This article was downloaded by: [University of Glasgow] On: 06 January 2015, At: 14:36 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20

Constructing a sex and marital therapy frame: Ways to help couples deconstruct sexual problems a

Joan D. Atwood & Susan Dershowitz

b

a

Director of the Marital and Family Clinic , Hofstra University , Hempstead, NY, 11550 b

Hofstra University Published online: 14 Jan 2008.

To cite this article: Joan D. Atwood & Susan Dershowitz (1992) Constructing a sex and marital therapy frame: Ways to help couples deconstruct sexual problems, Journal of Sex & Marital Therapy, 18:3, 196-218, DOI: 10.1080/00926239208403407 To link to this article: http://dx.doi.org/10.1080/00926239208403407

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Constructing a Sex and Marital Therapy Frame: Ways to Help Couples Deconstruct Sexual Problems

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JOAN D. ATWOOD and S U S A N DERSHOWITZ

I t has been pointed out that an integration of the fields of marital and family therapy and sex therapy is needed. This Paper proposes a model for the integration of sex therapy and marital therapy. Recently, social constructionism har made its way into the marital and family therapr literature. Using social constructionist notions, the present paper proposes an alternative perspective to the traditional sex therapy modelr-one that incorporates a constructionist therapeutic stance utilizing the notions of sexual meaning systems and sexual scripts. In so doing, an integrated model of sex and couple therapy is presented. T h e separation of sex therapy a n d marital therapy has a long history. Sager,’ in reflecting o n the evolution of the role of the therapist in treating couples with sexual problems, stated that he initially believed that one needed to keep sex therapy and couples therapy separate but later reversed his view and proposed that the couples therapist ought to be versed in the techniques of‘sexual therapy and bc ready t o shift focus when indicated rather than refer patients to a sex therapist. H e now believes that since many couples use their sexual activity as a metaphor for their relationship, only by integrating sexual and marital treatment can the therapist fully engage the couple. Lief,* a pioneer in the area of marital a n d sex therapies. also believes that it is impossible to do sex thcrapy without dealing with the nature of the couple’s relationship. As Hof a n d Berman3 point out, “Reintegration of sex therapy with marriage a n d family therapy is both possible and necessary” (p. 10). Hop states, “We have marriage therapists talking a lot about intimacy, but not about sex. Wc have sex therapists talking about sex, but not about intimacy. And w e have family therapists pretty mum o n the whole subject. Does this picture make sense?” (p. 4). Joan I). A t w t d , Ph.L)..C . S . W . .is the Coordinator o l the Graduate Programs in Marriage and Family Counseling, and the Director of the Marital and Family Clinic. IIofstra University, Iiempsread. ”I’ I 1550. Susan Dershowirz. M . A . . is a candidate in Marriage and Family Counseling. Hofbtra University. Please send all reprint requests t o the first author.

Journal of Sex & Marital Therapy, Vol. 18, No. 3, Fall 1992 0 BrunnerlMazel, Inc. 196

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Historically, the psychoanalytic position dominated the psychotherapeutic field. Prior to 1970, psychoanalytic theory and practice dominated the therapeutic approach to sexual problems. T h e aim of this approach was to achieve a more complete understanding of the person’s mental life. T h e sexual problem was seen as a manifestation of an underlying, usually unconscious, internal ~ o n f l i c t .T~h. e~ therapeutic goal was not to simply relieve the symptom, but to resolve its infrastructure-the underlying conflict. In this view, insight, understanding, mastery and psychological growth were highly valued therapeutic goals. Other means of symptom removal were regarded simply as “transference cures” or “suggestion” likely to be followed by symptom substitution. T h e rate at which psychoanalysis and psychoanalytic psychotherapy proceeded was largely controlled by the person’s inner life. In therapy, a patient with a sexual problem was usually seen alone. Presently, there are two widely accepted theoretical orientations currently used to treat sexual problems. They are the cognitive-behavioral and the newer sex therapies. T h e outcome data presented in Masters and Johnchallenged the psychoanalytic attitudes and suggested a radically different therapeutic approach, representative of cognitive-behavioral theory. “What Masters and Johnson proposed was an attempt to rescript an older domain of sexual problems that they recategorized (the first step in rescriptin ) as sexual dysfunctions, though they never used the word scripting (p. 32). Masters and Johnson’s work7 proposed a number of new possibilities for dealing with sexual problems. Both partners were included in the treatment. T h e concerns of each partner were considered without placing blame for the dysfunction. T h e symptoms belonged to the couple unit, not only the symptom bearer. T h e psychological mechanisms of the sexual problem were largely thought to be related to current rather than past influences (e.g., performance anxiety, spectatoring, anger at the dysfunctional spouse). In this view, a new emphasis was placed on social and interpersonal forces rather than on intrapersonal causes (e.g., cultural expectations that prevent the normal development of sexual expression, or religious orthodoxy). Male and female cotherapy teams were used, which were uniquely suited to fostering communication and mutual understanding between the spouses. In addition, they were also more effective in identifying and dealing with the high frequency of interpersonal problems. Since the appearance of Masters and Johnson’s behavioral approach to sexual dysfunctions, the view that there is little more to learn about sex therapy has grown. Later sex therapies, finding Masters and Johnson’s model difficult to re licate and inadequate in some including the work of Kaplan,’ began presenting information on a “desire” stage, preliminary to the excitement stage presented by Masters and Johnson. Kaplan13combined the work of Masters and Johnson with a psychoanalytic awareness of deeper conflicts. She believed that fear of intimacy and romanticism may underlie sexual problems such as seeming lack of desire. She cautions that when deep psychological stresses in a relationship are not resolved, therapy for overt sexual problems may not help much. 9

