O uickies

The Handbook of
Brief SexTherapy

ShelleyGreen,Ph.D.
DouglasFlemons,Ph.D.

W.W Norton & Company

NewYork . London
 eleven

A Catatyti.Approach to Brief
SexTherapy
J. ScottFraserandAndt4Solovet4

AwRENcEANDrrNA HADBEENENGAGED for nearly a yeat, and their wedding

day was a month away. Lawrence had recently lost all interest in sex,
and thus they sought therapy with a sense of urgency. During the past
month they had been interlocked in an intense conflict over sex, with no
resolution. Like most couples, they had revealed their sex histories early
in their courtship; they had both appreciated the openness of these dis-
cussions and had shared many details. As the wedding drew nearer,
Lawrence suddenly became uncomfortable when he and Tina were mak-
ing love. He explained that during their previous sex-hisrory discussions,
he had formed mental images of what Tina looked like when she was with
former lovers. Recently,these images had begun to enter his head when he
and Tina were making love. He had tried to deal with this on his own by
telling himself that these ideas were silly. However, his attempts were
futile; he simply would feel himself turn off whenever he and Tina started
to becomeintimate.
When Tina discovered Lawrence's distress and asked him what was
wrong, he reluctantly confessedand then asked Tina to describe more of
what she had done with other lovers, wondering if she did things with the
others that she hadnt done with him. Feeling very uncomfortable, Tina tried
to brush thesequestions off, but this led Lawrence to secretly conclude that
she had more of a past than she was revealing.When frustrated with her, the

189
19O Quickies

word whore popped into his head. He tried turning his anger into sarcastic had intercourse-*
remarks,but this brought out more defensivenessin Tina, which, in turn, in- concerned. she : --Ltro
spired more suspicions,not only of Tina'spast, but also of her present. very much ancll;nrm
They came to therapy with several concerns. Tina truly loved Lawrence she felt sympanl; tiinm
but was afraid that he had a serious emotional problem. Lawrence realized had an argumen:
that he was being irrational; however, try as he might, he was unable to didn't get "her' :
stop the images of Tina with other sex partners. Conversationshad only because Ivan h:l:
made things worse. Both admitted that they were emotionally and physi- bv his word. =--l*adrur
cally exhaustedfrom staying up into the early morning on most nights, to leave. \2dja ;-
ft)'rng to resolve their problem. They were hoping that the therapist could problem, referrt':
help them get out of this "downward spiral," so they could get on with en-
joying their relationship and wedding. Had the coures
the 1950sor 6n-s
Alicia and Dave appeared for therapy with what they thought was an
unusual problem-male frigidity. They reported that after 10 years of the underlrinE
marriage, Dave had become completely uninterested in sex. He hadn't sulted some s.r
approachedAlicia in 6 months, and he found excusesnot to have sex scriptive techn ;'irm;,
when she made advances toward him. Dave was puzzled by his lack of is a prerequisrit: lr
responsiveness, as Alicia was extremely attractive,worked out regularly to simultaneousrh:
stay in shape,and was wonderful with their two children. The couple did The manuals.i
not argue or fight, although there had been a growing tension over Dave's to be judged, ;n''rrrtrd|
lack of sexual interest in Alicia. mance anxietr*
They initiated therapy after a discussion in which Dave had revealed Had the cou:r*s
that he was questioning the possibility that he had fallen out love with would probab--.r.annro
Alicia. Considering her more friend than lover, he was spending more Johnson's plL'rn ..t:rmm,
time at work. In separateconversationswith the therapist, Dave denied quacy (1970 -a-in
that he was having an affair or was interested in other women. Alicia sus- briefer, 2nf, i6 --a.
:qru*d
pected that becauseDave was not having sex at home, he must be "getting would have }c:"mnn
it someplaceelse." Johnson, 195tr, frmdl
were probablr :asrudi
Nadia didn't like sex. Married to her husband, Ivan, for nearly 13 years, it, "Fear of irua:
and mother of their two young boys, ages4 and 5, she felt numb when functioning- -:-: p
they made love. Throughout their marriage she had tried to meet lvan's nlques at rLL_<.-i Irflr'
needs;however, lately he was becoming increasingly frustrated with her "sensate focu.-. t-:
over her lack of desire.Complaining that they did not have sex frequently suring," "receF:n'ry
enough, Ivan didn't like it when Nadia would "just lay there." "masturbatiorL lalmryl
Nadia agreedthat she wasn'tinterestedin lovemaking and that Ivan was One Of II1OI€ ttri --]flStr

right about the frequency issue. Given her responsibilitieswith the chil-
* Masters and
dren, she had been more tired lately, and, consequently, she was having Jc:::s:m
lems) by the ver :--::: l
more difficulty forcing herself to have sex with her husband. Not having lems, assuming iJ-:: rirr
 A CarervrtcAppnoecsro Bntnr SnxTusnapv 191
had intercourse in more than 6 months, Nadia said that as far as she was
concerned, she could live just fine without sex; she loved her children
very much and Ivan was a good husband who treated her well. If anything,
she felt sympathy for his plight. Howevet, several weeks earlier, they had
had an argument about sex, during which Ivan threatened divorce if Nadia
didn't get "her" problem solved. This was especially upsetting for Nadia
becauseIvan had never threatened to leave her before. Ivan always went
by his word, so Nadia knew that if she didn't do something, he was likely
to leave. Nadia consulted her gymecologist,who, unable to find a medical
problem, referred her for psychotherapy.

