The
Role
BY
of Sex
CLIFFORD
J.
Therapy
SAGER,
in Marital
Therapy
M.D.
Marital and sex therapy are clinically interrelated in most cases because they deal with different symptoms ofoverlapping aspects ofthe couple’s total relationship. The connection between marital discord and sexual dysfunction determines the emphasis and course oftreatment. For example, sex therapy is the immediate treatment ofchoice when sexual dysfunction produces secondary marital discord but not when severe discord precludes the possibility of good sexualfunctioning. The authorpresents case reports to illustrate the relationship ofremote and immediate causes ofmarital and sexual problems and to emphasize the value ofa multimodality approach to
Sex aspects
treatment.
ital
therapy and marital therapy deal with different ofthe same entity and consequently are almost clinically interrelated. However, each has a va-
always
lidity
of
its
own,
structure,
and
require
specialized
of sex
ROLE
therapy
in marital
vague and inconsistent Marital therapy generally
oven the past has included
py.
in our
New
developments
therapy
has
several some
knowledge
see no clear-cut marital symptoms.
nicians
and fourths discord
of whether
marital
discord
problem
marital
therapy
based
physi-
on my experience
private practice and in a large family, sex therapy clinic and training facility. Like the relationship between sex and
marital,
in
relationship
between
complex.
It would
to claim ‘.
that
sex
sex
and
be wrong therapy
marital
is deciding
therapy,
and
and
marriage,
the
is highly
an oversimplification
therapy.
is merely
viduals
by harnessing
the
forces
a subspecialty
within
the
of
marital
sys-
tem and directing them toward constructive ends. Therapeutic interventions coven a wide gamut from insight-oriented interpretations to behavior modification and from individual treatment to groups and couples’ groups. However, there is one common factor that categorizes all marital therapists: the use of the marital system
integral
in some
part
conceptual
of the
and
therapeutic
technical
fashion
Revised
version
of a paper
Psychiatric
presented
Association.
as an
program. at the
128th
Anaheim,
annual
Calif.
meeting .
experience.
that
Many
between that almost
cli-
sexual three-
have a mixture of marital in varying proportions ne-
chief
complaint
specific
sexual
to focus
forms
is strictly
of
dysfunction.
The
on sex therapy,
man-
of therapy.
FOCUS
they
must
be identified
relationship
and
May
of
5-9,
Dr. Sager is Psychiatric Director, Jewish Family Service, 33 West 60th St., New York, N.Y. 10023, and Clinical Professor of Psychiatry, Mount Sinai School ofMedicine, City University ofNew York.
reinforced
is to be strengthened.
More
often,
however,
fabric
treatment little
or other
with
of value
of the relationship.
importance
many
It is therefore
to be aware
of the
other
The
aspects
of marital
relationship
of the
marital
In evaluating
the
disharmony
to the
dysfunction
in this
tion existed spouses. 2. Marital
and
the initial with both
sexual
nature
of
difficulties.
the
discord
and
ofthe dysfunction to the discord, could be divided into three dereflecting the extent to which the
discord causes or results 1 Sexual dysfunction discord. Sex therapy
choice
of
and to dedysfunction
disharmony.
discord
qualitative
the temporal relation I found that couples scriptive categories,
the
of pri-
interrelatedness
seems to be the crucial factor in determining therapeutic focus in the treatment ofcouples
significant
disinter-
the dysfunction in mending
the various areas ofthe couple’s relationship fine the connection between the sexual and
it is onin which of choice.
dysfunction
connected
personal problems that alone will be of relatively
weakening
reinforcement, the treatment
sexual
is so intimately
ifthe
Occasionally
ly the sexual bond that needs case sex therapy is certainly
from
sexual
dysfunction
produces
.
the American 1975.
sub-
Sex is one strand in the cable of bonding and therefore is intricately entwined with the other strands that keep the couple together and allow them to develop and grow. When several of these strands begin to fray,
overall
The goal of marital therapy, as I conceive it, is not simply on necessarily to make the relationship work but also to foster the growth of two mdimarital
theoretical
of techniques
distinctions I have found
when
or both
satisfaction
therapy
and
their
or ofa
own
been
ology of sex and the treatment of sexual dysfunctions have led to changes that can currently be described only as trends because of their newness. In this paper, I will discuss the role of the new knowledge of sex therapy as it affects
its
a body
of the couples I see and sexual problems
gardless
decades. sex thera-
of the
in
employs training
THERAPEUTIC THE
rooted
each
is
situation,
secondary
generally
the
especially
before
the
discord
in
when
relationship other
Am J Psychiatry
areas /33:5,
(I).
marital
treatment
of
the dysfuncbetween impairs
Ma)’ 1976
the sexual 555
SEX
THERAPY
IN
MARITAL
THERAPY
functioning. While conjoint marital therapy may be the treatment of choice, sex therapy may be indicated if the couple’s positive feelings and desire to improve their marriage outweigh their negative feelings and the impairment in their relationship as is the case in the majority of such couples. A trial of sex therapy with these
couples
and
consequent
partners,
with ity,
result
in rapid
increase
creating
other
3.
may
in the
a more
pressing
Severe
marital
precludes
the
relief
marital
problems.
discord,
usually
possibility
extreme
hostility
augurs
The
couples
model
developed
applied by Masters and has been fed back into by Kaplan’s delineation
chosomatic
disorders
vidual
with
basic
hostil-
conflicts.
Most
in marital
symptoms
elaborated
have
therapy
and
a multi-
multiple
de-
terminants. Often the sexual malfunction results from the couple’s specific interaction, which may then serve as the overdetermining factor to produce symptoms (immediate cause) in an individual made susceptible by remote causes. The person without a partner often cannot be treated as effectively for a sexual dysfunction because the therapeutic leverage of intenactional factons can be used only when an involved partner participates in the treatment program (5). The recognition that the immediate cause occurs within a susceptibility diathesis due to remote causes within the person has important theoretical and clinical implications. It provides the theoretical rationale for combining task-oriented therapy with other treatment methods based on the therapist’s knowledge of the remote etiological factors. The remote causes may be bypassed but not ignored by the therapist. The terms used to describe intrapsychic pathology often carry questionable value judgments as, for example, in a situation in which a wife’s transactions with her spouse appear to “cause” his impotence; the woman is often labeled as castrating, while the man may be described as weak, dependent, or passive. These adjectives are grave indictments of both partners’ intrapsychic structure However, impotence may also be conceptualized as resulting from the quali.