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At the other end of the continuum are the marital therapists, whose work is grounded in systems theory and who generally see sexuality as a symptom or metaphor presented in therapy so that the couple might avoid dealing with more essential issues. This viewpoint stresses that sexual problems d o not exist in a vacuum but that they are often related to problems in the couple’semotional relationship, such as poor communication, hostility and competitiveness, power and intimacy issucs, or sex role problems. Systems theorists believe that even in those cases where the sexual problem is not necessarily related to relationship problems, the couple’s emotional relationship is often damaged as a result of the feelings of guilt, inadequacy, and frustration that usually accompany the sexual problem. There is a variety of ways that sexual issues are viewed by systems theorists. For example, sexual problems have a circular position in the couple’s interaction in that the wife’s demands may be the result of the husband’s sexual frustration and fears of rejection. T h e husband’s fears of rejection may be a combination of sexual conflict, self-doubt about sexuality, and fear of failure to please his partner. T h e important features of systemic therapy include interrupting whatever sexual cycle has developed. Therapy from this viewpoint, therefore, tends to focus on the couple’s interactions that serve to maintain problematic sexual patterns. In many cases, however, marriage therapists, basing their practice on systemic family therapy, have a history of referring couples reporting sexual dysfunctions to sex therapists. Thus, for the most part, the major approaches to sex therapy can be separated into t w o camps, and what could have been a natural relationship between the two disciplines are two separate fields of study represented by divergent views. On the one hand, using the Masters and Johnson approach and the newer sex therapies model, sexual problems are treated seriously and the sexual issue presented is the problem to be addressed. On the other hand, using the psychoanalytic and the more systemically based therapies, sexual problems are seen as manifestations of’some underlying unconscious conflict or as a metaphor or symptoms of a dysfunctional relationship. These two major divisions represent the division between the fields of sex therapy and couple therapy. It is time that the two fields are brought together. Ideas from social constructionism applied to the concepts of sexual meanings and sexual scripting theory’ hold the possibility for bringing the two fields together. Recently, concepts from constructionism have been applied to marital and family therapy theory. Constructionism is not new and may be traced back to philosophers such as Kant.15 Piaget16and Kelly” represent the proponents from psychology. Biologists Maturana18 and Varela,19cybernetician and biophysicist von Foerster,“’ physicists Prigogine and Stengers,21constructivist von Glaserfeld,22anthropologist Bateson,23and social psychologists Berger and I ~ c k m a nand ~ ~Gergen and Gergen*”“ also contributed to the notion that our knowledge about the world is constructed by the observer. Social constructionists believe that how wc know what we know is not through an exact pictorial duplication of the world: “The map is not the

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territory.” Rather, reality is seen ex erientially, in terms of how w e subjectively interpret the constructions.* In this sense, we are responsible for what we believe, feel, and see. What this means is that our story of the world and how it works is not the world, although we behave as though it is. Our experiencingof the world is limited to our description of it. Using language (languaging)is action, and it is through languaging that persons define and experience reality. It is, therefore, through languaging in therapy that an environment conducive to change is created.

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BASIC PREMISES OF THIS APPROACH T h e basic premises underlying the constructionist position are listed below. 1) Every human has a biological drive to unfold and to grow-to be the fullest s/he can be.27“You can let the organism take over without interfering, without interrupting we can rely on the wisdom of the organism” (p. 17). 2) There are no absolute truths and there are no absolute realities. 3) We co-construct reality through language with another in a continual interaction with the sociocultural environment. Thus, what is “real” is that which is co-constructed through language and interaction by the couple in continual interplay with the surrounding sociocultural environment. 4) Our inner world is a construct, colored by the past, and our past is a construction. 5 ) Couples tend to recreate an image of their world by noticing behavior in others that confirms their self-definitions and definitions of situations and by selectively ignoring discon firmator behavior. 6) How we “see” sexual problems, how we “see” sexual roles, how we “see” couple relationships-all these ideas d o not simply reflect o r elaborate on biological “givens” but are largely products of sociocultural processes. 7) Couples who come for sex therapy are experiencing problems in the sexual area of their marriage. They have tried many solutions-many of which have been unsuccessful. T h e problems they report are not seen as being functional in maintaining the system or as a manifestation of underlying pathology. They are seen as problems-problems that have negative effects for the couple. T h e way that couples language about problems is the way they can use language to co-construct a new story. 8) Repetitive knowledge of partner behavior that is discrepant with the perceptual view of the partner will result in a change in the person’s perceptual view. This is accomplished by focusing on and amplifying exceptions in the person’s description of their world. 9) Social constructionist sex therapy focuses on challenging the couple’s view of the sexual problem. I t accomplishes this by breaking u p the meaning that the problem holds for them and questioning their sexual script. This is achieved through the use of techniques like metaphors, reframes, etc. that amplify the couple’s process and by finding exceptions to the couple’s process (deconstruction or descripting), thereby providing seeds (construction or rescripting) for transformation.

