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Section 20
Sex Therapy with Couples

Question 20 | Test | Table of Contents

From Sex Therapy to Therapy With People Who Present With Sexual Concerns
A common factors perspective would suggest that successful sex therapy is more about therapy with people who happen to be experiencing sexual difficulties than about the application of a unique therapeutic modality or treatment technique (e.g., squeeze technique, sensate focus). While we would venture to say that most clinicians who practice sex therapy are aware of this (Schover & Leiblum, 1994; Levine, 1997), research still seems to be primarily focused on discovering what technique or treatment is more effective for any one particular sexual disorder. Our suggestion is that perhaps we should consider focusing our attention on how to heighten the contribution of the common factors in our clinical work with clients presenting with sexual problems, rather than focusing the majority of our time and resources on developing new therapies. As noted earlier, researchers point to the existence of four factors common to all forms of therapy despite theoretical orientation, mode, frequency and number of sessions, or specialty (problem type, professional discipline, etc.). In order of their relative contribution to change, these elements include: extratherapeutic (40%); relationship (30%); placebo, hope, and / or expectancy (15%); and structure, model, and/or technique (15%) (Lambert, 1992; Miller, Duncan & Hubble, 1997; Hubble, Duncan & Miller, 1999c). Application of these elements while working with clients who present with sexual problems is discussed below.

Extratherapeutic Factors: The Role of the Client and Chance Change-Producing Events Extratherapeutic factors are the single largest contributors to change and refer to any and all aspects of the client and his or her environment that facilitate recovery, regardless of formal participation in therapy. Curiously, most of the writing and thinking about therapy places the clinician at center stage in the drama of treatment. However, research on the extratherapeutic factors makes clear that clients play a significant role. By being mindful of the significant role that client strengths, capabilities, resources, social supports, and the fortuitous events that weave in and out of client's lives play in everyday practice, sex therapists can enhance their contribution to treatment outcome. Four suggestions can be useful in this regard, as described in the following paragraphs.

Becoming Change Focused
To develop a change focus, a therapist can listen for and validate change for the better, whenever and for whatever reason it occurs (Miller, Duncan & Hubble, 1997). As just one example, consider studies which show that 15% to 66% of clients experience positive, treatment-related gains prior to the formal initiation of treatment (Howard, Kopte, Krause & Orlinsky, 1986; Lawson, 1994). Obviously, such pretreatment change is extratherapeutic in origin, as it cannot be attributed to either the therapy or therapist. Whatever the cause, however, the high percentage reported in the studies indicates that clinicians can empower the contribution of extratherapeutic factors by listening for, inviting, and using the description of such change as a guide to therapeutic activity. For example, it is not unusual for couples to announce that prior to the first session, they had sex (if they haven't been sexual for a period of time), or have had fewer arguments since making the call for treatment. Therapists can also be changed focused in their work when clients return for additional visits by heeding and then amplifying any references the client makes during the session to between-session improvement (e.g., client experienced feelings of sexual desire, client reporting a spontaneous sexual encounter with his/her partner). Also, in the opening moments of the session, therapists can directly ask clients about what, if any changes have occurred since their last visit with the simplest question coming in the form, "What is different?" or "What is better?" A sizable body of research literature shows that improvement between treatment sessions is the rule rather than the exception, with the majority of clients experiencing significant symptomatic relief earlier rather than later in the treatment process (Howard et al., 1986).

Potentiating Change for the Future
Whether change begins before or during treatment, whether it results from the client's own actions or by happenstance, a crucial step in enhancing the effect of extratherapeutic factors is helping clients see any changes--as well as the maintenance of those changes--as a consequence of their own efforts (Miller et al., 1997). Naturally, a cardinal consideration is perception--specifically, the clients' perception of the relationship between their own efforts and the occurrence of change. It is important that clients come to view the change as resulting, at least in part, from something they did and can repeat in the future. Therapists can support these changes in several ways, such as exploring the client's role in changes that occur during treatment and asking questions or making direct statements that presuppose client involvement in the resulting change (Berg & Miller, 1992). Even if clients resolutely attribute change to luck, fate, the acumen of the therapist, or a medication, they can still be asked to consider in detail how they adopted the change in their lives, what they did to use the changes to their benefit, and what they will do in the future to ensure their gains remain in place.