556
Am J Psychiatry
133:5,
May
1976
at a particular be involved;
or passive
time. man
the
in his general
respond
to forms
couple’s
therapeutic
intrapsychic
that
which
might
BETWEEN
that necessi-
to change
This
the therapist is skilled only conflict resolution modalities.
RELATIONSHIP
without
efforts
structures.
from
of treatment
interactions
their
approach
be undertaken
in individual
MARITAL
mdi-
is quite
when
insight
AND
and
SEX
THERAPY
for sex thena-
therapy provided of both partners to or during this immay be initiated.
causal theory of the sexual dysfunctions, separating immediate forces in the couple’s interactions that contribute to malfunctioning from etiological factors based on earlier experiences that predispose the mdividual to be dysfunctional. Sexual dysfunctions are not necessarily caused by deep intrapsychic problems that reflect disturbance in gender identity or uncon-
scious
the
long-term
different function-
interaction traits need
dependent,
would
modify
tating
poorly
Kaplan
impotence
dealing
Johnson (2, 3) to sex therapy the mainstream of psychiatry of sexual dysfunctions as psy-
(4).
not be weak,
of both
ing. Immediate sex therapy would be contraindicated in this situation, since the couple’s hostility would not allow them to attain the level of cooperation necessary for the rapid treatment of their dysfunction.
While
may
for
sexual
of an character
content
conduct, and the wife may not have a need to control or humiliate her husband. We may then expect that the
milieu
of good
py, it is not a deterrent to marital there is a genuine desire on the part improve their relationship. After provement, more direct sex therapy
and
No negative
will
of symptoms
self-esteem
beneficial
ty
The marital
task-oriented, therapy has
having
witnessed
example,
the
symptom-removal approach in been given much impetus by our its effective use in sex therapy. For of erotic tasks in sex therapy has en-
use
couraged us to use tasks in marital therapy. I am currently applying this approach within the systems treatment model concept of the marital pair. Treatment
is facilitated
therapy are readily their chief complaint, ily Service Clinic. marital
and
we
cannot
and
must
treatment.
when
both
marital
and
sex
therapy increasingly appreciate focus simply on brief sex more flexible about length and
always be
There
sex
available to couples, regardless of as is the case at the Jewish FamProfessionals competent in both
must
often
be a significant
that therapy type of
amount
of
time allotted to marital therapy within the context of the sex therapy program, particularly if the interaction between the partners is not consistent with the pre-
requisites for sex therapy. When sex therapy has been initiated, the therapist must be cautious of the tendency to regard the upsurge of conflicts in other areas of the marriage merely as indicators treatment ofthe sexual dysfunction. such marital conflicts may indeed but it may also be a valid indication
increased
emphasis
I do not
lated
think
specialties
on marital of sex
that
and
view
of resistances to The emergence of signal resistance, for referral or for
therapy.
marital
the
therapy
couple
as two
from
system oftwo ist must also
Both try to examine and affect persons. Hence, the sex therapy be a well-trained marital therapist
able
interactional
perspectives.
to bring
sexual in
problems
marital
petent The
In
must
as well the
comfortable
patients’ attainment
as
specialist
and
com-
sexual problems. of some com-
in sex therapy (and vice versa) need not prereferral to experienced specialists when he he is getting beyond his expertise or into areas
definitely
both
the same specialwho is
intrapsychic
Conversely,
feel his
he is not comfortable my first published
stated use
therapy
and focus.
in dealing with marital therapist’s
petency dude knows that
into
iso-
different
marital
with or interested opinion on this
that
the
therapist
who
and
sex
therapy
should
in. issue
is qualified
keep
the
(1)
I to
two
CLIFFORD
sharply become and
separated. less rigid.
remote
With The
causes
additional interplay
often
experience, I have between immediate
requires
a frequent
shift
therapeutic emphasis. However, both the and the couple should know when the focus therapy and when some remote factor dealing tility
or
trust
changing
has
their
to
be
explored
before
of
therapist is on sex with hos-
one
can
risk
behavior.
The important principle is that a couple’s sexual functioning is only one aspect of their total dyadic system. It is readily influenced by and in turn readily influ-
ences other functions and processes. The therapist feel free to move between the special techniques each
modality
working
while
with
in one
area
The rapid
appreciating
numerous deeply
interrelated affect other
may
presenting treatment
that
problem of sexual
he
of
cord
this
marital
interactions
is such that seems to be
may than be the For
I prefer this term to “lack of libido” or “low sex drive’ because it implies a psychological rather than a physical etiology or a mystical crisis of libidinal enengy. When such a couple has sex, both partners may experience it as pleasurable and there may be no evi-
problem.
When
dence ofdysfunction. I find that treating this syndrome usually requires marital therapy in conjunction with various erotic and nonerotic tasks to be carried out at
focusing
marital
problem
titudinal
ofcourse, in accordance Often there must be
on the in order
more
remote
to achieve
aspects
behavioral
with several
of the and
at-
changes.
Some sex therapy techniques are very helpful in marital therapy and can be used in conjunction with more traditional techniques deriving from other
schools
of psychotherapy.
For example,
sensate
focus
with no genital stimulation (6) can be prescribed by the marital therapist as a way of highlighting and helping the couple work through hostilities, poor communica-
tion, fear of emotional balizing desires, and the importance ofquid
closeness, and difficulty in yenas a concrete demonstration of pro quo maneuvers. The proce-
dune of taking turns giving deep emotional reactions can be used as an evaluative
and receiving pleasure taps in both partners. This task test to determine several
interactional and intrapsychic therapist to arrive at the most ities
for
CASE
thus helping the and fruitful prior-
intervention.
present
that
a few
sex therapy
case
reports
cannot
to illustrate
and
should
that marital
1 A woman
done
on the dysfunc-
in
have
isolation
also
from
contributed
disharmony
the
to the
produces
sex
dys-
to break the cycle, freely between the in another specialist
but he must two forms of if necessary.
my con-
not be iso-
she
desired
sex.
complete
sexual
tasks
was
needs. focus were
woman
designed
her
husband,
she
cause.
I took
apparent
was
helped
determinants were primarily
internist
of her
to appreciate
as insensitivity
to
communication
to an understanding which
were
and
of her an-
then
modified
by
prepared for working through the immeof the woman’s lack of sexual desire, interactional. However, the wife’s con-
the couple’s
2. A young
a
history
malfunction
was also rooted
in intra-
psychic fears of rejection and feelings of inadequacy that had experienced since childhood. The man’s input was specific and more reactive. Their overall relationship proved, and frequent pleasurable sex returned.