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THEORETICAL CONCEPTS

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Constructed Perceptions Gergen and Gergen25*26 used the term self-narratives to describe the social psychological processes whereby people tell stories about themselves to themselves and others. These theorists characterize self-narratives as the way individuals establish coherent connections among life events. They believe that individuals have a set of schema by which they attempt to understand life events as meaningful and systematically related. In this way, events are rendered understandable and intelligible because they are located in a sequence or as part of an unfolding process. It is this process that enables individuals to make “sense out of nonsense” and to interpret events in a coherent, consistent manner. This paper sees sexuality and sexual problems as sociocultural symbolic constructs. Inquiry into the sources, processes, and consequences of their construction and organization is the therapy that flows from this view. The Social Construction of Sexual Meanings Applied t o sexuality, these narratives or sexual meaning systems are originally created by and maintained by interactions with significant others. T h e process begins at birth and continues until death. I f a person holds a particular sexual meaning system, s/he then will seek out events and persons that are consistent with that meaning system. These meaning systems in turn lead to sexual states, the emotional reaction to the meaning system, and sexual behaviors, the behaviors that are consistent with the sexual meaning system. These sexual meaning systems are socially constructed and are embedded in the larger sociocultural environment. Berger and L ~ c k m a n n de~~ scribe social constructions as the consensual recognition of the realness and rightness of a constructed reality, plus the socialization process by which people acquire this reality. A social construction includes not only the routines and the mechanisms for socializing the children of the system, but also the means for maintaining the definition of reality on which it is based. Language is one way that a community reaffirms the dominant reality and discredits competing social constructions. Sexual meanings, which are social constructions, refer to the complex and unique definitions in each individual that can influence sexual behavior. These meanings were constructed in childhood and are maintained by ongoing sociocultural influences. These sexual meanings are created, embedded in, and recognized by the larger social group and thus operatc at the social, interpersonal, and intrapersonal levels. The Social Construction of Sexual Scripts Individuals’ sexual meaning systems determine the content of their scxual scripts. T h e notion of sexual scripts was first introduced by Gagnon” in 1973. He believes that we are like actors with parts in scripts, which exist

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for our sexual lives as well as for other areas of life. Sexual scripts “are involved in learning the meaning of internal states, organizing the sequences of specifically sexual acts, decoding novel situations, setting the limits on sexual responses, and linking meanings from nonsexual aspects of life to specifically sexual e ~ p e r i e n c e ”(p. ~ 6). People develop sexual scripts out of their sexual meanin s stems. A script is a “devise for guiding ,,B y action and for understanding it (p. 6). Scripts are plans that people have about what they are doing and what they are going to do. They justify actions that are in agreement with them and challenge those that are not. Scripts are the “blueprints for behavior,” which specify who one will have sex with, what one will d o sexually, when one will have sex, and why one will have sexual behavior. “Sexual scripts constitute the available repertoire of socially recognized acts and statuses, and roles and the rules governing them”28 (p. 217). Scripts operate at a social, personal, and intrapsychic level. They are embedded in social institutions and as such are internalized by individuals. T h e overriding, dominant scripts receive most attention because of their primacy and potency among people’s sexual options. I t is against the dominant social sexual scripts that people attempt to match or reject their own personal social sexual script. “It is clear that the (sexual) script that individuals bring to treatment exist at the intrapsychic and the interpersonal levels and most, though not all, interventions involve changes in both”g (p. 33).

Constructing a Time Line T h e concept of time is an important part of this m ~ d e I . ~For - ~ example, ’ by asking questions such as “How long has this problem been around? When did you first start becoming depressed about the sexual part of your relationship?” the therapist introduces a historical context of a beginning, a middle, and, hopefully, an end. These types of questions give couples information about the origins and persistence of problems and how the trends developed over time. This also helps to dispel beliefs that people are born that way, o r are just like one of their parents, or any other genetic causality. T h e sexual problem becomes located in time rather than in the couple, and its characteristics are then examinable and observable.

Collapsing Time-The Rubber Band Backward and Forward Couples are asked, “If I were to take a rubber band and stretch it back to when the sexual problem was not there, what was your relationship like?” Asking “How long has this problem been around?”and “When did you first start having this problem?” places the couple’s experience of the sexual problem within a developing trend. Asking a couple about what life was like before the problem implies that there was a time when the problem was not there and further implies that perhaps at some point in time it will also not be there. As will be discussed in a later section, the rubber band can also be used (if requested by the client) to stretch back in time toexplore the two individual stories when they were children in their families-oforigin.

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Stretching the rubber band into the future enables couples to envision a future without the sexual problem. Here couples are asked, “If I were to take the rubber band and stretch it forward, say three months from now, and the problem was gone, what would your relationship be like?” Questioning about development over time is an effort that not only draws attention to the fact that the intensity of the experience of the problem varies over time but also identifies that there are times when the problem is absent and presents the possibility that the problem might not be there in the future. This lays the groundwork for ideas that the couple has some control over the problem and by implication that at some point the problem will no longer be there. l h e progressive use of directional description of the time metaphor allows couples to understand their participation in the problem’s persistence at different points in time.32 Chu?lgP

Watzlawick, Weakland, a n d F i ~ c describe h ~ ~ t w o types of change, first and second order change. Simply, first order change is a change that occurs within a system while second order change is a change of the system itself. It is considered a chunge of change. First order change maintains homeostasis; whereas, second order change is a change of the premises governing the system as a whole. First order changes are incremental modifications that make sense within an established frame.34,35 Second order change changes the frame itself. In order to accomplish second order change, the therapist phases in particular material a n d phases out other material. First order change is exemplified by traditional psychothera y. Second order chan e is represented by the approaches of Minuchin,“ Halcy and Hoffman, Watzlawick,33- 35 and White.31.3‘.38H.3g Because the focus of intervention is o n sexual meaning systems and sexual scripts, the change model adhered to in this paper is a second order change model. It is similar to Epston and White’s4”reccnt work whereby the therapist initially assists the couple in learning processes that help them to amplify (be aware of) their couple process, provides techniques that the couple can use to generate new possibilities, and is someone who creates a “safe environment” for the couple to explore their process, generate new possibilities, consider the implications of the possibilities, a n d negotiate a shared frame around the chosen change. These ways of learning can be used by the couple outside therapy. Over time, as the couple learns to rely on their own self-healing processes, they become more confident in the processes and in their own abilities to generate growth and change. T h e result is new structures that are of higher o r d c r - o n e s that are more connected and integrated than the prior ones. They are more complex, more flexible, and more susceptible to further change and development. Thus, the present article presents the underlying assumptions and theoretical concepts of constructionism, combines it with the notions of sexual meanings and sexual scripting theoryI4and presents a model of Social Constructionist Sex Thcrapy (see Figure 1). T h e approach to sex therapy presented in this paper is based o n the belief that we create o u r own reality.

