976), which focuses on permission to inquire about the client’s sexual wants and challenges, providing limited information and specific suggestions, and only if these solution-focused interventions do not work—move toward more intensive therapy. Kinsey’s studies and scales of the normative ranges of sexual behaviors (1998a, 1998b) of course had a profound effect on normalizing a range of sexual behaviors and choices, and Masters and Johnson’s (1970) assessment procedures created the frame for most sex therapy interventions. As noted above, the PLISSIT model suggests that, after the therapist gains permission from the client to explore sexual issues, limited information and specific suggestions are first discussed in an attempt to resolve the problem, and in the event that more layered or complex needs are involved, a course of more intense therapy is recommended. In other words, traditional sex therapy attempts to resolve problems on the levels they are presented and in as short a course of time as possible, guided by an understanding that addressing sexuality in itself is a challenging and sensitive task for many clients (permission), then providing more concrete assistance (psycho-education and relevant books, sex toys), and moving into more in-depth therapy—only if that is warranted to resolve the presenting issue.

Similarly intended to utilize the assessment to tailor the treatment to what the sexual issues necessitate, Masters and Johnson’s (1970) approach suggested that treatment always begins with assessment procedures, including a physical examination and thorough medical and personal histories. The therapists then met with the couple to discuss their assessment of the nature, extent, and origin of the sexual problem to recommend treatment procedures and answer any questions (Masters & Johnson, 1970).

While these methods are still taught as part of the core concepts of sex therapy, more systemic approaches are often taken for assessment and treatment—specifically, as Buehler (2013) illustrated in her sex therapy primer, an understanding that sociocultural variables and familial contexts are crucial for effective sex therapy treatment. Buehler (2013) drew from Bronfenbrenner’s five eco-systemic levels to assess sexuality as it relates to the micro-system (e.g., individual biological and psychological make-up as well as one’s family of origin and peers), meso-system (e.g., interactions between and among institutions, such as couples who are struggling in the bedroom), exo-system (e.g., influences of health or religious institutions), macro-system (e.g., the geographic, political, and judicial system one is part of), and chrono-system (e.g., contemporary influences, such as generational perceptions of sexuality). Buehler (2013) conceptualized the use of such multilevel assessment of sexuality as one that provides a broad and deep basis for treatment. In Chapter 4, I focus more on the eco-systemic approach for integrating art therapy and sex therapy, and illustrate working systemically on a meso-system with couples in Chapter 8. As I am trained as a marital and family therapist, I always consider the myriad systems in which we live and define ourselves, and how they manifest in familial, cultural-societal, and temporal considerations, as described throughout this book.

In line with this eco-systemic...

Table of contents

• Cover Page
• Half Title page
• Series
• Title Page
• Copyright Page
• Dedication
• Contents
• Figures
• Preface
• Outline of the Book
• Part 1 Why Should We Explore Sexuality Creatively?
• One Where Art Therapy and Sex Therapy Intertwine
• Two Creative Assessments of Sexual Needs and Wants
• Three The Visual Cultures of Sexuality
• Four The Many Layers of Sexuality
• Part 2 Implementation
• Five Exploring Gender Identity Through Art Making
• Six Sexual Health, Behaviors, and Shame, Explored Through Art Making
• Seven Treating Sexual Abuse While Integrating Body, Mind, and Spirit
• Eight Envisioning the Interpersonal Space in Couples' Lives, Through Art
• Nine Art Interventions for Parenting Issues Related to Sexuality
• Ten Love, Sex, and Addiction Exploring the Hunger Games
• Eleven Concluding Thoughts The Art of Embracing Our Most Intimate Selves
• References
• Index