Case
no
of marital therapy, inand receiving recipro-
to increase
behavior,
The way was thus
to
with
A short course and other giving
his evocative
tribution
told
for what she perceived
led both partners
ger and treatment.
wife
no
her
been
the
as well as an appropriate
The
that
sensitivity,
diate which
orgasmic
history,
her emotional cluding sensate
after
There
her husband
at
therapy
was
relationship.
fury
cal
sex
although
longer their
of 30 and a man of 31 had originally
.
to me for
that,
couple
was referred
for marital
she less im-
therapy
to
the Jewish Family Service by a private psychiatrist. The caseworker who saw the couple originally felt that the wife was extremely hostile and near decompensation. A staff psychiatrist then interviewed the couple in consultation. Al-
though
the psychiatrist
felt that
the woman
was
not
schizo-
he believed that at that time marital therapy would too anxiety provoking for her and recommended individtreatment for the husband and wife. The husband’s theraelicited a history ofmarked sexual dysfunction. The wife always been anorgasmic by any means and the husband a history suggestive ofpremature ejaculation. It was also
phrenic,
be ual pist had had
discovered
that
their sexual
relationship
was further
limited
by
the wife’s recurrent vaginal infections. A consultation with a gynecologist was arranged, and her therapist saw that she completed an adequate course of medical treatment. In the past, she had stopped taking medication prematurely and
her infections this
physical
to work
then
worsened. to coitus
barrier
on her
When pists,
REPORTS
I will
tention
therapeutic
factors, urgent
treatment
be
therapy in an attempt be prepared to move treatment or to bring
‘
sessions
cannot
function, it is generally best to resolve some of the interactional problems first. When sexual dysfunction and marital disharmony have become a circular on reverberating system, the therapist might begin with sex
Case
example, the dysfunction of many couples can be best described as an infrequent desire to initiate or pursue sexual relations, a syndrome I refer to as sexual ennui.
varies, factor(s).
it may be best to focus
,
referred
sexual. The sexual dysfunction may points to the interactional “dyscrasia.”
home. Treatment the etiological
areas of the marital system. When a is the major cause of marital dis-
tion-but
Failure
called for; however, more thorough examination indicate that the problems are interactional rather specifically sign that
from other dysfunction
SAGER
is always
functions. functions.
ofmany couples dysfunction
can
lated sexual
J.
patients
well
to eradicate
for her readiness
anorgasmia.
a conference the
Her willingness augured
was also
held
participated
with
all the concerned in
the
thera-
decision-making
process. It was decided that individual treatment would be discontinued within a few sessions and the wife’s therapist would see the couple in sex therapy, emphasizing the overall relationship problems, particularly those in the areas of trust and closeness. The wife rapidly became orgasmic by selfmasturbation and by her husband’s masturbation ofher. His
Am J Psychiatry
133:5,
May
1976
557
SEX
THERAPY
IN
MARITAL
THERAPY
premature ejaculation had been situational and cleared as he felt welcomed as a sex partner and respected as a person by his wife. Formal sex therapy was then stopped and the emphasis was changed. with the couple’s agreement, to a new contract for time-limited marital therapy.
If this couple had continued with individual therapy instead of changing to a flexible multifaceted therapeutic approach, they would probably have proceeded to a di-
vorce.
Both
partners
scarred
and
inadequate.
might
then
have
The case approach
of a multimodality the total relationship. tages
been
illustrates to the
left feeling the advantreatment of
their
feelings
poor. Case a man
they
3. Two
married professionals 30) came to therapy with
aged
were
growing
apart.
The
(a woman aged a chief complaint
husband
stated
26 and that
that
he was
subject to depressions that caused him to withdraw; the wife reacted to his withdrawal initially with anger and later with resignation and hopelessness. They were compatible in many areas, believed they loved one another, and wanted to make the marriage work.
When
the sexual
history
was taken.
the partners
were
both
very definite that sex was fine mechanically; they were both invariably orgasmic during coitus. However, sex was not emotionally satisfying to the wife, and for several months pnior to their seeking professional help she had allowed sex only sporadically. She had had sex with other men before marriage and with two men when she and her husband separated
for a few months, tionally distance having
and
she had found
that
sex could
be emo-
as well as physically satisfying for her. She sensed a between herself and her husband when they were coitus. particularly immediately after orgasm. He
would
turn away
and withdraw,
and talk. “That’s “and he just isn’t
while
she wanted
scribing
an intolerable
He
desire
sensed
her
to get
away
vulnerability
after
but
felt
threatened by her desire for closeness. The man’s mother and father had had
she
said,
this,
they
had
deinter-
controlled
separate
and
bedrooms
from his first memory until he was 10 years old. During these years he slept with his mother. She was seductive toward him, which he found frightening. As an adult, he disliked and distrusted his mother and was ambivalent toward his father. His parents had a distant relationship in all aspects.
The
wife
had
slept
in the same
room
with
her father
from
age 3 to age 8. Although he was seductive toward her, she recalls no actual sexual acting out. Unlike her husband’s experience with his mother, she was close to her father. Although they were both aware of these facts in each other’s lives, neither had ever put these unusual ‘ ‘coincidences’ ‘ together. The wife apparently yearned for the closeness she had or wished for with her father, and sex held no fears, anxieties, or inhibitions for her. The husband. although he did not suffer inhibition ofsexual performance, experienced terrible anxiety at the prospect ofemotional closeness, which was clearly related to his experience with his mother. Such a couple might provide a field day for our psychoanalytic concepts of the etiology of sexual inadequacy. Although
were
there
as distressed
couples
no
impairment
about
their
of
sexual
with actual dysfunction. situation required a therapist
This
sex
therapy
pist
saw
558
was
and
psychoanalytic
the
couple
conjointly
Am
J Psychiatry
functions
performance versed
May
them
1976
they
as other
in marital
psychotherapy. to help
133:5,
sexual
The openly
conflictual
aspects
of their
sexual
and
the
Individual first
step
therapy
for the man was recommended
in an attempt
to interrupt
interactions. Marital therapy but left us at a therapeutic The
husband
referral.