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Couples make sense of their ongoing experience, and it is this process of making sense that is the object of this therapy. T h e therapy takes as its focus client’s sexual meanings, viewed from the past, present, and future-both negative and positive. T h e initial focus of the past is affective-understanding how their sexual meanings developed and how they believe these meanings affected them in the past. Once the past is put in perspective, the second focus of the approach is cognitive-n the couple’s sexual script in the present and on the maintenance of the couple’s sexual meanings, helping the couple to be aware of their processes, and facilitating learning about and amplifying exceptions to the process in order to provide possibilities for new solutions. Future focus enables the couple to image how different sexual meanings and the resultant sexual scripts could effect their relationship in a positive way. Revisioning the relationship is the last stage of this therapy and emphasizes future visions of the couple relationship without the sexual problem. CONSTRUCTING A SEX THERAPY FRAME

T h e sexual meanings that sexual incidents, behaviors, and encounters have for individuals are determined by their sociocultural environment. T h e sociocultural environment equips them with methods and ways of understanding and making judgments about aspects of sexuality, ranging from how they feel about their bodies to sexual values. These ways of making sense of experiences are embedded in a sexual meaning system which is accepted as reality by the social group and in the sexual scripts that are a part of the individual’s world view. T h e dialectical relationship between individual realities and the socially constructed sexual meanings is the recurring focus of this article. Using the above as a background for constructing a sex therapy frame, couple therapy around sexual issues can be divided into three different stories: the couple’s story about their families of origin (how the sexual meanings and sexual scripts developed in the first place), their story about their relationship (how the sexual meanings are maintained and an exploration of the couple’s sexual script), and their story about what they see for their future (how their sexual meanings and their sexual script can change). Knowledge of each of these three stories helps the therapist to understand the couple’s frame of the sexual problem. T h e telling of these stories helps the couple learn about their frame of the problem. Hoffman4’ states, “Problems are stories people have agreed to tell themselves, then we have to persuade them to tell themselves a different, more empowering story, have conversations with them, though the awareness that the findings of their conversations have no other reality than that bestowed by mutual consent” (p. 38). Thus, clients are asked about what sexual problems mean to them in their given sociocultural contexts. Sexuality is treated as a symbol invested with meaning by society, as all symbols are. T h e approach to the sexual problem is thus a matter of symbolic analysis and interpretation. T h e sexual problem is seen as emanating from various forms of action or practice within the person’s sexual life.

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MODEL OF CONSTRUCI'IONIST SEX THERAPY

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DEVELOPMENT OF T H E W O R L D VIEW

Family of Origin Significant Childhood Others Socio-Cultural Environment

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Person's Sexual Meaning Systen

Person's Sexual S c r i p t

Person S e e k s O u t Definitions Consistent With T h i s Sexual Mcaning System

T h e PersonlCouple who sees a sexual problem as part o f their sexual meaning system seeks o u t information that i s consistent with this view. Behaviors, interactions, and affect (the person's sexual script) reflect this view. A vicious cycle i s set up whereby the personkouple experiences the problem as flowing from their past, reinforced by interactions in the present, and not having a solution in the future.

FIGURE 1. Development of a World View

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Identification of Organic Causes

Whenever doing psychotherapy in general but especially when there is a reported sexual problem, it is important to explore the possibility of organic causes. Organic factors can affect sexual functioning. They may be a direct cause, the primary cause, or a contributing factor. Even in people who appear to be organically intact, there may be some biophysiological process which can be implicated in the sexual problem.42 Initial questioning then could include: there a physical disease or disability? (e.g., renal failure, circulatory problems, diabetes?) -Does the partner of the person who is presenting the sexual dysfunction have a disease? (The person may be responding to the partner’s postcardiac vulnerability, cancer, prostatectomy, or mastectomy.) -1s the client taking any drugs which could effect sexual functioning? (e.g., hypertensive medicine, alcohol, methadone, antihistamines?) -Has the person had any surgery which could affect sexual functioning, such as prostate gland removal or vulvectomy? -1s there an escalation in the aging process (due to an organic problem) which may be effecting sexual functioning?

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In addition to exploring organic bases to sexual problems, it is useful for the couple’s therapist to be familiar with basic sex therapy exercises that have proven useful. Some of these exercises are: kegeling, sensate focus, systematic desensitization, squeeze technique, and handriding.7 Conttructing a Workable Reality

Underlying the beginning of any therapy is the importance of joining or constructing a workable reality. Cimmarustu and lap pi^^^^ believe that the dynamic interplay of joining and constructing a workable reality initiates the process of change. T h e construction of workable realities can be defined as the process in which the view of the problem is transformed from a paradigm of individual causality toa paradigm of interaction. It isa process analogous to socializing by which an empathic rapport is developed with the clients. T h e therapist’s reflections serve to create a n environment conducive to change. In this environment, the therapist listens to the couple’s language, learns it, and uses it to create a comfortable environment. T h e basic assumption is that the client is the expert in knowing what is best for them. T h e role of the therapist is that of curious observer-interested in learning about the couple’s story. T h e therapist interacts with the couple orthogonally, so as not t o become part of the system; rather, s/he selectively interacts with only selected parts of the couple system. The Past-The Development of the Sexual Meanings