Had the couples described in these vignettes gone to a sex therapist in

the I950s or 60s, they would have probably found themselvesinvolved in
long-term psychodl'namic work, with their therapist going in search of
the underlying causes of their sexual difficulties. Had they simply con-
sulted some sex manuals, they probably would have encountered pre-
scriptive techniques, heterosexual assumptions, and the idea that foreplay
is a prerequisite to insertion and orgasm for both partners (the closer to
simultaneous the better)-the universally desired end (Apfelbaum, 2001).
The manuals, implicitly suggesting that sexual contact is a "performance"
to be judged, would have inadvertently heightened the couples' perfor-
mance anxiety.
Had the couples gone to a sex therapist in the 1970s,B0s, or 90s, they
would probably have worked with someone influenced by Masters and
Johnson's pioneering and widely influential work, Human Sexual lnade-
quacy (L970). As a result, their time in therapy would have been much
briefer, and it would have been organizedmuch differently. Their therapist
would have known much about their sexual response cycles (Masters &
Johnson, L966), and he or she would have assumed that their difficulties
were probably based on performance anxiety. As Masters andJohnson put
it, "Fear of inadequacy is the greatest known deterrent to effective sexual
functioning" (1970, p. f2).- The therapist would have had several tech-
niques at his or her disposal-including "avoiding goal directedness,"
"sensatefocus exercises,""intercourse prohibitions," "nondemand plea-
suring," "receptive kissing," "start-stopmethods," "squeezetechniques,"
"masturbation training and self-pleasuring," and "vaginal dilators"-and
one or more of these might have been helpful in resolving their problems.

* Masters andJohnson (1970) themselves inadvertently played into these fears (among other prob-
lems) by the very title of their work, which focused oninadequacy rather than on difficulties or prob-
lems, assuming that there was some tacit norm of adequacy.
192 Quickies
However, it is possible that the therapist's drive toward brevity and effi- penis, u-ith :':
ciency,along with his or her assumptionsand biases,might have only ex- understancr,g Ifu
acerbatedthe couples'distress. the focus r.- :
Despite the many improvements to sex therapy offered by Masters and aren't gir-en ;:-
Johnson and others, current approachesare still burdened with significant ships or to u
problems. PeggyKleinplatz (2001) afiiculated a telling critique: Too often =en.
white coat l'-
. There is no unifying theoretical base for sex therapy. ity and neurrru"rnn
. Sex therapists' fundamental assumptions are laden with sexual ity, and to q;,-
myths and stereotlpes (e.g.,about gender and "normalcy"). only have Lt -r; Jn
. Current sex therapy practicesare basedon gender-biased,phallo- the pure pa*ia-r:nml
centric, and heterosexistassumptions.For example, rapid ejacu- tributed to i:: ffi
lation in malesis seenas a seriousproblem, whereasrapid orgasm low desire- :: -frnrnrnil
in femalesis seenas reasonfor celebration (Reiss,1990). their sexuaLi:;
. Sex therapy'sbasic conception of sexuality remains biologically In the facr :i
based,rather than offering equal attention to personal and inter- de-sac,u herc
personalprocesses,cultural norms, and genderbias. plied in serr--:-- lrt
. The field continues to focus on body parts, rather than on the per- criteria. Thr. :i
sons attachedto them. sights and pr:::
. Sex therapistsare least successfulwhere the greatestneeds are- the metatheu.:r,*s
in problems related to desire. proach" to hr".: ;u:m,
passions of ;::
We concur with thesecriticisms. The sex therapy field has, historically, strugglesrr-lrl
paid too little attention to cultural, contextual, theoretical,and interper- with a conter:--,au
sonal competence.As Apfelbaum (2000) pointed out, the societalenthusi- their sexual ri:
asm that has greeted the introduction of Viagra highlights a continued
emphasison sustainederections.Delayedejaculationis considereda bless-
ing, enabling sustained intercourse rather than the troubling dilemma it
can often presentfor thosewho experienceit. Sexfor pleasureis left out of Before we cann
the picture, in favor of intercourse-based, orgasm-mandatedacts.Sex ther- our brief theri:"'
apy writers rarely address the positive ways of expressingjoyful and pas- both the strati'':r:
sionate sexuality or consider that many men and women prefer same-sex Weakland. ,s :esroli
paftners. 1976, l9B-1:--\'
The treatments of vaginismus or erectile dysfunction mark two addi- Watzalwick.'s -:,;rdnuu.
tional examplesof this focus on performance.The fact that vaginal dila- the Brief Them:'' lf
tors are used with nearly l00o/osuccessto eventually enableintercourseis, de Shazeret a-
on the one hand, good news. However, this news also supports the myth 1992;O'Hanlo:
that intercourseis the ultimate desirablegoal. The target of treatment is a
" Yearsago, mos! :-:"-:r!
set of parts in disrepair, and the context for the problem remains irrele- portion of male. -::: i':muru,el
vant. Similarlv. the treatment for erectile dysfunction tends to be on the 2000).
 A Cereryrrc Appno.a,curo Bnrnr Ssx Tssru.py 193
penis, with frequency and firmness of erections taking precedence over
understanding the contextual pressure of performance on demand. When
the focus of treatment is on techniques to enhance performance, clients
aren't given an opportunity to discover multiple ways of being in relation-
ships or to understand the contexts in which sex disappoints them.
Too often, sex researchersand sex therapists have (literally) put on the
white coat of medical lab researchersto assumean air of medical objectiv-
ity and neutrality in their work, to desensationalizetheir focus on sexual-
ity, and to gain credibility for their research grants. In doing so, they not
only have lost the broader contexts of sexuality,but also have overlooked
the pure passion and pleasure that sexuality offers. Perhaps this has con-
tributed to the field's limited success in helping clients presenting with
low desire* to find the erotic intimacy and fulfillment necessary to fuel
their sexuality.
In the face of such critiques, sex therapy appears to be caught in a cul-
de-sac,where disjointed and ungrounded techniquesare atheoreticallyap-
plied in service of traditionally defined and medically driven performance
criteria. This chapter offers away out of this dead end. Drawing on the in-
sights and fractices of the strategicand systemicbrief therapies,as well as
the metatheories that have influenced them, we present a "catalytic ap-
proach" to brief sex therapy that honors the complexities and particular
passions of our clients and their partners, attending not only to their
struggleswith performance,but also to their levels of desire.This is done
with a contextual sensitivity to their cultural understandings, as well as to
their sexual identities and expressions.