He
he and
ther
sent liked
his
me
his
wife
had been impasse.
a note
recently
therapist.
were
more
their
He
said
optimistic.
circular
helpful
as
negative
diagnostically
thanking things
me were
Outcome
for
quiet
the and
awaits
fur-
for
this
developments. Although
cbuple,
sex
it was
was
mechanically
affectively
inadequate
This is a syndrome quency. Inappropriate
ing or after in the
sex
we
may
couple’s
good
and
dissatisfying.
are seeing with increasing feelings (or lack offeelings)
be due
relationship
to immediate
causes
(as they
for
or to remote and intrapsychic were for the husband).
were
determinants
fredun-
with-
the
(as
wife)
they
CONCLUSIONS
to snuggle
the time I can be most open.” there. “ The husband confirmed
course.
regarding
emotional contracts. The marriage contract approach (7) uncovered many hitherto unconscious conflicting contractual terms. The source of the difficulty was found to reside largely within the man’s intrapsychic dynamics (remote causes), which caused him to precipitate transactions with his wife (immediate causes) that were terribly destructive. She played the game with him. He had to see her as he had seen his threatening seductive mother. He feared being drawn into emotional closeness with his wife and reacted to this anxiety by manifesting hostile depression and withdrawal. The woman reacted in a way that was consistent with her vulnerability and reinforced his fears. Without major changes in their basic adaptations, the prognosis for their marriage was
and
theradiscuss
The sexual components of a couple’s relationship cannot be separated from their total relationship, eithen in the reality of their daily life or in treatment. Sex therapy has had and will continue to have a profound
effect on marital therapy. The effectiveness ofthe new sex therapy has substantiated the value of the systems approach and of a multifaceted, goal-directed, taskoriented
form
of
the fullest
volves
marital
range
therapy.
This
of the therapist’s
approach
skills
in-
in deal-
ing with those factors that interfere with the patients’ collaboration in their own change. Symptom removal and tasks mobilize resistance; an eclectic approach to treatment allows us to make use of a panoply of new and old treatment methods and techniques to deal with these
deterrents
to
change. REFERENCES
I . Sager CJ: Sexual dysfunctions and marital discord, in The New Sex Therapy. By Kaplan HS. New York, Brunner/Mazel, 1974, pp 501-516 2. Masters WH, Johnson VE: Human Sexual Response. Boston, Little,
Brown
& Co.
1966
3. Masters WH, Johnson VE: Human Sexual Inadequacy. Boston, Little, Brown & Co. 1970 4. Kaplan HS: The New Sex Therapy. New York, Brunner/Mazel, 1974 5. Sager CJ: The couples model in the treatment ofsexual dysfunctions in the single person, in Sexuality and Psychoanalysis. Edited by Adelson ET. New York, Brunner/Mazel, pp 124-142
ANDERSON,
FRANK,
6. Kaplan HS: The Illustrated Manual ofSex Therapy. Quadrangle/New York Times Book Co. 1975
Profiles BY
of Couples
ELLEN
FRANK,
M.A.,
New
Seeking CAROL
Sex
YEARS
workers
marital therapy was the or marital counselors,
M.S.W.,
were
rarely,
recent
explosion
ifever,
of scientific
discussed.
of the by In to
the
about
human
sexual experience, coinciding with the women’s movement and the new freedom granted women to acknowledge their own sexuality, has focused considerable attention on this aspect of human interaction (1 2). At present there are thousands ofclinics and individual therapists throughout the country offering what is ,
commonly dysfunction of deep-seated to long-term
called
“sex
Psychiatric
Symptoms
were once considered psychological problems individual psychotherapy
Revised version of a paper the American Psychiatric 1975. The authors
therapy.”
that
are with Institute
presented Association,
the Department and
of sexual
manifestations amenable only are now consid-
at the I 28th annual Anaheim, Calif. of Psychiatry
Clinic, University St. , Pittsburgh, Pa.
meeting of , May 5-9,
School
AND
RH, et al: The 1974
Marital
DAVID
J.
marriage
of
Medicine. 381 1 O’Hara Ms. Frank is Research Assistant in Psychiatry, Ms. Anderson is Associate Professor of Clinical Psychiatry and Director, Family Therapy Clinic, and Dr. Kupfer is Professor of Psychiatry and Director of Research.
con-
Therapy
KUPFER,
M.D.
and sexual dysfunction clinics, offers a unique
couples coming for one form er. This report is a preliminary similarities and the differences seek marital therapy and those sexual dysfunction.
therapy opportunity
almost intercouple marital to be attack to be action at the marital
in separate to study
of treatment on the attempt to examine between those who seek treatment
oththe who for
METHOD
In order to study the characteristics of the couples coming for these two modes of therapy, we examined the initial marital evaluation form (KDS-15) given to all couples seeking marital therapy in the Family Then-
apy
Unit
and
to all couples
seeking
treatment
for sex-
ual dysfunction in the Sexual Behavior Center oven a 6-month period. Couples were given the questionnames at their first appointment and instructed to complete them without consulting one another and return them at their next appointment. KDS-15 is an extensive self-report questionnaire that covers many as-
pects
of a marriage,
including
individual
development
and parental family situation, psychosocial history, courtship, current marital relationship, current living
situation,
and the Western
of Pittsburgh 15261 , where
and
therapy specialty
sole pnovwho con-
However,
knowledge
CJ, Kaplan HS, Gundlach Family Process 10:311-326,
KUPFER
ered not only eminently treatable, but treatable exclusively within the context of short-term vention involving both members of the affected (3). Perhaps because of their divergent origins, therapy and sexual dysfunction therapy continue thought of as different forms of treatment that quite different problems. Yet often the two seem inseparable aspects of a complex interplay of and reaction. The Western Psychiatric Institute and Clinic University of Pittsburgh, which provides both
and
centrated on the overt interactional difficulties being experienced by the couple. The marriage itself was the focus ofthe therapy, and the sexual aspects ofthe relationship
7. Sager tract.
Therapy
ANDERSON,
Assessment of29 couples seeking marital therapy 25 seeking sexual therapy at the same institution permitted the delineation oftwo distinct profiles. Although the two groups were similar in the degree their sexual and marital difficulties and in demographic characteristics, the relationships of sex therapy couples were generally characterized satisfaction and affection, whereas those of the marital therapy couples were often antagonistic. addition, the sex therapy couples tended to be less conservative and more thoughtful in their approach life and their problems.
FOR MANY ince of social
York,
AND
premarital
and
marital
sexual work
activity,
of children
tivities, titudes
the use ofleisure time, medical history, about role behavior in the marriage.
The
entire
on the
marriage,
impact
sample
of
108
Am J Psychiatry
patients 133:5,
and
was May
the
social
divided 1976
ac-
and atby 559
Role
BY
of Sex
CLIFFORD
J.