Berger and IAuckmann24 believe that the socially constructed meanings we have inherited are “opaque” (p. 55). By this they mean the ways in which

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our meanings are constructed are invisible to us, as a r e the elements that compose them. T h e social world w e are born into is experienced by the child as the sole reality. T h e rules of the world we are born into are nonproblematic; they require n o explanation, and they are neither challenged nor doubted. Through socialization, the socially constructed meanings are internalized; they are filtered and understood through meaningful symbols. From these socially constructed meanings flow sexual meanings and sexual scripts. A person attempts to match hidher own experience with the available meanings and scripts. T h e person learns the language, the appropriate behavior for hidher gender, age, and culture. In this way, a person develops a n individual identity, an individual sexual script, and along with it individual sexual meanings-all of which are created by and embedded in the dominant culture. Many times, at the onset of therapy, individuals are prepared to verbalize all of their childhood painful experiences with the hope that this will alleviate the problem in the present. More cognitively or behaviorally oriented therapists who attempt to focus the client on the here-and-now often meet with client “resistance” because clients tend to believe that presentoriented therapy isjust “skimming the surface” and that if they do not “dig deep” they will not get to the “root” of their problems. Clients who feel this way are doing the only thing that makes sense for them. “Every system is where it is, in a resent, in congruence with its medium, and cannot be anywhere el~e*’~‘(p. 19). T h us, with clients who believe that past events are effecting their present behavior, during the initial phases of therapy, a recreation of these childhood events is often helpful. This exploration is based not on the notion that clients need to have a cathartic experience in order to move forward, but rather that if the client wants to tell the story of the past, it can often rather quickly facilitate the “letting go of the past” or putting the past in perspective. In some cases, exploring the client’s past is a useful first step in restorying the present and opening u p new possibilities for the future. In many cases, it brings forth the client’s new awareness of competencies and strengths. When therapists feel this exploration would be helpful for the client (as indicated by the client’s request), therapists can use the rubber band to help the client move back in time. “If 1 were to take a rubber band and stretch it back to when you were a little girl/boy, when you first began thinking about your body, could you tell m e what that was like? Could you tell me how you first learned about your different body parts? What did you learn about your body from the way you were treated by your mother, father? What meanings did you give these experiences?” Here the therapist can also ask about any painful sexual experiences the client may have had. “Did anyone ever make you do anything sexual that you did not want to do? What did this mean to you? How do you think it effected your relationships then?” This occurs with the partner listening, which helps him/her to understand more about the way hidher partner learned about sexuality and helps to increase feelings of intimacy. “Do you remember what meanings you were given about sexuality by your mother, father? What meanings did they give you a b u t affection? About being a man or a woman? What

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meanings did they give you about how to treat (and how to be treated by) men and women? How d o you feel those meanings affected your behavior, relationships then? Based on the sexual meanings you held then, what was your sexual script then? How did this script influence your sexual behavior? How did your sexual script influence your relationship(s) then?”

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Closing the Door on the Past After both partners have told the story of how they believe they first developed their sexual meanings and their sexual scripts, the past is put in perspective. This is best accomplished by a ritual. T h e clients can write down all the important childhood events that relate to developing sexuality, both negative and positive, and place the paper in a shoe box and bury it (symbolically burying the past). Some clients may want to write a letter to their significant caretakers from their childhood forgiving them for their mistakes and thanking them for the gifts they gave them. This letter could either be mailed or buried. T h e client could have a ritualistic ceremony, whereby they symbolically let go of their pain, and the effects of the pain, by setting a balloon or kite free at the beach. They can symbolically show appreciation for early gifts from caretakers by doing something special for them.

The Present: Exploring the Couple Script Berger and Kellner45define marriage as a definitional process. T w o separate individuals come together with separate identities and begin to construct a life as a couple. What once were the independent identities of the two individuals are now modified to incorporate the “relationship” identity. Now the two individuals construct a relationship reality where all conversations serve to validate this coupled identity. At this point in therapy, the couple tell their present story, how they combined their individual sexual meanings and sexual scripts to cocreate a couple script for sexual behavior. Here the therapist attempts to obtain as complete an understanding as possible of the couple’s story about the sexual problem. That is, their discussion centers around how the sexual problem became scripted into the couple relationship, at both the individual and the couple level. Therapists can learn about the couple’s story by paying careful attention to linguistic symbolizations such as couple myths, legends, rites, and metaphors. An individual’s reality is maintained by developing a personal sense of self that is congruent with the social constructions. As stated earlier, based on early interactions and ongoing socialization, individuals construct a reality around sexual meanings that includes a preferred way of relating to others. This then becomes the basis for how they view others and how they expect others to view them. In many ways, this perceptual set determines predictable ways of interacting with others. Here relevant questions might be, “How do you think of the sexual problem? What meaning(s) d o you hold about sexuality in general? What meaning(s) does sexuality hold for you, for your relationship? What is your individual sexual script? What is

