Integrating Sex And Marital Therapy

A Clinical Guide

Gerald R. Weeks

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780876304471
• eBook ISBN: 9781134846092
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The field of sex therapy has experienced tremendous growth in the last 20 years . The use of the term "sex therapy" for most clinicians brings several well-known therapists to mind and is associated with the treatment of a fairly limited number of sexual problems. The view of sex therapy as a profession has had both positive and negative consequences. The editor's state that the purpose in writing and editing this book was to build on the work of individually oriented sex therapy by adding the systems perspective. This book, then, represents an attempt at the integration of sex and marital or systems therapy.

Part I

Conceptualizing Sexual Problems from a Systems Perspective

Section I

Theoretical Issues

Chapter 1

Evaluating the Marital Relationship of Clients with Sexual Complaints

Larry Hof

Although the short-term, behaviorally oriented approach to the treatment of sexual dysfunctions has proven to be an effective treatment modality over the last 15 years, couples who experience severe marital distress demonstrate a poorer prognosis for treatment in a variety of forms of sex therapy. The research that supports this conclusion (see Berg and Snyder, 1981, for a listing of studies) confirms the belief that sexual dysfunctions do not occur in a vacuum, and they must be viewed within the context of the total system of the client(s).

The various subsystems (e.g., marital, extended family, individual, biological, social, etc.) interact with each other and impact on one another. The marital relationship impacts on the sexual problem, and, in turn, the sexual problem impacts on the marital relationship, as each of these interacts with a variety of other forces. This being the case, it is obvious that a comprehensive and multidimensional approach to the treatment of sexual dysfunctions must include a thorough evaluation of the marital relationship. This conceptualization enables the therapist to assess and understand the place of forces within the marriage in the etiology and maintenance of the sexual dysfunction; the relative strength of relationship-enhancing forces that could potentially facilitate and support the process of sex therapy; and the relative strength of relationship-diminishing forces that could potentially inhibit and even undermine the process of sex therapy. With this information, the practitioner and client(s) are better able to decide whether sex therapy is appropriate at the time and what strengths might be drawn upon. The therapist can also better anticipate potential problem areas in therapy and thus be prepared for them and plan more effectively to resolve them should they emerge. If sex therapy is contraindicated (because of the presence of severe, rather than moderate, marital distress), the marital evaluation can indicate what needs to be addressed in marital therapy in order to pave the way for the future treatment of the sexual problem.

A review of the literature relevant to sexual assessment and evaluation reveals a significant deficit in the area of information pertaining to the marital evaluation of clients with sexual problems. Masters and Johnson (1970) stressed that the couple is “always” the patient and in so doing noted that a systems perspective was needed when treating sexual dysfunctions. The process and content of the individual and conjoint interviews were discussed in great detail, with the focus on the specifically sexual aspects of the relationship. The broader, nonsexual dimensions of relationship functioning were barely noted. From this early publication, little can be gained regarding the nature and theoretical base of a comprehensive marital evaluation.

In another early publication, the Group For The Advancement of Psychiatry (1973) emphasized the concepts of “marital unit,” “mutual responsibility,” and “complex multidimensional system based on the way each partner sees the other and sees the marriage itself, on the self-image of each, and on each partner’s perception of how he or she appears to the other” (pp. 775–776). Beyond this, little was said to enable the clinician to identify and evaluate the component parts of the marital system and their relationship to sexual problems. The extensive listing of topics covered in a sexual history (pp. 827–836) contained no questions specifically designed to evaluate the marital relationship.

At about the same time, Kaplan’s important work on the treatment of sexual dysfunctions appeared (1974). In that work, a systems perspective pervaded the assessment section of the book. Intrapsychic “causes” of sexual dysfunctions were described from a Freudian perspective, along with a brief review of cultural and developmental sources of the kinds of conflict that can lead to sexual dysfunctions. In discussing “The Relationship – Dyadic Causes of Sexual Dysfunctions” (Chapter 9), Kaplan focused on partner rejection, transferences, lack of trust, power struggles, contractual disappointments, and sexual sabotage. She also discussed the need to assess when relationship factors require direct intervention in treatment, and when they can perhaps be bypassed. In addition, there was a strong emphasis on social learning theory (as well as psychoanalytical theory) as providing a helpful base for understanding the etiology and treatment of sexual dysfunctions. In spite of the wealth of material presented, the reader is left without a broad-based, systematic, and detailed format for evaluating the marital relationship of clients with sexual problems.