Therapy
SAGER,
in Marital
Therapy
M.D.
Marital and sex therapy are clinically interrelated in most cases because they deal with different symptoms ofoverlapping aspects ofthe couple’s total relationship. The connection between marital discord and sexual dysfunction determines the emphasis and course oftreatment. For example, sex therapy is the immediate treatment ofchoice when sexual dysfunction produces secondary marital discord but not when severe discord precludes the possibility of good sexualfunctioning. The authorpresents case reports to illustrate the relationship ofremote and immediate causes ofmarital and sexual problems and to emphasize the value ofa multimodality approach to
Sex aspects
treatment.
ital
therapy and marital therapy deal with different ofthe same entity and consequently are almost clinically interrelated. However, each has a va-
always
lidity
of
its
own,
structure,
and
require
specialized
of sex
ROLE
therapy
in marital
vague and inconsistent Marital therapy generally
oven the past has included
py.
in our
New
developments
therapy
has
several some
knowledge
see no clear-cut marital symptoms.
nicians
and fourths discord
of whether
marital
discord
problem
marital
therapy
based
physi-
on my experience
private practice and in a large family, sex therapy clinic and training facility. Like the relationship between sex and
marital,
in
relationship
between
complex.
It would
to claim ‘.
that
sex
sex
and
be wrong therapy
marital
is deciding
therapy,
and
and
marriage,
the
is highly
an oversimplification
therapy.
is merely
viduals
by harnessing
the
forces
a subspecialty
within
the
of
marital
sys-
tem and directing them toward constructive ends. Therapeutic interventions coven a wide gamut from insight-oriented interpretations to behavior modification and from individual treatment to groups and couples’ groups. However, there is one common factor that categorizes all marital therapists: the use of the marital system
integral
in some
part
conceptual
of the
and
therapeutic
technical
fashion
Revised
version
of a paper
Psychiatric
presented
Association.
as an
program. at the
128th
Anaheim,
annual
Calif.
meeting .
experience.
that
Many
between that almost
cli-
sexual three-
have a mixture of marital in varying proportions ne-
chief
complaint
specific
sexual
to focus
forms
is strictly
of
dysfunction.
The
on sex therapy,
man-
of therapy.
FOCUS
they
must
be identified
relationship
and
May
of
5-9,
Dr. Sager is Psychiatric Director, Jewish Family Service, 33 West 60th St., New York, N.Y. 10023, and Clinical Professor of Psychiatry, Mount Sinai School ofMedicine, City University ofNew York.
reinforced
is to be strengthened.
More
often,
however,
fabric
treatment little
or other
with
of value
of the relationship.
importance
many
It is therefore
to be aware
of the
other
The
aspects
of marital
relationship
of the
marital
In evaluating
the
disharmony
to the
dysfunction
in this
tion existed spouses. 2. Marital
and
the initial with both
sexual
nature
of
difficulties.
the
discord
and
ofthe dysfunction to the discord, could be divided into three dereflecting the extent to which the
discord causes or results 1 Sexual dysfunction discord. Sex therapy
choice
of
and to dedysfunction
disharmony.
discord
qualitative
the temporal relation I found that couples scriptive categories,
the
of pri-
interrelatedness
seems to be the crucial factor in determining therapeutic focus in the treatment ofcouples
significant
disinter-
the dysfunction in mending
the various areas ofthe couple’s relationship fine the connection between the sexual and
it is onin which of choice.
dysfunction
connected
personal problems that alone will be of relatively
weakening
reinforcement, the treatment
sexual
is so intimately
ifthe
Occasionally
ly the sexual bond that needs case sex therapy is certainly
from
sexual
dysfunction
produces
.
the American 1975.
sub-
Sex is one strand in the cable of bonding and therefore is intricately entwined with the other strands that keep the couple together and allow them to develop and grow. When several of these strands begin to fray,
overall
The goal of marital therapy, as I conceive it, is not simply on necessarily to make the relationship work but also to foster the growth of two mdimarital
theoretical
of techniques
distinctions I have found
when
or both
satisfaction
therapy
and
their
or ofa
own
been
ology of sex and the treatment of sexual dysfunctions have led to changes that can currently be described only as trends because of their newness. In this paper, I will discuss the role of the new knowledge of sex therapy as it affects
its
a body
of the couples I see and sexual problems
gardless
decades. sex thera-
of the
in
employs training
THERAPEUTIC THE
rooted
each
is
situation,
secondary
generally
the
especially
before
the
discord
in
when
relationship other
Am J Psychiatry
areas /33:5,
(I).
marital
treatment
of
the dysfuncbetween impairs
Ma)’ 1976
the sexual 555
SEX
THERAPY
IN
MARITAL
THERAPY
functioning. While conjoint marital therapy may be the treatment of choice, sex therapy may be indicated if the couple’s positive feelings and desire to improve their marriage outweigh their negative feelings and the impairment in their relationship as is the case in the majority of such couples. A trial of sex therapy with these
couples
and
consequent
partners,
with ity,
result
in rapid
increase
creating
other
3.
may
in the
a more
pressing
Severe
marital
precludes
the
relief
marital
problems.
discord,
usually
possibility
extreme
hostility
augurs
The
couples
model
developed
applied by Masters and has been fed back into by Kaplan’s delineation
chosomatic
disorders
vidual
with
basic
hostil-
conflicts.
Most
in marital
symptoms
elaborated
have
therapy
and
a multi-
multiple
de-
terminants. Often the sexual malfunction results from the couple’s specific interaction, which may then serve as the overdetermining factor to produce symptoms (immediate cause) in an individual made susceptible by remote causes. The person without a partner often cannot be treated as effectively for a sexual dysfunction because the therapeutic leverage of intenactional factons can be used only when an involved partner participates in the treatment program (5). The recognition that the immediate cause occurs within a susceptibility diathesis due to remote causes within the person has important theoretical and clinical implications. It provides the theoretical rationale for combining task-oriented therapy with other treatment methods based on the therapist’s knowledge of the remote etiological factors. The remote causes may be bypassed but not ignored by the therapist. The terms used to describe intrapsychic pathology often carry questionable value judgments as, for example, in a situation in which a wife’s transactions with her spouse appear to “cause” his impotence; the woman is often labeled as castrating, while the man may be described as weak, dependent, or passive. These adjectives are grave indictments of both partners’ intrapsychic structure However, impotence may also be conceptualized as resulting from the quali.