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your couple script around sexuality? What is problematic for you about your sexual script? Do you see any other options? What solutions have you attempted?” When uncovering the couple’s story about the present, both the therapist and the couple learn what information the couple selects out of their environment and how they fit that information into an already existing sexual meaning system so as to reinforce that system. T h e therapist and the couple learn how the couple’s patterned conversations and attempted solutions (the couple’s sexual script) reflect this world view and they learn how the sexual problem became scripted into the couple relationship. According to cybernetic theory elaborated by B a t e ~ o n and * ~ employed by White,38 circularity is a fundamental phenomenon whereby events in systems feed back o n themselves a n d causes a n d effects become indistinguishable. When couples learn about their sexual meaning system and their sexual scripts and connect them to thc way they “see” their sexual problems, they gather information about how they have inadvertently participated in the perpetuation of the problem. For many couples, telling their story invokes a revolving door image with no exits, as they begin to see themselves as going around a n d around in the same cycle, unable to break out of the pattern. For example, holding a sexual meaning system that dictates sex is for reproductive purposes only can be influential in the development of a sexual script wherein a person will have sex as rarely as possible unless they want to reproduce. By exploring the individual’s sexual meaning system and resultant sexual script a n d then connecting the information to a possible diagnosis of inhibited sexual desire, the individual is able to explore the utility of the old definitions and examine new possibilities. Applying these concepts, questions can also be asked about the beginnings of the couple story. “How did you meet? What did you think about each other when you first met? How did you know “this was it”? How did your relationship evolve? Did you find each other attractive? How did you feel in each other’s presence? How was your first sexual encounter? How do you both “see”the beginning of your couple story-similarly or differently? Where is there agreement? Where does the story differ?”T h e therapist, facilitating the couple story, at this point focuses o n the themes and metaphors that run through the couple’s construction of their sexual meaning system. At this point also, the couple can explore the different facets, the rigidity, the conventionality, and the satisfaction a n d dissatisfaction of their sexual script.

Chullenpng the Sexuul Meanings ‘l‘hroughoutthis paper, a view of constructed sexual meanings and resultant scripts has been put forth. Once it is accepted that sexual meanings are socially constructed, it then becomes possible to deconstruct them. Ways of doing this can involve learning about their origins a n d exploring the extent of their validity and usefulness. T h e following section elaborates o n thc process by which the couple’s sexual meaning system can be challenged

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and/or rescripted to create new experiences. Techniques used to amplify the couple’s process can be used. They often help the couple “see” where they are stuck. T h e aim here is to see the couple’s world through their eyes, not so that the therapist can change the couple’s views, but rather to help them develop alternative perspectives, a new view. Some ways of amplifying the process are tracking a n d circular and reflexive questioning. Tracking is where the therapist focuses o n the symbols, metaphors, themes, and language of the couple in order to help the couple better understand their transactional process. Tracking can help the couple to see the recursiveness of their actions. Sometimes tracking the presenting problem is enough for the couple to see the recursiveness of their language about the problem. It often serves to help the client ‘‘see’’ the redundancy of their interactions. Circular questioning is where the therapist invites one member to comment on the relationship of two other members. “When you attempt to have sex with your wife, who else would your wife say was metaphorically in the bedroom with you-your parents or her parents?” Through circular questioning, a view of the sexual problem and the meaning it holds for the couple emerges that allows both the therapist a n d couple to appreciate its interconnectedness and circular nature. Reflexive uestions enable the couple’s own healing processes to emerge. Tomm4 believes that therapists can ask questions that emphasize a family’s healthy patterns and/or stabilize patterns that are still fragile. He believes that change occurs because of changes that occur in the family’s meaning system. Examples of reflexive questions are: “If you made no changes in your relationship, what do you think the consequences would be? What would have to happen in order for you to realize that the problem was getting a little better?’

9

Explore the Effects of the Problem It is useful for the couple to focus o n the effects of holding the problematic sexual meaning rather than specifically focusing o n the content of each problem.47 I n so doing, the problem begins to be located external to the couple. They begin to see themselves not as “having” a sexual problem, but rather as holding sexual meanings and a sexual script that have negative effects for the marriage. “How has the sexual meaning influenced your relationship? What was it like before your particular sexual meaning was there? How was your relationship different? What was different about your relationship when the problematic meaning was not there?” T h e therapist uses language that presupposes change. Parts and Wholes As stated earlier, “Sexual scripts, as do all scripts, exist at the levels of the individual, the interpersonal, and the cultural. T h e performance of sexual acts draws upon scripts at all levels and potential chan es in sexual conduct can emerge from changes at any level of scripting” (p. 35). At this point, the therapist has the option of intervening at the level of

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construction, the sexual meaning system, either by focusing on a part of the meaning system or by concentrating o n the whole. Here the therapist can move into finding and amplifying exceptions to the presented problem, working on a “part” of the sexual meaning or exploring a part of the sexual script. Or, the therapist can work on the couple’s meaning system as a “whole.” Both ways of working eventually will result in change. Working with a “part” is like chipping away at a brick wall, piece by piece. Eventually the wall is down. Working with the “whole” with metaphors, reframes, etc. is more like going in with a bulldozer. T h e wall falls away with one sweep. This might be because working with a “part” of the frame means working through a problem entrenched in language. Working with metaphors or the “whole” bypasses this entrenched language system, going directly to right brain processes, which give new definitions to whole frames. Both ways of working give rise to new frames-ones containing emergent possibilities. T h e above methods primarily address meaning systems, but in addition the therapist can work at the level of action by prescribing tasks or rituals, thereby offering a framework at both the meaning and behavioral levels. Working wilh the Whole

