Real Advice: SEX THERAPY: Through the lens of Relational Life Therapy

By Dan F. Pollets, Ph.D.

Dr. Pollets describes himself as "an enthusiastic practitioner" of Relational Life Therapy (RLT). He is a faculty member of the Relational Life Institute, and an ASSECT certified sex therapist.

EDITOR'S NOTE: The names of all clients as well as any other identifying information in the REAL Advice blog are changed to protect their confidentiality and privacy. Also this post discusses the topic of sexual intimacy in a frank manner.

THE CASE:

Alissa and Matt are a late 30s couple with no kids. They are not married. They have been together for three years and living together for two. They are both successful business people. Alissa and Matt presented with the major complaint of dissatisfaction with their sex life. They were in a rut of sexual avoidance. They told me they only have sex once every six weeks, and they were increasingly angry and resentful towards each other.

We discussed their sexual history individually and together, and they revealed dramatic differences in what they like as far as arousal goes. Alissa states, "We have different warm-up interests." She expressed that she needs more romance and extended foreplay other than genitally focused.

Alissa said she has a history of pain upon intromission -- a medical condition called vulvodynia. At the time, she had not had this thoroughly evaluated, in fact, according to WebMD, physicians are only now addressing this as a real gynecological disorder, so for most of her life, she has had the shame of doctors telling her the pain is not real. I referred Alissa to a gynecologist who specializes in sexual medicine who prescribed sessions with a physical therapist who uses biofeedback in order to re-condition the pelvic floor muscles and help her relax during intercourse and feel less pain. A thorough test of her hormones by an endocrinologist was also part of the medical piece of this case.

By contrast, Matt 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. He said, the wind goes out of his sail. I encouraged Matt to get his erectile dysfunction evaluated. He was prescribed Viagra.

The combination of her pain and his E.D. left them both frustrated and only increased their anxiety about sex, and this spilled over into the other aspects of their relationship.

Alissa wished for more sensuousness; Matt wanted to just get down to business. She believed that her painful intercourse and sexual avoidance would be remedied by a change in Matt's behavior towards her. She said that their difference in sexual needs played out in their relationship in general in so much as she wished that Matt could be more expansive, social, and more interested in her world. Matt said he wished that Alissa would not be so anxious and "compulsive." He felt that her anxiety about things being out of place made relaxing -- and sex in particular -- very difficult. He said he finds this off-putting, and acknowledged that he escapes from the tensions between them by watching cyber-sex and masturbating.

THE RLT SEX THERAPY:

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 what Terry Real calls "the more, the more" -- an emotional dance which means the more she pushes, the more he retreats.

Sex couples therapy from the perspective of Relational Life Therapy (RLT) is as didactic as it is emotionally focused. It 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. RLT helps the therapist identify the obstacles that hinder each partner from articulating what they need sexually and how to guide them in making direct requests of each other -- how they transmit. The other half of the equation is to elevate their understanding of how each partner receives the information that is being shared. This is about "listening to give what you can," versus finding ways to defend, rationalize, blame or retaliate against your partner's request. In RLT, therapists teach these winning and losing strategies to develop the couple's communication skills. It is taught and practiced in the therapy session.

THE OUTCOME:

Using this technique, Alissa was empowered to articulate her sexual needs more clearly and was taught how to accomplish this using good boundaries -- in a way that isn't pushy, off-putting or nagging. We call this "speaking relationally." Regarding Matt, we first had to address his grandiose behavior -- his determination to want to have sex his way which resulted in his resentment of Alissa's need for foreplay and special considerations. Much of this due to his lack of knowledge about the female sexual response. We remedied this by educating him and having Alissa speak about her arousal needs. We also addressed Matt's avoidance of creating a romantic environment. The RLT therapy helped him re-frame foreplay from an "obstacle" into a way to get what he really wanted -- more and better sex! He learned that a little of "this" would get him a lot of "that".

What should be obvious but is often obscured in these cases is that a good sexual relationship (as with the relationship in general) is about Cherishing, 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 Relational Life principles. You can see how the sexual dance between Alissa and Matt is a metaphor of the relationship dynamics in general. As a RLT therapist, I will often make this explicit by suggesting the connection between effective sexual communication in the bedroom and what happens (or could happen) in the other rooms of the house.

Alissa and Matt have done extremely well in just three months of treatment. They have more frequent sex (now two times per week). An interesting note is that Alissa has found a way to move through her discomfort by changing positions. She continues to pursue medical treatment for her vulvodynia and hormone issues. Matt has "come down" from grandiosity and has turned off the "misery stabilizers" (TV, cyber-sex) and is more present in the relationship. He is able to give in his sexual behavior toward Alissa and not judge or criticize her needs. He appreciates it when Alissa give him more specific feedback and verbal/non-verbal cues as to what she needs to become aroused, and he enjoys her. In turn, Alissa has attempted to give Matt more of what he wants which is less anxiety and compulsion on her part and more relaxed playfulness. The tension and conflict in the relationship overall has been reduced. As we would expect, their overall level of intimacy has improved along with their sex life.

I have found that Integrating the powerful techniques of RLT with traditional sex therapy has proved extremely effective in my treatment of couples presenting with sexual complaints.

Comments

A COMMENT FOR PRACTICING THERAPISTS: 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 RLT extremely helpful in diagnosing this “deformity” and then correcting it. In this blog post, I described my method of working with these couples and how to integrate RLT into the sex therapy (or the sex therapy into the RLT).

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.

Posted by: Dr. Dan Pollets | January 09, 2008 at 07:22 PM