556
Am J Psychiatry
133:5,
May
1976
at a particular be involved;
or passive
time. man
the
in his general
respond
to forms
couple’s
therapeutic
intrapsychic
that
which
might
BETWEEN
that necessi-
to change
This
the therapist is skilled only conflict resolution modalities.
RELATIONSHIP
without
efforts
structures.
from
of treatment
interactions
their
approach
be undertaken
in individual
MARITAL
mdi-
is quite
when
insight
AND
and
SEX
THERAPY
for sex thena-
therapy provided of both partners to or during this immay be initiated.
causal theory of the sexual dysfunctions, separating immediate forces in the couple’s interactions that contribute to malfunctioning from etiological factors based on earlier experiences that predispose the mdividual to be dysfunctional. Sexual dysfunctions are not necessarily caused by deep intrapsychic problems that reflect disturbance in gender identity or uncon-
scious
the
long-term
different function-
interaction traits need
dependent,
would
modify
tating
poorly
Kaplan
impotence
dealing
Johnson (2, 3) to sex therapy the mainstream of psychiatry of sexual dysfunctions as psy-
(4).
not be weak,
of both
ing. Immediate sex therapy would be contraindicated in this situation, since the couple’s hostility would not allow them to attain the level of cooperation necessary for the rapid treatment of their dysfunction.
While
may
for
sexual
of an character
content
conduct, and the wife may not have a need to control or humiliate her husband. We may then expect that the
milieu
of good
py, it is not a deterrent to marital there is a genuine desire on the part improve their relationship. After provement, more direct sex therapy
and
No negative
will
of symptoms
self-esteem
beneficial
ty
The marital
task-oriented, therapy has
having
witnessed
example,
the
symptom-removal approach in been given much impetus by our its effective use in sex therapy. For of erotic tasks in sex therapy has en-
use
couraged us to use tasks in marital therapy. I am currently applying this approach within the systems treatment model concept of the marital pair. Treatment
is facilitated
therapy are readily their chief complaint, ily Service Clinic. marital
and
we
cannot
and
must
treatment.
when
both
marital
and
sex
therapy increasingly appreciate focus simply on brief sex more flexible about length and
always be
There
sex
available to couples, regardless of as is the case at the Jewish FamProfessionals competent in both
must
often
be a significant
that therapy type of
amount
of
time allotted to marital therapy within the context of the sex therapy program, particularly if the interaction between the partners is not consistent with the pre-
requisites for sex therapy. When sex therapy has been initiated, the therapist must be cautious of the tendency to regard the upsurge of conflicts in other areas of the marriage merely as indicators treatment ofthe sexual dysfunction. such marital conflicts may indeed but it may also be a valid indication
increased
emphasis
I do not
lated
think
specialties
on marital of sex
that
and
view
of resistances to The emergence of signal resistance, for referral or for
therapy.
marital
the
therapy
couple
as two
from
system oftwo ist must also
Both try to examine and affect persons. Hence, the sex therapy be a well-trained marital therapist
able
interactional
perspectives.
to bring
sexual in
problems
marital
petent The
In
must
as well the
comfortable
patients’ attainment
as
specialist
and
com-
sexual problems. of some com-
in sex therapy (and vice versa) need not prereferral to experienced specialists when he he is getting beyond his expertise or into areas
definitely
both
the same specialwho is
intrapsychic
Conversely,
feel his
he is not comfortable my first published
stated use
therapy
and focus.
in dealing with marital therapist’s
petency dude knows that
into
iso-
different
marital
with or interested opinion on this
that
the
therapist
who
and
sex
therapy
should
in. issue
is qualified
keep
the
(1)
I to
two
CLIFFORD
sharply become and
separated. less rigid.
remote
With The
causes
additional interplay
often
experience, I have between immediate
requires
a frequent
shift
therapeutic emphasis. However, both the and the couple should know when the focus therapy and when some remote factor dealing tility
or
trust
changing
has
their
to
be
explored
before
of
therapist is on sex with hos-
one
can
risk
behavior.
The important principle is that a couple’s sexual functioning is only one aspect of their total dyadic system. It is readily influenced by and in turn readily influ-
ences other functions and processes. The therapist feel free to move between the special techniques each
modality
working
while
with
in one
area
The rapid
appreciating
numerous deeply
interrelated affect other
may
presenting treatment
that
problem of sexual
he
of
cord
this
marital
interactions
is such that seems to be
may than be the For
I prefer this term to “lack of libido” or “low sex drive’ because it implies a psychological rather than a physical etiology or a mystical crisis of libidinal enengy. When such a couple has sex, both partners may experience it as pleasurable and there may be no evi-
problem.
When
dence ofdysfunction. I find that treating this syndrome usually requires marital therapy in conjunction with various erotic and nonerotic tasks to be carried out at
focusing
marital
problem
titudinal
ofcourse, in accordance Often there must be
on the in order
more
remote
to achieve
aspects
behavioral
with several
of the and
at-
changes.
Some sex therapy techniques are very helpful in marital therapy and can be used in conjunction with more traditional techniques deriving from other
schools
of psychotherapy.
For example,
sensate
focus
with no genital stimulation (6) can be prescribed by the marital therapist as a way of highlighting and helping the couple work through hostilities, poor communica-
tion, fear of emotional balizing desires, and the importance ofquid
closeness, and difficulty in yenas a concrete demonstration of pro quo maneuvers. The proce-
dune of taking turns giving deep emotional reactions can be used as an evaluative
and receiving pleasure taps in both partners. This task test to determine several
interactional and intrapsychic therapist to arrive at the most ities
for
CASE
thus helping the and fruitful prior-
intervention.
present
that
a few
sex therapy
case
reports
cannot
to illustrate
and
should
that marital
1 A woman
done
on the dysfunc-
in
have
isolation
also
from
contributed
disharmony
the
to the
produces
sex
dys-
to break the cycle, freely between the in another specialist
but he must two forms of if necessary.
my con-
not be iso-
she
desired
sex.
complete
sexual
tasks
was
needs. focus were
woman
designed
her
husband,
she
cause.
I took
apparent
was
helped
determinants were primarily
internist
of her
to appreciate
as insensitivity
to
communication
to an understanding which
were
and
of her an-
then
modified
by
prepared for working through the immeof the woman’s lack of sexual desire, interactional. However, the wife’s con-
the couple’s
2. A young
a
history
malfunction
was also rooted
in intra-
psychic fears of rejection and feelings of inadequacy that had experienced since childhood. The man’s input was specific and more reactive. Their overall relationship proved, and frequent pleasurable sex returned.