CATALYTIC
BzuEFTHERAPY
Before we can describe our approach to sex therapy, we must first explain
our brief therapy foundations. We have been significanrly influenced by
both the strategic model of the Mental ResearchInstitute (Unt) (Fisch,
Weakland, & Segal, 1982; Nardone & Watzlawick, 1993; Watzlawick,
1976, 1984; Watzlawick, Weakland, & Fisch, 1974; Weakland, Fisch,
Wazalwick, & Bodin, 1974) and the solution-focusedmodel advancedby
the Brief Therapy Center (de Shazer, 1982, 1985, 1988, 199I, 1994;
de Shazeret al., 1986) and others (O'Hanlon, l9B7 O'Hanlon & Martin,
1992;O'Hanlon & Weiner-Davis,1989;Walter & Peller, 1992).

* Yearsago, most clients presenting with this problem were women. However, more
recently the pro-
portion of males and females presenting with low desire has become essentially equal (Apfelbaum,
2000).
 194 Quickies

Although many would suggest that MRI and solution-focused ap- variety of acmons
proaches to brief therapy should be considered separatemodels, others change."He ana inm
have strongly argued that they are best considered two variations of the
same process-basedorientation (Fraser, 1995; presbury Echterling, & a try to h^a'ne
McKee, 2002; Quick, 1996). Adopting the latter perspecrive,we use the a try to a'nnrd
term "catalyst" to refer to a blending of the two (cummings, 1995; Fraser, traung:
Morris, Smith, & Solovey,200I,2002). try hariiff fmrr
A catalytic approach is organized with a simple focus-to introduce a tendinr n,'q
small but significant shift in the relationship interactions or descriptions
around a problem, and then to amplify the subsequent ripples in the sys- All such soiu:r,mmr
tem to foster change. Like MRI therapists, we view problems as vicious the statusquo rf
cycles of well-meaning attemprs to solve a perceived difficulty. when the ner(s) are tn-ini, to'
attempted solutions don't work, people tend to try them again and again, to solve the pr,l':ltrnml
which makes the difficulty itself worse, or in factbecomesthe problem. failure, the so
our basic interventions involve finding or creating significant excep- sured bv the desrefr
tions to the problem pattern, or finding or creating small but significant the man, his par:mro'
differences in the vicious cycle of the problem. The first step involves mance anxien amdil
identifying the vicious cycle patrern around the described problem. Like that leads to ar.-usnflX"
MRI therapists, we then initiate new action by redirecting solution at- Second-ordn3
tempts or reframing the problem. Like solution-focused therapisrs, we tions, praclices" *flll
also identify and amplify already-occurring exceprions to the problem pat- often represenr &
tern and build upon fhem to support change. commonlyhenc
Both components of the catalytic approach seek to introduce shifts in the able solutions" 1: hw
action or conceptualizationof the interaction around the identified problem. (Fraser.198+ . iumfu
In this chapter,we describesome of the major ways brief therapistsintroduce given system or"
such shifts in the "doing" or the "viewing" of the problem, but first we must solutions.
elaborateon two metatheoreticalideas that inform this way of working-the The man wr:-t
systemic concept of second-orderchangeand the social constructionist no- change in manl
tions of the coevolutionandrelativity of reality, or second-order
reality.
He rug:lr
or srnxEl]Te
Second-Order Change
terest rr-.Iufrsi
Although the concepts of first- and second-order change are based on there m';,rmtlldl
rather complex theoreticalpremises(watzlawick et al., r974), they can be He rmE:r
explained quite simply. First-order changerefers ro change within the nor- fatigue"
mal definitions, understandings,premises,rules, and practicesof a given a molre
system. It may be described as change in frequency,intensity, location, du- remedr :hq
ration, and so on of a given practice or action. that n-as
For example, a man experiencing difficulties in attaining and maintain- In an efrnn
ing an erection may (along with his partner or partners) initiate a wide parulen- :
 ro Bruer SnxTHnnapv
A Cerervuc Appno.q.cH 195
variety of actions that would fall under the heading of "first-order
change."He and his partner(s) might, for example,

a try to have sex more frequently, while rating his "erection success";
a try to avoid or reduce sexual interactions, thus reducing the frus-
trating potential of "failure";
try harder to produce and sustain his erections, while closely at-
tending to the "success" of their efforts in terms of hard penises.