Some four years later, LoPiccolo and LoPiccolo (1978) edited their Handbook of Sex Therapy, to update the reader on the then most current developments in the treatment of sexual dysfunctions. Generally speaking, a systems approach was assumed as a foundation for the book. In the discussion of clinical assessment, Lobitz and Lobitz (Chapter 5) presented their approach to the initial evaluation. They stressed the importance of relationship factors, but there was insufficient breadth and depth in this area. In LoPiccolo and Heiman’s discussion of the sexual assessment and history interview (Chapter 6), nine questions pertaining directly to the relationship were included, but without any theoretical framework for the questions.

Kaplan’s most recent work, The Evaluation of Sexual Disorders (1983), represented the first systematic integration of the biological and psychological aspects of the evaluation process. Relationship factors were given a place of appropriate prominence and were addressed from a conceptual and methodological perspective, with a specific focus on the following: (1) specific problems in the sexual interaction – inadequate techniques, poor communication, and incompatible sexual fantasies; (2) neurotic interactions – power struggles, contractual problems, parental transferences, and ambivalence about intimacy, commitment, and romantic success; (3) psychopathology of the spouse; and (4) incompatible marriage. A few specific questions gave the reader insight into Kaplan’s approach. Yet, when this writer finished reading the relationship-oriented sections, he was left with a degree of dissatisfaction. There simply was insufficient depth and systematization to enable the reader to know how to make a comprehensive marital evaluation of clients with sexual complaints or dysfunctions.

In fairness to the above writers, it must be stated that the marital evaluation of clients with sexual problems was not their major focus. As the years have progressed, however, the need for more thorough attention to this area has become evident. Students and therapy trainees have continued to ask for more “specifics” in this area. In addition, knowledge regarding the nature and aspects of effective marital relationships and the important role of the extended family/multigenerational context in the etiology and maintenance of some sexual problems has increased dramatically.

The purpose of this chapter, then, is not to replace anything that has been written before. Rather, its purpose is to add more flesh to the skeleton created by those who have previously written, to attempt to provide the clinician with a broader, more specific, and more current systematic framework for evaluating the marital relationship of clients with sexual problems and dysfunctions.

EVALUATING THE MARITAL RELATIONSHIP: AREAS OF FOCUS

When evaluating the marital relationship within the context of sex therapy, four specific areas of focus are indicated: (1) psychometric indicators of marital adjustment; (2) assessment of the current relationship style of the couple; (3) identification and assessment of the original and current marital contract; and (4) exploration of the extended family/multigenerational context.

Psychometric Indicators of Marital Adjustment

A variety of inventories and scales are available to enable the therapist to assess sexual and marital adjustment. A special issue of the Journal of Sex and Marital Therapy (5:3, Fall, 1979) was devoted to the subject and described over 50 instruments. A comprehensive and updated review and critique of instruments that assess sexual functioning and adjustment is beyond the scope of this chapter, and the focus here will be on three instruments of practical use to the clinician.

The use of brief, valid, and reliable instruments such as the Locke-Wallace Marriage Inventory or the Dyadic Adjustment Scale can give the therapist a good overall sense of the clients’ perceptions of marital adjustment and satisfaction (Locke & Wallace, 1959) and dyadic adjustment (not necessarily marital), the latter with a focus on dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression (Spanier, 1976). Without at least a moderate level of satisfaction, sex therapy is unlikely to be successful.

The Marital Satisfaction Inventory (Snyder, 1979), which focuses on a variety of relationship issues, including affective communication, problem-solving communication, quality of leisure time together, etc., has proved useful in “differentiating couples with generalized marital distress from those with specific sexual dysfunctions” (Berg & Snyder, 1981, p. 294).

Inventories and scales such as these can help the therapist distinguish couples with severe marital distress (poor prognostic indicator for sexual therapy) from those with moderate or less marital stress. The latter group is much more likely to benefit from sex therapy, and, in some cases, successful sex therapy with people in this group may even facilitate resolution of other marital problems (Sager, 1976b).

Assessment of the Current
Relationship Style of the Couple

The assessment of the current relationship style of the couple enables the therapist to identify positive forces and processes within their relationship that could facilitate treatment and to identify relationship-diminishing forces and processes that could disrupt or block desired growth and change in therapy. When evaluating the current relationship style of the couple, the therapist seeks information via questioning and direct observation regarding the following issues:

• How are the inclusion, control, and affection/intimacy issues handled within this relationship?

• What is the balance between feelings, rationality, and behavior in this relationship?

• How effectively do the partners communicate with each other?

• How effective is the couple’s problem-solving and decision-making process?

• How effectively do the partners manage conflict?

