Sex Therapy through the Lens of Relationship Empowerment Therapy
By Dan Pollets, Ph.D.
I am an enthusiastic practitioner of Relationship Empowerment Therapy (RET), on the faculty of the Institute, and a sex therapist (ASSECT Certified). In this capacity, I am often referred couples whose presenting problem is a sexual one and where there often is a physically-based sexual dysfunction. At the same time, there is inevitably a deformity in the relationship dynamics which confounds and interacts with the sexual dysfunction. I have found RET extremely helpful in diagnosing this “deformity” and then correcting it.
In this brief space, I would like to describe my method of working with these couples and how to integrate RET into the sex therapy (or the sex therapy into the RET). To paraphrase Terry Real, here’s the deal on cases that involve a sexual problem or dysfunction: identify the physical, refer the medical, and then focus on the relational.
Treating cases that involve a sexual problem or dysfunction necessitates a level of knowledge about the medical aspects of sexual dysfunction so that a valid physical issue (e.g. erectile dysfunction, desire disorder, premature ejaculation, sexual pain disorder, arousal disorder, anorgasmia) is not glossed over. It is crucial not to “psychologize” a sexual problem that has an underlying physical basis. The specific sexual problem and physical correlate needs to be validated in its own right and referred for medical evaluation and then treatment. This, of course, can go on concomitant with the couples’ work. An urologist or gynecologist who specializes in sexual medicine would be your best bet to refer to. Acknowledging the reality of the physical component by the therapist and getting the partner appropriate help can be extremely stress/anxiety/shame relieving. I am reminded of Terry’s concept of “joining through the truth.” You solidify your standing as a knowledgeable treatment agent when you are able to juggle the three “balls” of mind, body, and relationship in these cases. A strong alliance follows.
Once you get the partner with the sexual dysfunction referred for medical evaluation you can focus on the relational “dance” that plays out between the two. The problematic interpersonal dynamics that interacts with the sexual problem is your “patient” and needs correcting if there is to be recovery of a functional sex life. What has been so helpful to me about using RET in these cases is how you can label and define with accuracy the couples’ self-defeating “dance” that generates the conflict from which they withdrawal. It is often the case that the conflict in the sexual realm parallels the couples’ classic “fight.”
For instance, the more the woman asks for romance, foreplay and sensitivity from her man, the more he feels criticized, inadequate and then withdrawals or gets angry. In other words, it is one partner’s Core Negative Image (CNI) versus the other’s CNI in the bedroom. Once “the more, the more” takes hold, the romantic and relaxing environment that is needed for good sex evaporates and instead, it is “off to the races.” In the bedroom as in the other rooms in the house, there is often the “blatant” and “latent” and the therapist move is to empower the latent, find leverage, and connect the blatant. The leverage can be that they both want a better sex life. Let me illustrate with a case I have recently worked on.
Maggie and John are a late 30s couple with no kids. They are not married. They havebeen together for three years and living together for two. They are both successful business people. Maggie and John present with the major complaint of dissatisfaction with their sex life, sexual avoidance (once every six weeks) and increasingly angry and resentful towards each other. Maggie reports a history of pain upon intromission (vulvadynia). She has not had this thoroughly evaluated. Discussion of their sex history individually and together revealed dramatic differences in what they like as far as arousal goes. Maggie states, “We have different warm up interests.” Maggie verbalized the need for more romance and extended foreplay other then genitally focused. John said he is not all that interested in foreplay and likes to “cut to the chase.” He acknowledged that this might have to do with his difficulty sustaining his erection, especially when he has to stop midstream and put on a condom. The wind goes out of his sail as he says. Maggie’s wish is for more sensuousness; John would like to get down to business. She believes that her painful intercourse and sexual avoidance would be remedied by a change in John’s behavior towards her. She states that their difference in sexual needs plays out in their relationship in general in so much as she would wish John could be more expansive, social, and interested more in her world. He wishes that Maggie would not be so anxious and “compulsive.” He feels that her anxiety about “things out of place” make relaxing into play and sex in particular, very difficult and is off-putting. He acknowledges that he escapes from the tensions between them by watching cyber-sex and masturbating.
In this case, as in all sex therapy cases, the first move is to get a very detailed picture of the sexual dysfunction and how the relationship dynamics interact to create “the more, the more.” Maggie has a sexual pain disorder called vulvadynia. She was referred to a gynecologist who specializes in sexual medicine. She was referred by this specialist to a physical therapist who does uses biofeedback in order to re-condition the pelvic floor muscles. This hopefully helps Maggie relax during intercourse and feel less pain. A thorough test of her hormones by an endocrinologist was also apart of the medical piece. John was encouraged to get his erectile dysfunction evaluated and was prescribed Viagra.
The RET/Sex couples therapy is didactic as it is emotionally focused. Maggie was empowered to articulate her sexual needs more clearly and was taught how to accomplish this using good boundaries (“speaking relationally”). John’s perspective was determined to be “grandiose” in so much as he wanted to do “it” his way and resented Maggie needing so much time and special considerations. His lack of knowledge as to female sexual response was remedied by educating him and having Maggie speak as to what her arousal needs are. John’s avoidance of creating a romantic environment and more “warm-up time” was and framed as an obstacle in the way of his getting what he wanted – more and better sex. What should be obvious but is often obscured in these cases is that a good sexual relationship (as in the relationship in general) is predicated on what Terry calls the “Golden Rule” of relationship: Tell me what I need to know so that I can give you more of what you want. RET helps the therapist identify the obstacles to each partner articulating what they need sexually and making direct requests (transmission). The reception piece is about “listening to give what you can,” not about defending, rationalizing, blaming, retaliating or other “Losing Strategies.” This communication skill is taught and practiced in the session.
Cherishing, one of the “Winning Strategies,” is about being empathically attuned to the other’s physical needs, not judging or going “one-up” and then “walling off” or disconnecting. This skill can be explicitly taught using RET principles. You can see how the sexual dance between the two is a metaphor of the relationship dynamics in general. I will often make this explicit by suggesting the connection between effective sexual communication in the bedroom and what happens (or could happen) in other rooms in the house.
Maggie and John have done extremely well in just three months of treatment. They have more frequent sex (two times per week). Interesting is that Maggie has found how to move through her discomfort by changing positions. She continues to pursue medical treatment for her vulvadynia and hormone issues. John has “come down” from Grandiosity and has turned off the “misery stabilizers” (TV, Cyber-sex) and is more present. He is able to give in his sexual behavior toward Maggie and not judge or criticize her needs. He appreciates Maggie giving him more specific feedback and verbal/non-verbal cues as to what she needs to become aroused and enjoy her. In turn, Maggie has attempted to give John more of what he wants which is less anxiety, compulsion on her part and more relaxed playfulness. The tension and conflict in the relationship overall has been reduced. As we would expect, their level of intimacy has improved along with their sex life. Integrating the powerful techniques of RET with traditional sex therapy has proven extremely effective in my treatment of couples presenting with sexual complaints.