Case
no
of marital therapy, inand receiving recipro-
to increase
behavior,
The way was thus
to
with
A short course and other giving
his evocative
tribution
told
for what she perceived
led both partners
ger and treatment.
wife
no
her
been
the
as well as an appropriate
The
that
sensitivity,
diate which
orgasmic
history,
her emotional cluding sensate
after
There
her husband
at
therapy
was
relationship.
fury
cal
sex
although
longer their
of 30 and a man of 31 had originally
.
to me for
that,
couple
was referred
for marital
she less im-
therapy
to
the Jewish Family Service by a private psychiatrist. The caseworker who saw the couple originally felt that the wife was extremely hostile and near decompensation. A staff psychiatrist then interviewed the couple in consultation. Al-
though
the psychiatrist
felt that
the woman
was
not
schizo-
he believed that at that time marital therapy would too anxiety provoking for her and recommended individtreatment for the husband and wife. The husband’s theraelicited a history ofmarked sexual dysfunction. The wife always been anorgasmic by any means and the husband a history suggestive ofpremature ejaculation. It was also
phrenic,
be ual pist had had
discovered
that
their sexual
relationship
was further
limited
by
the wife’s recurrent vaginal infections. A consultation with a gynecologist was arranged, and her therapist saw that she completed an adequate course of medical treatment. In the past, she had stopped taking medication prematurely and
her infections this
physical
to work
then
worsened. to coitus
barrier
on her
When pists,
REPORTS
I will
tention
therapeutic
factors, urgent
treatment
be
therapy in an attempt be prepared to move treatment or to bring
‘
sessions
cannot
function, it is generally best to resolve some of the interactional problems first. When sexual dysfunction and marital disharmony have become a circular on reverberating system, the therapist might begin with sex
Case
example, the dysfunction of many couples can be best described as an infrequent desire to initiate or pursue sexual relations, a syndrome I refer to as sexual ennui.
varies, factor(s).
it may be best to focus
,
referred
sexual. The sexual dysfunction may points to the interactional “dyscrasia.”
home. Treatment the etiological
areas of the marital system. When a is the major cause of marital dis-
tion-but
Failure
called for; however, more thorough examination indicate that the problems are interactional rather specifically sign that
from other dysfunction
SAGER
is always
functions. functions.
ofmany couples dysfunction
can
lated sexual
J.
patients
well
to eradicate
for her readiness
anorgasmia.
a conference the
Her willingness augured
was also
held
participated
with
all the concerned in
the
thera-
decision-making
process. It was decided that individual treatment would be discontinued within a few sessions and the wife’s therapist would see the couple in sex therapy, emphasizing the overall relationship problems, particularly those in the areas of trust and closeness. The wife rapidly became orgasmic by selfmasturbation and by her husband’s masturbation ofher. His
Am J Psychiatry
133:5,
May
1976
557
SEX
THERAPY
IN
MARITAL
THERAPY
premature ejaculation had been situational and cleared as he felt welcomed as a sex partner and respected as a person by his wife. Formal sex therapy was then stopped and the emphasis was changed. with the couple’s agreement, to a new contract for time-limited marital therapy.
If this couple had continued with individual therapy instead of changing to a flexible multifaceted therapeutic approach, they would probably have proceeded to a di-
vorce.
Both
partners
scarred
and
inadequate.
might
then
have
The case approach
of a multimodality the total relationship. tages
been
illustrates to the
left feeling the advantreatment of
their
feelings
poor. Case a man
they
3. Two
married professionals 30) came to therapy with
aged
were
growing
apart.
The
(a woman aged a chief complaint
husband
stated
26 and that
that
he was
subject to depressions that caused him to withdraw; the wife reacted to his withdrawal initially with anger and later with resignation and hopelessness. They were compatible in many areas, believed they loved one another, and wanted to make the marriage work.
When
the sexual
history
was taken.
the partners
were
both
very definite that sex was fine mechanically; they were both invariably orgasmic during coitus. However, sex was not emotionally satisfying to the wife, and for several months pnior to their seeking professional help she had allowed sex only sporadically. She had had sex with other men before marriage and with two men when she and her husband separated
for a few months, tionally distance having
and
she had found
that
sex could
be emo-
as well as physically satisfying for her. She sensed a between herself and her husband when they were coitus. particularly immediately after orgasm. He
would
turn away
and withdraw,
and talk. “That’s “and he just isn’t
while
she wanted
scribing
an intolerable
He
desire
sensed
her
to get
away
vulnerability
after
but
felt
threatened by her desire for closeness. The man’s mother and father had had
she
said,
this,
they
had
deinter-
controlled
separate
and
bedrooms
from his first memory until he was 10 years old. During these years he slept with his mother. She was seductive toward him, which he found frightening. As an adult, he disliked and distrusted his mother and was ambivalent toward his father. His parents had a distant relationship in all aspects.
The
wife
had
slept
in the same
room
with
her father
from
age 3 to age 8. Although he was seductive toward her, she recalls no actual sexual acting out. Unlike her husband’s experience with his mother, she was close to her father. Although they were both aware of these facts in each other’s lives, neither had ever put these unusual ‘ ‘coincidences’ ‘ together. The wife apparently yearned for the closeness she had or wished for with her father, and sex held no fears, anxieties, or inhibitions for her. The husband. although he did not suffer inhibition ofsexual performance, experienced terrible anxiety at the prospect ofemotional closeness, which was clearly related to his experience with his mother. Such a couple might provide a field day for our psychoanalytic concepts of the etiology of sexual inadequacy. Although
were
there
as distressed
couples
no
impairment
about
their
of
sexual
with actual dysfunction. situation required a therapist
This
sex
therapy
pist
saw
558
was
and
psychoanalytic
the
couple
conjointly
Am
J Psychiatry
functions
performance versed
May
them
1976
they
as other
in marital
psychotherapy. to help
133:5,
sexual
The openly
conflictual
aspects
of their
sexual
and
the
Individual first
step
therapy
for the man was recommended
in an attempt
to interrupt
interactions. Marital therapy but left us at a therapeutic The
husband
referral.