Minding the Client's Competence
As suggested, therapists can begin to cast their clients in the role as the primary agents of change by listening for and being curious about their competencies (i.e., their part in bringing about and maintaining positive change). This approach requires a balance between listening empathically to their difficulties and mindfulness of their strengths and resources.

Tapping the Client's World Outside Therapy
Clinicians also mind clients' contribution to change by incorporating resources from their world outside therapy. Whether seeking out a trusted friend or family member, purchasing a book or tape, attending church or a self-help group, research indicates that the majority of clients both seek out and find support outside the formal therapy relationship (Garfield, 1994). This natural tendency can be facilitated by the therapist's simply listening for and then being curious about what happens in the client's life that is helpful. Some questions are useful to keep in mind:
1. What persons, places, or things have the client sought out in the past that were useful?
2. What was different about those times that enabled the client to use those resources?
3. What is the client doing now (in addition to therapy) that she or he considers helpful in understanding or solving the problem?

Relationship Factors: The Client and Therapist Together
With the contemporary emphasis on models and techniques, attributions of success to something as seemingly vague and intangible as the therapeutic relationship cannot help but sound misplaced and simpleminded. For the last three decades, professional discourse has basically regarded the therapeutic relationship a nonspecific factor--a means to an end, so to speak (Strupp, Hadley & Gomez-Schwartz, 1979). Common clinical expressions such as "I am establishing rapport," "fostering an alliance," and others convey a view of the relationship as a precursor to the real or active ingredients of treatment--namely techniques (confronting dysfunctional thinking, making transference interpretations, teaching sensate focus activities, etc.) (Bachelor & Horvath, 1999). But the research is clear; as much as 30% of the variance in psychotherapy outcome is attributable to relationship factors (Lambert, 1992). The same is true for marital therapy (Estrada & Holmes, 1999). Research on the power of the therapeutic alliance now reflects more than 1,000 findings (Orlinsky, Grave & Parks, 1994) and provides concrete guidelines for enhancing the contribution of relationship factors to treatment outcome. These guidelines include accommodating treatment to the client's motivational level or readiness for change, and accommodating the client's view of the therapeutic alliance.

- Donahey, K., & Miller, S. (2000) Applying a Common Factors Perspective to Sex Therapy. Journal of Sex Education & Therapy, 25(4).
Reviewed 2023

Update
The Effect of Psychological Interventions on Sexual and Marital Satisfaction:
A Systematic Review and Meta-Analysis

Arab Bafrani, M., Nourizadeh, R., Hakimi, S., Mortazavi, S. A., Mehrabi, E., & Vahed, N. (2023). The Effect of Psychological Interventions on Sexual and Marital Satisfaction: A Systematic Review and Meta-Analysis. Iranian journal of public health, 52(1), 49–63. https://doi.org/10.18502/ijph.v52i1.11666


Peer-Reviewed Journal Article References:
Brandt, S. A., Sullivan, T. J., Luginbuehl, T., O'Leary, K. D., & Davila, J. (2023). Associations between internalized heterosexism, verbal intimacy, and affectionate touch provision among sexual minority couples. Couple and Family Psychology: Research and Practice. Advance online publication. https://doi.org/10.1037/cfp0000245

Dubé, J. P., Bergeron, S., Bosisio, M., Vaillancourt-Morel, M.-P., Drudge, E., & Rosen, N. O. (2023). Hooked on a feeling: Downregulation of negative emotion during sexual conflict is associated with sexual well-being among long-term couples. Emotion. Advance online publication. https://doi.org/10.1037/emo0001251

Feuerman, M. L. (2018). Therapeutic presence in emotionally focused couples therapy. Journal of Experiential Psychotherapy, 21(3), 22-32.

Kenneally, L. B., Milam, A. L., & Paulson, J. F. (2023). Pathways to intimacy: The direct and indirect effects of cognitive flexibility and emotion dysregulation. Couple and Family Psychology: Research and Practice. Advance online publication. https://doi.org/10.1037/cfp0000247

Li, P., & Johnson, L. N. (2018). Couples' depression and relationship satisfaction: Examining the moderating effects of demand/withdraw Communication Patterns. Journal of Family Therapy, Supplement, 40, 63-85.

Riekkola, J., Rutberg, S., Lilja, M., & Isaksson, G. (2019). Strategies of older couples to sustain togetherness. Journal of Aging Studies, 48, 60–66.

QUESTION 20
According to Donahey, how can therapists be change-focused when clients return for additional visits? To select and enter your answer go to Test.

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Section 21
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