All such solution attempts are first-order changes that either maintain
the status quo or exacerbatethe very difficulty that the client and his part-
ner(s) are trying to resolve. Based on the shared assumption that the way
to solve the problem is to try harder and to attend closely to successand
failure, the solutions themselvesbecome the problem. With successmea-
sured by the degree to which a sustained erection facilitates an orgasm by
the man, his partner, or both of them, the man will be caught up in perfor-
mance anxiety and continual distraction from the intimacy and passion
that leads to arousal.
Second-orderchange is a change of the premises, definitions, assump-
tions, practices,and traditions of a given system of relationships.It most
often represents a counterintuitive stepping out-or a reversal-of. the
commonly held ideas on the nature of a situation and its logical and reason-
able solutions. It has thus often been described as paradoxical or ironic
(Fraser, 1984). Such change tends to alter the premises or corollaries of a
given system or, building upon them, to evolve new, different, or opposite
solutions.
The man with erectile difficulties could experience a second-order
change in many different ways:

He might question whether his difficulty was actually a problem,

or simply a reflection of other circumstances,such as reduced in-
terest in his sexual partner(s) or their sexual practices. In this case,
there would be little reason to expect firm and sustained erections.
He might realize that his difficulty was situational-a result, say,of
fatigue, worry distraction, or illness-rather than an indication of
a more severe problem. This could allow him to stop trying to
remedy the situation, thus reducing the very pressureand distress
that was precluding resolution.
In an effort to learn more about what was going on, he and his
partner(s) might purposefully try to make him lose his erections.
196 Quickies

Many of Masters and Johnson'smost effective intervention5-f1sp "5gn- ways throug: rr

satefocus" techniquesto giving directions for going slow and not engagingin Slight shift-. r
ints166u15s-introducethe possibility for second-orderchange.For exam- effects in ahei::rs
ple, in male-femalecouples, the therapist reversescompulsions for male 1trg1n.n6g; 3:,r;
direction by putting the woman equally or more in charge of portions of and accept ::r:r:
nondemanding pleasuring, or start-stop approachesto rapid ejaculation. l 9B2; Nar d; : - '"- u
The compulsion to reciprocate is reversedin the exercisesof receptive et al., 19i-1. -,'*i
kissing and nondemanding pleasuring. And redirecting women away from terventlon-< >L,:J. ilfrh
attempting to achieve orgasm and toward self-pleasuring often reverses
their difficulty in reaching orgasm.
Restrainin g : -r{::mtils;
rectly attem;::q
The Co-evolution and Relativity of Reality itself. Cata--'-:L: Irfilulllfll
give clienrs -;:'t
Both MRI and solution-focused therapists have been significantly influ-
some resLtrh: :,rn,rummdill
encedby the constructivist and social constructionist position that all of our
ideas and constructs are individually and interactively created; they aren't goal-orienre:
For exar:::Lg iutil
floating "out there" as truths to be discovered.Constructivism (Bateson,
1972; Gergen,1985, I99I,1992; Watzlawick, L976,1984) refers to the Joh nson. la: :
other kinds :i
philosophical and epistemological viewpoint that individuals co-create
;T;
OT SU C C C S S ::
their views of reality through interacting with the world. Social construc-
cautioush-:'-:
tionism (Gergen,1985,1994; Hoyt, 1994; Mahoney,1995;McNamee&
turn out'-'-'i-- :lmill
Gergen, 1992; Neimeyer, L993; Neimeyer & Feixas, 1990; Neimeyer &
slow mes-.o."-
Mahoney, 1995) builds upon the constructivist premise by emphasizing
the influence of the social context on the making of meaning.
These postmodern understandings emphasize that all interactions This inter'-.:'l::rr
should be considered in terms of the contexts of language and culture their diffi i :---lE* rmli'
(Gergen, I99I,1994). Thus, our ideas of gender roles, sexuality,and nor-
tions. Altr"-;a*,:lg
mative sexual practices,for example,must be consideredwithin the indi- ceived drm--:";lLml
vidual and cultural assumptions from which they have evolved. As the whatever --:i"r ifrillllt.
MRI group (Watzlawick, f976; Watzlawick, et al., 1974) noted. any given the sarne ::-Lt[
action or situation can be describedand understoodwithin any number of explananc:n
useful realities or frames of reference.These frames, which both enable
and constrain possibilities, are applied not only by clients, but also by
therapistsand theoreticians. Framing ,i'i,': lr4Yi
Such a recognition invites us to examine our implicit assumptions on ticular cLtrn
-:.!,r;
sexuality and normative practices,reminding us that there are many entirely tlon, or F\r--:r.l{ml
positive ways of defining and expressingsexuality that don't fall within cul- context. L't:]il:m.flrygl
turally dominant norms. Further, if all views of reality are created through lrame of :.:|:,rglmlililll(

social interaction and the use of language,then they can co-evolve in new absolute :Ei.*r-il
 ways
rhrourn,"*,l,Tlffi
ffi-:" ;'#::'"#Tl]nn,,,"llJ
slight shifts in interaction with therapists and others can have watershed
effectsin altering the path of formerly problematic patterns.
Influenced by these ideas, catalytic brief therapists attend to, respect,
and accept their clients' language and conceptual frames (Fisch et al.,
I 982 ; Nardone & Watzlawick, 1993; W atzlawick, I97 6, I97 8 : Wa tzlawick
et al., 1974; Weakland et al., 1974), creating pathways to change with in-
terventions such as the following.