Since the therapist can only make constructions of the couple system (of which s/he is a part), there are no correct views, only ones that “fit” the system and are acceptable to it.4n Using this therapeutic frame, the therapist focuses o n second order change-those that promote changes of the frame itself. The Reframe. Watzlawick et aL3“ dcfine the constructivist concept of reframing as changing “the conceptual and/or emotional setting or viewpoint in relation to which a situation is experienced and to place it in another frame which fits the ‘facts’ of the same situation equally well or even better and thereby changes its meaning” (p. 95). Here the couple presents their story to the therapist, and the therapist takes the same story and, using the client’s language, gives it a new meaning, one which is equally believable to the couple. A woman labeled by her husband as “undersexed” and “unloving” can become an unselfish woman who does not want to be demanding of her husband. In subsequent sessions, the therapist can assist the woman to find better ways to be unselfish. T h e wife who is called a “nymphomaniac” by her husband can be described as a woman who is interested in enriching all dimensions of their relationship or a woman who enjoys pleasing her husband. The Use of Metaphor. Our concepts of reality are influenced by our language and o u r language is grounded in metaphor. A metaphor can also be seen as a model for changing the way we look at the world. Metaphors are intended to help couples elicit an unconscious search for alternatives and new meanings. Couples’ choreography, as defined by Papp,”’ can be applied to sexual problems in order to get to the core of the couple’s struggle. Using the

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metaphors generated by the couple, the therapist can explore their sexual meaning system and their sexual script. Using imagery, the couple are asked to visually depict themselves and the struggles of their sexual problem in a nonhuman form. T h e imagery that they each develop eliminates their description of the problem in the language that they most typically use (and get stuck in) and replaces it with images. It is then easier for the couple to accept the images depicted in the metaphor because each spouse is viewed as “playing a particular role” not as “being” a certain kind of person. This indirectness allows the couple to see the reciprocal relationship in a gentle way and each person’s participation in its maintenance without the usual resistance. An example of a metaphor given by a client who was sexually abused as a child was: “There were two cats, one big one and one smaller one. T h e big cat was nasty and mean. Sometimes the big cat wanted to come close, but the smaller cat was afraid and tried to run away. T h e n the big cat came u p to the smaller cat and jumped inside the smaller cat’s mouth and started eating the smaller cat from the inside out.” T h e metaphors given by couples are ripe with substance about core issues and provide couples with many new avenues for problem-solving possibilities. Using the metaphor, the individual and the couple sexual meaning systems, the individual and the couple scripts, the sequence of activities, and the future of the couple are explored in detail. Through the exploration, discussion, and the consequential expansion and “rewriting” of this metaphor, the couple can then begin to reconstruct a new metaphorical image of their relationshi-ne that incorporates a sexual meaning system and a sexual script without the problem. T h e creation of different images and perceptions can also be accomplished through the uses of fantasy work depending on the creativity and investment of the therapist and clients. Working with a Part, Looking for Competing Meanings (Excepfions)

It is not apparent to most individuals that there are alternative scripts at each stage of the life cycle. O u r sexual meaning systems makes areas outside the dominant sexual scripts appear invisible. This invisibility serves to maintain and foster adherence to the dominant definitions. In fact, the function of sexual socialization and the sanctions surrounding the dominant script is to keep individuals within it.’ To find, name, focus on, and help the couple experience alternative sexual meanings and sexual scripts is the intention of this section. T h e view expressed in this paper is that change is normal and we have a choice in change. O u r knowledge about how to behave sexually is patterned by sexual scripts; however, we can choose to develop our own personal attitudes and concepts which differ from our traditional ones. There are numerous sexual scripts available to us for examination. Here the role of the therapist is to notice competing constructions or exceptions in the couple’s sexual meanings and sexual scripts. Change requires a two-sided perspective, and a therapist may seek to construct a relational definition by developing

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two (or complementary) descriptions of the p r ~ b l e m . ~Complementary ‘ questions are derived and introduced to challenge or to help deconstruct the dominant explanation and to assist couples in achieving a relational or double description of the problem. This double description then provides the source of new response^.^^^^^ T h e couple’s explanation, or frame, begins to overlap the frame offered by the therapist (like two overlapping Venn diagrams), and it is in this overlap that there is the possibility for change. White’s”’ notion of “exceptions” was originally based in Bateson’s idea of restraints-those ideas, events, experiences that are less likely to be noticed by people because they are dissonant with individuals’ description of the problem. Exceptions are noticing the flip side of the coin. White” believes that as a couple’s view of reality is challenged through questioning about these exceptions, couples ultimately recognize other aspects of their reality that do not involve the problem. In so doing they create another story (narrative), a second story, about their lives which does not include the problem. In his binocular theory of change, de Shazer5’ states that all that is needed for two different descriptions of a problem to develop is a therapist and a client. He believes that it is necessary for the t w o descriptions to be similar yet different enough to create a new view-different from both the client’s and the therapist’s view. “Exceptions are those bits of experiences, behavior, interaction, or selfperception which serve to challenge the dominant d e ~ c r i p t i o n ”(p. ~ ~6). de Shazer’s5’ notion of exceptions-times in the client’s life when the problem was not happening, added to the assumption that the way clients use language is crucial to the way they make sense of themselves, their partner, their problems, their world and is therefore crucial to the process of therapy. T h e therapist “seeks to find the element in the system studied (their conversation about the client’s complaint, goals, etc.) which is alogical, the thread . . . which will unravel it all, or the loose stone which will pull down the whole b ~ i l d i n g ” (p. ~ ’ 68). Here the therapist reinforces alternatives to the dominant description of the problem-helping to make visible areas outside the dominant script. In so doing, s/he begins to undermine the past scripts that specify ~ ~ “To and justify the couple’s real it^.^' Anderson and G o o l i ~ h i a nstate, deconstruct means to take apart the interpretive assumption of the system of meaning that you are examining, to challenge the interpretive system in such a manner that you reveal the assumption on which the model is based. At the same time as these are revealed, you open the space for alternative understanding” (p. 1 1). These exceptions can also be applied to those therapeutic techniques that address the “whole” frame. For example, in the reframes cited earlier, the couple can be asked, “Are there ever times when the sexual problem is not there? What is it like to be sexually satisfied by your partner?” Now the therapist begins to plant new seeds (which tend to create more disorder) and the old frame begins to break up. Prigogine and Stengers*’ believe that information increases as disorder increases. T h e old frame