He
he and
ther
sent liked
his
me
his
wife
had been impasse.
a note
recently
therapist.
were
more
their
He
said
optimistic.
circular
helpful
as
negative
diagnostically
thanking things
me were
Outcome
for
quiet
the and
awaits
fur-
for
this
developments. Although
cbuple,
sex
it was
was
mechanically
affectively
inadequate
This is a syndrome quency. Inappropriate
ing or after in the
sex
we
may
couple’s
good
and
dissatisfying.
are seeing with increasing feelings (or lack offeelings)
be due
relationship
to immediate
causes
(as they
for
or to remote and intrapsychic were for the husband).
were
determinants
fredun-
with-
the
(as
wife)
they
CONCLUSIONS
to snuggle
the time I can be most open.” there. “ The husband confirmed
course.
regarding
emotional contracts. The marriage contract approach (7) uncovered many hitherto unconscious conflicting contractual terms. The source of the difficulty was found to reside largely within the man’s intrapsychic dynamics (remote causes), which caused him to precipitate transactions with his wife (immediate causes) that were terribly destructive. She played the game with him. He had to see her as he had seen his threatening seductive mother. He feared being drawn into emotional closeness with his wife and reacted to this anxiety by manifesting hostile depression and withdrawal. The woman reacted in a way that was consistent with her vulnerability and reinforced his fears. Without major changes in their basic adaptations, the prognosis for their marriage was
and
theradiscuss
The sexual components of a couple’s relationship cannot be separated from their total relationship, eithen in the reality of their daily life or in treatment. Sex therapy has had and will continue to have a profound
effect on marital therapy. The effectiveness ofthe new sex therapy has substantiated the value of the systems approach and of a multifaceted, goal-directed, taskoriented
form
of
the fullest
volves
marital
range
therapy.
This
of the therapist’s
approach
skills
in-
in deal-
ing with those factors that interfere with the patients’ collaboration in their own change. Symptom removal and tasks mobilize resistance; an eclectic approach to treatment allows us to make use of a panoply of new and old treatment methods and techniques to deal with these
deterrents
to
change. REFERENCES
I . Sager CJ: Sexual dysfunctions and marital discord, in The New Sex Therapy. By Kaplan HS. New York, Brunner/Mazel, 1974, pp 501-516 2. Masters WH, Johnson VE: Human Sexual Response. Boston, Little,
Brown
& Co.
1966
3. Masters WH, Johnson VE: Human Sexual Inadequacy. Boston, Little, Brown & Co. 1970 4. Kaplan HS: The New Sex Therapy. New York, Brunner/Mazel, 1974 5. Sager CJ: The couples model in the treatment ofsexual dysfunctions in the single person, in Sexuality and Psychoanalysis. Edited by Adelson ET. New York, Brunner/Mazel, pp 124-142
ANDERSON,
FRANK,
6. Kaplan HS: The Illustrated Manual ofSex Therapy. Quadrangle/New York Times Book Co. 1975
Profiles BY
of Couples
ELLEN
FRANK,
M.A.,
New
Seeking CAROL
Sex
YEARS
workers
marital therapy was the or marital counselors,
M.S.W.,
were
rarely,
recent
explosion
ifever,
of scientific
discussed.
of the by In to
the
about
human
sexual experience, coinciding with the women’s movement and the new freedom granted women to acknowledge their own sexuality, has focused considerable attention on this aspect of human interaction (1 2). At present there are thousands ofclinics and individual therapists throughout the country offering what is ,
commonly dysfunction of deep-seated to long-term
called
“sex
Psychiatric
Symptoms
were once considered psychological problems individual psychotherapy
Revised version of a paper the American Psychiatric 1975. The authors
therapy.”
that
are with Institute
presented Association,
the Department and
of sexual
manifestations amenable only are now consid-
at the I 28th annual Anaheim, Calif. of Psychiatry
Clinic, University St. , Pittsburgh, Pa.
meeting of , May 5-9,
School
AND
RH, et al: The 1974
Marital
DAVID
J.
marriage
of
Medicine. 381 1 O’Hara Ms. Frank is Research Assistant in Psychiatry, Ms. Anderson is Associate Professor of Clinical Psychiatry and Director, Family Therapy Clinic, and Dr. Kupfer is Professor of Psychiatry and Director of Research.
con-
Therapy
KUPFER,
M.D.
and sexual dysfunction clinics, offers a unique
couples coming for one form er. This report is a preliminary similarities and the differences seek marital therapy and those sexual dysfunction.
therapy opportunity
almost intercouple marital to be attack to be action at the marital
in separate to study
of treatment on the attempt to examine between those who seek treatment
oththe who for
METHOD
In order to study the characteristics of the couples coming for these two modes of therapy, we examined the initial marital evaluation form (KDS-15) given to all couples seeking marital therapy in the Family Then-
apy
Unit
and
to all couples
seeking
treatment
for sex-
ual dysfunction in the Sexual Behavior Center oven a 6-month period. Couples were given the questionnames at their first appointment and instructed to complete them without consulting one another and return them at their next appointment. KDS-15 is an extensive self-report questionnaire that covers many as-
pects
of a marriage,
including
individual
development
and parental family situation, psychosocial history, courtship, current marital relationship, current living
situation,
and the Western
of Pittsburgh 15261 , where
and
therapy specialty
sole pnovwho con-
However,
knowledge
CJ, Kaplan HS, Gundlach Family Process 10:311-326,
KUPFER
ered not only eminently treatable, but treatable exclusively within the context of short-term vention involving both members of the affected (3). Perhaps because of their divergent origins, therapy and sexual dysfunction therapy continue thought of as different forms of treatment that quite different problems. Yet often the two seem inseparable aspects of a complex interplay of and reaction. The Western Psychiatric Institute and Clinic University of Pittsburgh, which provides both
and
centrated on the overt interactional difficulties being experienced by the couple. The marriage itself was the focus ofthe therapy, and the sexual aspects ofthe relationship
7. Sager tract.
Therapy
ANDERSON,
Assessment of29 couples seeking marital therapy 25 seeking sexual therapy at the same institution permitted the delineation oftwo distinct profiles. Although the two groups were similar in the degree their sexual and marital difficulties and in demographic characteristics, the relationships of sex therapy couples were generally characterized satisfaction and affection, whereas those of the marital therapy couples were often antagonistic. addition, the sex therapy couples tended to be less conservative and more thoughtful in their approach life and their problems.
FOR MANY ince of social
York,
AND
premarital
and
marital
sexual work
activity,
of children
tivities, titudes
the use ofleisure time, medical history, about role behavior in the marriage.
The
entire
on the
marriage,
impact
sample
of
108
Am J Psychiatry
patients 133:5,
and
was May
the
social
divided 1976
ac-
and atby 559