RestrainingChange
Restraining clients from moving too quickly, or prohibiting them from di-
rectly attempting their desiredgoal, is often a second-orderchangein and of
itself. catalytic brief therapists employ both "soft restraints," where they
give clients the directive to "go slow" in their attempts to rush headlong into
some resolution, and "hard restraints," which involve either prohibiting a
goal-oriented action or offering challengesto clients.
For example, a catalytic brief therapist may, not unlike Masters and
Johnson, recommend that clients refrain from engaging in intercourse or
other kinds of sexual interaction. When the couples "slip up" and attempt
or successfully engagein their desired sexual pleasure, the therapist may
cautiously celebratetheir unexpectedsuccess.when their slip-up doesn't
turn out well, the therapist can use their experienceto reinforce the go-
slow message.

Normalizing
This intervention attempts to put clients at greatereaseby contextualizing
their difficulties as normal reactions, given the constraints of their situa-
tions. Allowing clients to relax their often-pressured efforts to solve a per'
ceived difficulty, normalizing helps them depathologize themselves and
whatever they are struggling with. Sex therapists often accomplish much
the same thing through psychoeducation, outside readings, and direct
explanations.

Framing, Reframing,and Deframing

Framing involves placing a person, situation, action, or problem in a par-
ticular context. Reframinginvolves putting the sameperson,situation, ac-
tion, or problem in an alternate but equally sensible and often more useful
context. Deframing refers to deconstructing the context of a particular
frame of reference to eliminate it as a cause for a problem, challenge its
absolutereality base,or simply point out that it is but a point of view
198 Quic(ies

\A ith ::,,r
Positroning
]uur,'
we'd nu.* "tLritl*n
Catalytic brief therapists adopt a position relative to their clients that is
metho,i "'- w'
designed to facilitate therapeutic change. They might take a position of
three fr:r,:,,r:
"cautious optimism," a "one-down" position, or a position that is signifi-
chapter. l'- -li
cantly different from that of the clients or "helpful" others.

Prescnbing Symptoms
Symptom prescription involves asking clients to engagepurposefully in
some variation of the describedproblem behaviors,allowing the therapist As notec -* ;umc
to learn how they think, act, or react during the problematic cycle, or to cntrquei.:)r
learn more about what brings the problem on or what makes it worse. lems anui --:rsn
Such prescriptionsmake the problem pattern less "automatic" or less out medicatr'::: n"mnruu
oI the clients'controL. therapl.= :-r'.,t
brief ther":' i:unrnr
PredicttngDifficulttesor Relapses world hr:-::
This technique is often used to deflect clients from being discouragedat cial treattr::::rms
perceived setbacks or to encourage them to consolidate their gains by cated i R r-s"-tr-
reencountering old perceived dangers. For example, clients might be a C fl tl c ai :.:
warned that their first attempts at a new sexual exerciseor technique is clients're;
unlikely to produce instant successor pleasureand that the main objec- Beth an: lrqmr
tive is to learn something about themselves or their partner. Once they've helped li.-- 'rfl''rmft
achieved greater intimacy, they might be asked to see if they can reignite the coup't i:rnn
one of their old struggles. If they fail to fight, they further solidify their was Tornr i*:rrMl
new patterns. If they succeedat fighting, they learn in what ways they are another r:rr:
still vulnerable to the old pulls. Tom see:rsd
Finding and Amphfy ing Ercepttons,D iff erences, had recen:,
familv phtislrum
and PositweSoluttons
Once desired goals are identified, clients and therapistsjointly look for when he i:;:urL m

times in the past and present when the problem hasn't happened. This Tu'o r-*:s
processof searchingfor positivesand identifying how they've come about college tr' ::rJsh.
is itself a second-orderchange,a reversalof the common client processof chanic si'1":
focusing only on problem-saturatedstories. As exceptions to the sexual had prere;:::':
1,{
ship. If St-1
.
difficulty are identified, the contingenciessurrounding them can be iden-
tified, and these positives may then be amplified, creating successiveap- tressed. fffi:::rg

proximations of the desiredgoals. found her ;::m,ruidliilmr

they both ruc
Adopttng a Goal-OientedFuturePositton to insertio:: ;:ril
Catalytic brief therapists help clients identify small, achievable, and rele- ure, and T'-;. i*ud
vant goalsthat are action-orientedand observable.The more clients orient Respecrr:-:-:nt
toward a possiblefuture, the more successfulthey becomeat realizing it. for their p:::,rem"
 A CerervncAppnoacsro BrusFSnxTHnnepv 199
With the theoretical framework of our catalyst approach established,
we'd now like to discuss some cases. The first two demonstrate our
method of working with clients who have medical concerns; the following
three further elaborate on the vignettes presented at the beginning of the
chapter, illustrating away of dealing with level-of-desire problems.