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breaking u p is the basis of a different level of order. “Are there ever times when the problem is not there? Are there ever times when you enjoy yourselves sexually?” T h e receipt of news of difference is essential for the revelation of new ideas and a triggering of new responses for the discovery of new solutions. An exception (fluctuation) is found and this perturbation is amplified. A piece has been found that does not fit the overall puzzle. This piece has the possibility to grow, beginning the deconstruction or descripting of the old frame (sexual meaning system) and through amplification and activation of the new construction-the new frame. “As we are exposed to invalidational perturbations in the medium our construct system will vary to compensate for these aspects of our e ~ p e r i e n c e (p. ” ~ ~117). Amp1ifring Difference

T h e amplification of the exception is essential for trifgering the new construction that holds the possibility of new solutions.2 Here the therapist amplifies the competing constructions in the couple’s sexual meanings and sexual scripts. “When the sexual problem is not there, how is your relationship? When the sexual problem is not there, what meanings d o you hold about sexuality? If you were to enjoy the relationship more frequently, how would notice? What would be different? What else would be different? How would that be for you?” By helping the couple to deepen the experience of the relationship when the sexual problem is not there, the therapist is facilitating a new construction, that of a more positive relationship. This new construction holds new meanings and new scripts for the couple.

T h Future: New Possibilities At this point, alternative scripts are available to the couple, and what once was invisible now holds potential for new solutions. T h e original sexual meaning system within which the sexual problem was scripted has been deconstructed and replaced by a new description. T h e couple can now begin to focus on the future. Future Focus enables the couple to visualize their relationship without the sexual problem. For example, the couple can speculate that in the future, the couple’s sexual script may reflect choice. It stretches the rubber band into a future without the sexual problem and helps the couple visualize a more positive relationship. Questions include: “If you could stretch the rubber band three years into the future and the sexual problem was gone, what would that look like? How would your relationship be different? How else would it be different?” By asking questions around future trends and choices, the therapist is making that future more real. As Penn3’ suggests, when faced with questions about the future-even if that future really only has the status of the hypothetical-“the system is free to create a new map” (p. 300). Questions such as “How will your future without the problem be different

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from the future with the problem?” require speculation about difference and help consolidate the emerging new sexual meaning system and sexual script of the couple. Often rehearsal precedes performance. N e w sexual scripts give individuals preparation for situations they have yet to encounter. Here, a version of de Shazer’s5’ Miracle Question can be used: ‘If a miracle were to happen tonight while you were asleep and tomorrow morning you awoke to find that this sexual problem were no longer a part of your life, what would be different? How would you know that this miracle had taken place? How could your partner be able t o tell without your telling himlher?” These exercises, while they seem at first glance, simplistic, often have the complicated result of providing a context for change for the couple in that they provide the couple with seeds for a new reality-nes that hold a more positive image of the partner and the relationship. The End of Therapy: Tying I t All up and Rituals for Fresh Starts

Epston and White4’ discuss how they invite persons to a special meeting where, through questioning, they discuss the person’s story of their therapy adventure. Applying this idea to this paper, the couple are asked to recount how they became aware of their sexual problem and what steps they took to solve it. They can recount how and which resources they mobilized as they generated solutions to their problems. Epston and White believe that here the therapist can ask the couple to recount their transition from a problematic status to a resolved one. “What is different about your sexual script? What new meanings do you hold about sexual behavior?” In addition, the therapist also can provide hidher story of the person’s therapy adventure, and they can then discuss their collaborative efforts. At the end of therapy, a ritual for a fresh start may be in order. At this time, couples might choose a date when they have a party to celebrate their new life without the problem. They can do this alone or with their children, friends, and/or relatives attending. Some couples might discuss the type of new relationship they want. Others rekindle positive feelings by restating their original vows. Along with redoing their commitment to each other and to the relationship, they can write down their future script. This then becomes their future image, their future template for their relationship. Now, they can see that they can write and rewrite their own future story. (See Figure 2.) SUMMARY As Gagnorig points out, “Examining sexual conduct from the perspective of scripting allows one to organize and link together what people think, what they do, and how they are affected by the socio-cultural context in which they live. Seeing the conduct as ‘scripted’ on the interpersonal and intrapsychic levels gives the behavior the quality o f a narrative in which

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THERAPY FLOWING FROM THIS VIEW

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T H E PAST

T H E PRESENT-

Explore T h e Development of Sexual Meanings and Sexual T Bury T h e Scripts Past

Explore T h e Couple's Story Explore Their Co-Created Sexual Meaning System And Sexual Script

Challenge T h e Couple's Sexual Meanings And Sexual Scripts I

I

Working With A Part Look For Exceptions Amplify Exceptions

Working With T h e Whole Reframe Metaphors, etc.

t I

THEFUTURE

Create a Frame For Seeing A Future Without A Sexual Problem New Sexual Meanings New Sexual Scripts Fresh Starts

FIGURE 2. Specific Therapeutic Application

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conduct is composed of events ordered in time” (p. 35). Changes in the narratives that couples hold about their sexual scripts can lead to opportunities for change in their sexual meaning systems, which can ultimately reorganize the way they “see” their sexual goals and sexual conduct. Utilizing these concepts as a basis for sex therapy, this paper has presented a model for the integration of couple and sex therapy. Taking a social constructionist epistemological therapeutic stance, the model utilizes the concepts of sexual meaning systems and sexual scripts. (See Figure 3.)

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