A basic tenant in couple's therapy is to assess both relationship satisfaction and sexual satisfaction before beginning a treatment intervention. Published correlations between the two (relationship satisfaction and sexual satisfaction) vary enormously, from nonsignificant to .65 (Braden, 2015; Ellison, 2012). While there are many satisfying relationships that co-exist with sexual frustrations and some sexually satisfying relationships that struggle with other relationship tensions, it is common to see couples struggle with both issues. Each distress area can fuel the other, like forest flames torching adjoining trees with abandon. Many moderators and mediators can affect the relationship; the two most important being adult attachment style and cultural norms.
Historically, the most prevalent treatments have compartmentalized the skill components of sex from the psychodynamic insights and cognitive skills needed for better communication and relationship satisfaction. Therapists who have advocated bridging the two approaches and treating them concurrently include David Schnarch (1997), who examines how lack of differentiation negatively impacts sexual interest; Carol Ellison (2012), who focuses on the moderating influence of emotional connection on both sexual and relationship satisfaction; and Esther Perel (2006), who highlights how role confusion and contradictory expectations stem from the dual roles of friend and lover.
Stella Resnick has been pioneering a deeper and more extensive integration of the two for more than twenty years. An American Association of Sexuality Educators Counselors & Therapists certified sex therapist who conducts couple workshops at the Esalen Institute, she guides therapists on how to treat sexual dysfunctions by healing relationship ruptures in her newest book, Body to Body Intimacy: Transformation Through Love, Sex, and Neurobiology. While cognitive behavioral therapy (CBT) and psychodynamic theory is included in the technique, the therapy is more deeply rooted in the neurobiology of attachment and Gestalt techniques that foster healthy attachment as an adult. The intervention involves each partner consciously experiencing their own internal body experiences and then learning to soothe the partner's distress body experiences through one's own empathic and nurturing body expressions. It is truly a body to body approach and unlike what most couple therapists have in the toolbox.
Her approach centers on the primacy of experiential awareness and the resolution of rejection trauma. The therapist learns to foster experiential awareness in the couple from the get-go. For example, Resnick says couples should never sit side by side in the therapy room; they need to be looking across from one another where the visual cues, eye contact and body availability are up front. Each body needs to send the sensory messages of self-openness, availability and empathy through body messages that say, "I hear you," "I respect what you are saying" and "I can feel your pain." The emotional meta-message of having a partner with an empathic, loving body communication is that safety and acceptance are available now, with this partner, irrespective of any relationship failures in the past. Each partner is made aware, at an experiential level, that rejection and shame from childhood can be tamed and new vessels of love and safety created so as adults we can explore our interests and expand our horizons with joy.
Resnick assumes that as adults, we re-experience new attachment processes in the same order that we did as infants. The sensory experiences are foundational: eye gaze, soothing voice, gentle touch, responsiveness, availability and playfulness. We all seek these encounters throughout our life but rarely can find them. When our partner is nondefensive and offering these gifts of connection, the power of the relationship fuels our libido, sexual desires and a range of erotic pleasures.
As body to body communication improves and secure attachments are forged, like the young child, each partner begins to feel safe. They naturally start to explore and play with one another. Resnick believes good sex is sown on the adult playground. Play encompasses everything from to a tickle to a walk through the snow to a game of bridge. The defining feature is interpersonal sharing and experimentation without fear of judgment and without a specific goal.
Shapiro reminds couples that good sex comes in many different varieties and flavors. All are good, from the tension releasing sex, which wipes out the day's worries and is nature's Ambien, to ecstatic sex, where beyond the release of pressure there is a transcendent expansiveness that feeds us physiologically, emotionally and spiritually. Resnick gives an excellent theoretical framework, but she also describes some of the nuts and bolts. Embodied Relational Sex Therapy involves three interacting therapeutic processes:
- Reframing the problem as originating in body-to-body interaction.
- Relabeling the sex problem as attachment dysregulation.
- Developmentally analyzing one's pain-pleasure continuum in terms of childhood experiences and trauma.
Using CBT with Somatic Experiential techniques, the couple moves from a cognitive reframing of the problem to a somatic focus on the body and the senses, to processing cognitions and affect in real time interactions, to finally reaching desired behavioral and sexual goals.
The processing of real time interactions requires helping the couple resolve the following dialectics
- Focused attention, each partner is mindfully present, vs. outside preoccupation.
- Body-based empathy, registering the pain, love or fear expressed through the other's body within your body, vs. detachment.
- Emotional attunement, using one's eyes and facial expression as a healing mirror to create body empathy, seeking safety and offering safety, vs. distance.
- Down-regulating stress (ability to reduce stress in partner) vs. agitation.
For the therapist to do this work, they must hear with the third ear and see with the third eye. It is all process, the meta-story and neuro-affective unconscious wiring. While this focus on process over content is the hallmark of psychodynamic work, here it is beautifully woven into the gestalt-oriented discoveries and interventions.
Another psychodynamic contribution to this therapy is working through the family transference. Shifting from the erotic stranger one knows in the beginning of the relationship to someone who is my day-to-day family can inhibit sexual play and spontaneity. The soothing, predictable and functional family rituals are antithetical to the exciting and novel lover rituals. Couples can and need to learn to be transcultural in this regard: moving back and forth from the family culture to the lover culture. In a way, those of us who keep our sexual lives popping due so by creating multiple selves.
A most interesting part of the book is where Resnick discusses the wider social implications of her working model. Most importantly, she warns us not to assume that the current torrent of sexual misconduct being exposed by men in power is devoid of sexual impulse and sexual gratification. Such conduct is not simply about power. For the perpetrator, it often truly is about sex. It is about the mixed feelings of guilt and shame the perpetrator carries within him about pleasurable sex, intimacy and worthiness. If we are to meaningfully address misogynist sexual exploitation, we must focus on the sexual-affective dysfunction of the perpetrator as well as the abuse of power. When shame and fear in a partner are sexually gratifying, we have a sex problem as well as a power problem.
In short, as I have been seeing couples nearly a half century and have taught couples therapy for just as long, I believe this book should be read by the novice as well as by us seniors. Like the slow food movement, this is the slow intimacy movement: nourishing, needed and just plain nice to experience.
References
Braden, D. (2015). Marriage and sex: A study comparing sexual satisfaction and marital satisfaction in age and gender. Dissertation Abstracts International Section Humanities and the Social Sciences. 76(3-AVE).
Dunn, W. (2001). The sensations of everyday life: Empirical, theoretical, and pragmatic considerations. The Journal of Occupational Therapy, 55(6), 608-620. doi:10.5014/ajot.55.6.608.
Ellison, C.R. (2012). Sexual choreography: Am I enjoying this right now? Not "How am I doing?" In P. Kleinplatz (Ed.), New directions in sex therapy (2 nd ed., pp. 141-160). New York: Routledge.
Holmberg, D., Blair, K., Phillips, M. (2010). Women's Sexual Satisfaction as a Predictor of Well-Being in Same-Sex Versus Mixed-Sex Relationships. Journal of Sex Research, 47(1), 1-11.
Perel, E. (2006). Mating in captivity: Reconciling the erotic and the domestic. New York: HarperCollins.
Schnarch, D. (1991). Constructing the sexual crucible. New York: W.W. Norton.