Inclusion, control, and affection/intimacy issues. Schutz (1966) has stated that all individuals have three basic interpersonal needs, which are manifested in various behaviors and feelings in the individuals’ relationships with other people: the need for inclusion, the need for control, and the need for affection/intimacy. Berman and Lief (1975), Hof and Miller (1981), and Doherty and Colangelo (1984) have discussed and developed the relationship of Schutz’s concepts to marital and family functioning, emphasizing that these are perhaps the three core issues in relationship functioning.

The key “inclusion” question in a marriage is: What is the extent of each partner’s commitment to the other and to the relationship? A continuum from noncommitment or disengagement to extreme enmeshment, where boundaries are virtually nonexistent, expresses the various possibilities. The therapist can inquire directly regarding the extent and nature of commitment (e.g., high versus low level of commitment; commitment out of duty, fear, religious values, financial realities, for the sake of the children or maintaining a family unit; or commitment based on love, shared values, interests, and intimacies). In addition, further insights can be gained as the couple’s communication and interaction is observed (e.g., to what extent do they speak of a future together?).

It is important that each partner has a sense of personal identity (versus enmeshment), commitment, belonging or membership (versus disengagement), and a belief that the other person is committed to the relationship at a somewhat similar level. Without some sense of parity in this area, trust will remain relatively low, as will the willingness to risk self-disclosure in potentially vulnerable areas. The implications for the sex therapist are obvious. Without a sufficient level of self-identity and commitment to the relationship, many partners are unable or unwilling to expose their pain, embarrassment, shame, etc., or to risk trying to change behaviors when failure could possibly lead to feared ridicule or abandonment.

Some key “control” questions in a marriage are: How equitably is power distributed and what is the level of satisfaction with the power distribution? How are decisions made and roles renegotiated? To what extent does each partner see himself/herself and the other as a responsible person? The therapist can inquire directly regarding these issues and can observe the interaction of the couple when a decision is required in the therapeutic process on even such a small issue as the day and time of the next appointment (e.g., does each express opinions? do they consult each other in the decision-making process? do they value each other’s ideas? can they compromise?).

When one partner believes he/she is somewhat powerless or resents the other’s unilateral decision making or role definition, the situation is ripe for the control struggle to spill over into the sexual relationship in overt attempts to control sexual expression, in the withholding of sex, or, even more passive-aggressively, in the inhibition of sexual desire. On the other hand, when both partners believe that they themselves and their partner are powerful and responsible, mutual and satisfying problem solving, decision making, and role renegotiation become real possibilities in many areas, including the area of sexual expression.

The key “affection/intimacy” question in a marriage is: What is the degree of intimacy experienced between the partners and to what extent are they each satisfied with it? Intimacy here refers to the in-depth sharing of core aspects of oneself with one’s partner. As with the inclusion and control issues, direct questioning in this area can yield significant information. For example, “what is each partner’s perception of the quantity and quality of physical and non-physical affection expressed in the relationship?” “what types of intimacy do they share and what is their satisfaction level with each type?” Direct observation can also give important clues (e.g., to what extent do they employ touch during the sessions? to what extent are supportive, warm, and caring expressions exchanged during the sessions?).

With Clinebell and Clinebell (1970), the author believes that there are at least 12 varieties or facets of intimacy: sexual, emotional, intellectual, aesthetic, creative, recreational, work, crisis, commitment, spiritual, communication, and conflict. Since no one can be intimate with all people in all ways, it is important that a couple define for themselves in what ways they desire intimacy and work to achieve those goals. When in-depth intimacy in one area is desired by one partner to a certain degree, but to a lesser degree or not at all by the other, the potential for deep hurt and diminished satisfaction in the relationship is obvious. When core intimacy needs are not addressed satisfactorily, the potential for sexual problems increases dramatically.

Feelings, rationality, and behavior. In order for an individual and a relationship to function at its optimal potential, it is necessary that there be a balance between feelings, rationality, and behavior. Many therapies emphasize one of these dimensions of the self to the virtual exclusion of the others, encouraging the development of skills in one area as the so-called “key” to effective interpersonal functioning. We thus have behaviorists, cognitionists, and affective expressionists. All, in the author’s view, err to the extent that they do not seek a balance between all three of these areas of the self.

Egan (1970) has expressed the need for “total human expression” in relationships, the blending of “thought-full” and “feeling-full” expression in effective communication processes. L’Abate ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Foreword
• Contents
• Preface
• Contributors
• Part I. Conceptualizing Sexual Problems from a Systems Perspective
• Part II. Special Problems
• Name Index
• Subject Index