"MEDICAL'PROBLEMS
As noted in the first section of the chapter, sex therapy has recently been
critiqued for becoming overly biological in its approach to sexual prob-
lems and their resolution. Hormone therapies, surgical procedures, and
medication have been seen as so successfulthat clients, physicians, and
therapists have begun to view these paths to treatment as the ultimate
brief therapy for sexual difficulties. This is despite recent resolutions by
world health bodies, who recbmmend combined medical and psychoso-
cial treatments even when biological interventions are most strongly indi-
cated (Rosen, 2000). For brief therapy to be successful,therapists have
a critical responsibility to approach all problems within the context of the
clients' relationships and worldviews.
Beth and Tom came to therapy complaining that even Viagra hadn't
helped Tom with his sexual performance problems. Married for 7 years,
the couple had had a mutually satisfying sex life until the past year. This
was Tom's second marriage and Beth's first; his first wife had left him for
another man she'd met at work.
Tom seemedto have lost the ability to have or maintain erections, and he
had recently stopped initiating sex or responding to Beth'sadvances.Their
family physician had prescribed Viagra; however, Tom stopped using it
when he found it to be inconsistent and rather strange and unnatural.
Two years earlier, Beth had quit her job as a secretary and returned to
college to finish her bachelor's degree. Tom, the owner of an auto me-
chanic shop, thought that perhaps Beth's involvement with her studies
had prevented them from paying more attention to their sexual relation-
ship. If so, he would just wait it out until she was finished. Beth was dis-
tressed,fearing that either he had some physical problem or he no longer
found her sexually attractive. When they had tried sexual encounters,
they both had quickly responded to the first signs of an erection, rushing
to insertion and attempts at intercourse. These efforts had all ended in fail-
ure, and Tom had withdrawn still more.
Respecting the couple's concern that there was some biological basis
for their problem, the lead therapist, our colleague Mary Talen, invited
2OO Quickies
a physician (who was also a family therapist) to consult with them. His which poir:
work-ups revealed some vascular difficulties that had probably initiated ally withdm-w;
some of Tom'serection problems. The couple was relieved to learn of this, "hot," so C:rsl
but they were also concerned, given that Yiagra hadn't worked. ciency \\-he:
Mary and her colleaguesaw in addition to Tom'sbiological condition, Bobfeeltue
three other interrelated problems potentially contributing [o the couple's The therumml
difficulty. First, Beth's going back to college had resulted in her both sexualhL"tcrq;
withdrawing from Tom and potentially surpassinghim in education and dressing. A:-.m
aspirations. Second, the couple had become locked in a vicious cycle orous se\]ui
of demanding and withdrawing. And third, overfocusing on the state of might happm mm'
Tom's erections, they had pressed toward intercourse whenever they were history of rqE
apparent. lieve that hE: mrm*
The therapistsrecognizedthat their interventions needed to attend to Man- nc:
the biological component of Tom'scondition, honor eachof their views on tioning rtre :
sexuality and on each other, and reverse the demand/withdraw cycle. kicked offi ; ;
Working within Tom's worldview, they used metaphors of auto repair and meanlngs t,] :
maintenance, suggesting that he indeed needed a "new transmission" a step back rmrm{l
when it came to enjoying and having sex with his wife. However, he cer- love of 1i[s -;lmt
tainly needed instructions from his own "mechanics," or physicians, on WaS the Sm.j,nttq{qml
what to expect of the new transmissionand how exactly to break it in so each other'
he could eventually resume the pleasureof the driving experience. *i6-r 626fupirr,ent
Mary and her colleaguetold the couple to "slow down" when it came to Mary a.,ir:*
having sex, avoiding intercourse for the time being. Tom was to learn how separatene:is.
to utilize the effects of Viagra through masturbation and then gradually time, ther "m'-.nru'
teach Beth what he had learned. In the past, the couple had found each returnrng [.-
other most attractive when they went out with friends and flirted with These genl-r.
each other. The therapiststhus asked them to go out on dateswith other track.
couplesand look for each other'ssecretflirtations. Beth and Tom would be
a little rusty,but it was important to get the "car back on the road." As they
got aroused,they were to restrict themselvesto some gradual pleasuring
exercises,having intercourseonly if they absolutelycouldn't abstain. As noted ff:ldrn
Within the next 3 weeks, Tom had adjusted to using the Viagra, he and therapy for *:ul
Beth had made time to socialize, and they not only had learned more about the most fre;ulm
each other's pleasure, but also had rediscovered both intimacy and inter- ences rn o#mry
course. By reversing the couple'ssolution attempts, the therapists were able 2001). Ind.aa:c-
to resolve Tom'sbiologically based difficulty and help put the couple'srela- of the 1990s I
tionship back on a firm foundation. and both he--s
Couples often hope that there are biological causesand cures for their As we rerl::[
sexual difficulties, but this is often not the case.Bob and Cheri had en- ual desire.-s:
joyed a passionatesexual relationship until moving in with each other, at patterns bec"-.ri'ne
 ro Brunr Ssx Tunne.pv
A Cerervrrc Appno,c.cFr 2O1
which point, much to Cheri's puzzlement and dismay, Bob started to sexu-
ally withdraw. He, and all the other men in her life, had always found her
"hot," so Cheri figured that he must be experiencing a testosterone defi-
ciency When this proved not to be the case, they came for therapy, with
Bob feeling singled out and accusedof being the one with the problem.
The therapist, again Mary Talen, had the couple share some of their
sexual history. Bob, when he was young, had walked in on his father cross-
dressing. After that, he'd strongly affirmed his own heterosexuality in vig-
orous sexual relationships with women, while remaining sensitive to what
might happen to him in a long-term committed relationship. Cheri had a
history of drug abuse and prostitution, during which she'd come to be-
lieve that her main value was her sexual attractiveness to men.
Mary normalized the changes the couple had been experiencing, men-
tioning the transition in their living situation and pointing out how it had
kicked off a problematic spiral. This reframing helped them attach new
meanings to their recent difficulties, allowing them to simultaneously take
a step back and draw closer to each other. Bob told Cheri that it was her
love of life that made him want to be with her, and she told him that he
was the strongest and truest man she'd ever been with. They reaffirmed
each other's attractiveness and acknowledged the stressesof moving in
with each other.
Mary asked them to make lists of what each wanted to retain of their
separateness,while evaluating what they wanted together. During this
time, they were to refrain from sexual contact and reinitiate dating, only
returning to lovemaking as their transition to living together settled in.
These gentle changes gradually got their sexual relationship back on
track.

LE\TL OF DESIREPROBLEMS
As noted earlier, several recent sources have critiqued mainstream sex
therapy for not having an adequateway of treating what has now become
the most frequent sexual complaint in the offices of sex therapists; differ-
ences in desire among partners (Apfelbaum, 2000, 2001; Kleinplatz,
200I). Indeed, "low sexual desire" has been called the sexual dysfunction
of the 1990s (Pridal & LoPiccolo, 2000), affectingmen as often as women
and both heterosexualand same-sexcouples.
As we return to the opening vignettes, notice how deframing "low sex-
ual desire," shifting the pattern of relationships, and disrupting solution
patterns become the keys to "reawakening desire."
2O2 Quickies

Recall that Lawrence, Tina's fianc€, had lost all interest in sex after hadn't reahri
Iearning of her prior sexual experiences.The more he thought of her with reactions. es:] irmmiil

other men, the more distractedand distressedhe became.When Tina real- Scott the:
ized why he was withdrawing from intimacy, she was reluctant to share for Lagren;rs
any more information with him. This aroused his suspicions, and they past, she c"-,;-Lrn
were off on a "downward spiral." where ther
With accuser-defendervicious cycles, one partner typically accusesthe After the lcss
other of some type of infidelity. The defender denies the infidelity, but to think a'b,.-::smm,
does so in a tentative or defensive manner, which fuels the insecurity of interested rr.
the accuser,leading to more accusations,followed by more defensivede- Upon he:::rug Mu
nials, and so on. Lawrence'saccusationshad begun with concerns about and. with e $nniilir,
Tina's former sex partners, but they'd quickly escalated to speculations with that lcss'
about current betrayalsas an explanation for her loss of interest in sex. "antidote.-
Catalytic brief therapists seek to inteffupt this type of cycle, helping the Lawren,ccnmrdl
accuserto stop accusing,or helping the defenderto respond in a more de- for a follon-:ir
finitive way to the accusations.In this case,the therapist, Scott, selected lowed the pr
the latter approach.Honoring Tina'sconcernsabout Lawrence'semotional ject, and he I
well-being and respectingher frame of reference,he sought to use her lan- on track. rhe-,,
guagewhile reframing the situation and normalizing Lawrence'sbehavior. were gorng :. ilnfre
Scott explained that the couple had fallen into what some might refer to By refrarn:*,g
as a "gender trap," which was being maintained by their deep love and vite passicn. :'rumut
strong passion.Deep love often brings out primitive emotions and a need moving ther
to mark the relationship as something very special and exclusive. Men Alicia ani lmrq,'m"
and women sometimes do this in different ways. A competitive man may ter, were aX,*'-
want to be viewed by his woman as the greatestof all lovers. He feelssecure, and a disun;::
knowing that his virility and skill will keep his woman from wandering, Earlier in::en
given that the sexual experiencehe offers is beyond comparison. to be a vorac::xurft$
In contrast,a passionatewoman may like to mark the importance of her months. and l;snirro
relationship by forgetting previous sexual experiencesand pretending that Alicia more e :lmdi
her man is her only real lover. Lawrence and Tina's conversation about the out of love m,::n fomn:
past, although understandable,was interfering with their ability to com- despite his s,:]:siu
plete their somewhat separatetasks before the wedding. The more that ship was beci-n'lnnm
Lawrencebrought up the subject of previous relationships,the more Tina Andy maCerunrm
was reminded of the past that she was ftying to forget. On the other hand, interest. She h r,r
her tentative responseswere not providing Lawrence with the assurance candle-lighr,;-* ln*{ns^
that he was seeking. kisses. and a.qrg
Scott told Lawrence that he could offer him a strategy for dealing with When he'd i"::-r",rmmr
his unsettling questions,but before proceedinghe wanted to answer any tearful.
questionsthey might want to pose to him. Tina askedhow he could possi- The more ffer
bly have known exactly what was going on inside of her. Lawrence said he drawn, at one::rqmil
 A CerervrrcAppRoecHro BrunrSsxTHenapv 205
hadn't realizedwhat Tina had been trying to do. Scott acknowledged these
reactions,explaining that "love makes us all a bit crazy."
Scott then turned to Tina and explainedthat therewas a good "antidote"
for Lawrence's condition. The next time Lawrence asked her about her
past, she could simply give him a big Holll.wood-style kiss, regardlessof
where they were-the mall, a family gathering, in bed, or in a restaurant.
After the kiss, she should tell him the truth, which was that she didn't want
to think about sex with anyone but him, that he was the only one she was
interestedin.
Upon hearing this, Lawrenceburst out laughing. Scott looked at Tina,
and, with a smile, told her to "make sure to give Lawrence some tongue
with that kiss." They both left the session laughing, excited about the
"antidote."
Lawrence and Tina were married on schedule.When they came back
for a follow-up interview after the wedding, Tina said that she had fol-
lowed the prescription once. Lawrencehad laughed and dropped the sub-
ject, and he hadn't brought it up since.With their sexual relationship back
on track, they moved on to discussother challenges,such as where they
were going to live and when they were going to start a family.
By reframing Lawrence and Tina's interaction and by using humor to in-
vite passion, Scott was able to help them interrupt their vicious cycle,
moving them beyond jealousy and fear.
Alicia and Dave,the secondcouple presentedat the beginning of the chap-
ter, were also trapped in an escalatingcycle, in their casebetween a pursuer
and a distancer.
Earlier in their l0-year marriage,Dave had had what Alicia considered
to be a voracious sexual appetite. No longer. They hadn't made Iove in 6
months, and Dave seemedto have lost all interest in sex. He considered
Alicia more a friend than a lover, and he was concerned that he had fallen
out of love with her. Alicia, in turn, suspectedDave was having an affair,
despite his sincere denials to her and Andy, the therapist. Their relation-
ship was becoming more and more polarized.
Andy made note of how hard Alicia had been working to attract Dave's
interest. Shehad waited up for him when he was late from wotk, arranged
candle-light dinners, worn sexy lingerie to bed, given him long suggestive
kisses,and asked him about what he was thinking and feeling about her.
When he'd failed to respond in an assuring manner, Alicia had become
tearful.
The more eagerAlicia had been for Dave'sattention, the more he'd with-
drawn, at one point talking about suicide. Convinced he was suffering from
2O4 Quic(ies

depression, he'd obtained an antidepressant prescdption from his family had sparkr;
doctor, but the medication didn't change the problems with the relation- could fL-]ri:: :[d]
ship. He felt especiallyguilty that Alicia was going out of her way to make She mighl a"s,m
the relationship work. Wondering what would happen if his feelings for When Da-.:
her didn't return, he considered the possibility that he would have to leave Dave rvou":
his marriage. estin her ;:
Pursuit-flight cycles may kick off when something tips the delicate bal- press it-<el :n,
ance of initiation in a couple'srelationship.When one partner, feeling un- work or. ts iimf
wanted, pursues the other partner for affection and validation, it can The
"-t;::r:rnt'*
inspire attempts for him or her to flee or withdraw. Just as pursuit stimu- tially:-{L;; i
lates flight, flight stimulates insecurity and more pursuit. The fleeing part- cussed: -l.,:r't'
ner may read this cycle as a sign that they are no longer in love. lf this fear trFng so::r:'lmimq
is spoken, the situation is further complicated and may lead to an extra- came ea-.-t: dlitrmmt
marital affair or divorce. At the nil: resro
By the time Dave and Alicia enteredtherapy,their cycle had becomea full- not gir-lnl lnmrmu
time endeavor.Alicia, spending most of her day dwelling on her fears of book. he r.ir{dl tnm'
Dave'sleaving her, had quit her part-time job to concentrateon the relation- what she ,m-ru
,M
ship. Dave was also devoting considerabletime to worrying about his mar- Later tha: :
riage, and his job performancewas declining. ReenEa::f mr
Andy's therapeutic objective was to interrupt this cycle by having one or to feel mii-e
both partners stop or even reverse their part in the cycle. If Alicia were to Dave repnii:-dL
stop pursuing Dave, he might rediscover his interest in her. Alternatively, if soon ther :
Dave were to reversehis participation and pursue Alicia, she might feel less fallen baii; im
compelledto pursue him. others .lr'a,'
Dave didn't consider himself capableof making changes,given his loss Somert-:*s
of feelings, so Andy met with him separately,validating the difficulty of his d1g g25g r,,:it
position and praising his willingness to stay in the relationship. Andy re- all u-hen :$r,'.'ltmwl
framed the nature of long-term relationships,talking about how sexualin- months
terestnaturally waxes and wanes,and normalizing his loss of interest. :-s; llrrll*ililil
gynecolo -:-:
Meeting alone also with Alicia, Andy validated her concerns and as- cameto i;:n
sured her that Dave'slack of interest did not mean she was unattractive. Nadia :*aLl
He explained that sometimespeople withdraw in relationshipswhen their more ofne:: o;;'"f,lllh
partner becomestoo predictableor losessome of the uniquenessand pas- sibilin o- .a,:
sion for life that originally drew them together. He wondered with Alicia yes, she"ii---*erlun
about ways that she might make herself a bit more mysterious to Dave, In gath.::nLE,urL
while recapturing her own interests. They agreed that unpredictability make seru;
should be expressedin subtle yet honest ways. Certainly, she wouldn't Nadia. bu: silg
want to hurt him. From age: -l nm,
Alicia had a habit of kissing Dave at bedtime, telling him that she loved cousin rr!: ' -frfi...............mi
him and, when he didn't respond, asking him if he loved her. Becausethis lnterCOUI-:€ :m mm!:,
 ro BnrnnSrxTHsnqpv
A CararvrrcAppRoecH 205
had sparked recent arguments and bad feelings, Andy suggestedthat she
could forget to kiss him or kiss him and forget to say that she loved him.
She might also dress for bed in a way that downplayed her interest in sex.
When Davecamehome late, she might be so absorbedin someactivity that
Dave would have to seekher attention. Becausethe renewal of Dave'sinter-
est in her couldn't be forced, his free will would need to be given time to ex-
press itself by Alicia's getting more involved in her own life, going back to
work or, as she was an avid reader,joining a book club.
The outcome of this shift did not appear until two sessionslater. Ini-
tially, Alicia found it difficult to disengagefrom Dave in the way they'd dis-
cussed;Andy validated her struggle by acknowledging the challenge of
tr)'rng something different when the stakes are very high. Disengagement
came easier after this, as did reengaging in the things that interested her.
At the next session,Alicia describedwhat happenedafter a few nights of
not giving Dave a kiss. Coming home late and finding Alicia reading a
book, he tried to get her attention. However, she really was absorbedin
what she was doing, and when she stayedengagedin it, Dave felt uneasy.
Later that evening,he initiated sex.
Reengagedin her own life again, Alicia returned to work. She continued
to feel more energy and assuranceof her love for Dave and of his for her.
Dave reported that his feelings for Alicia were starting to come back, and
soon their sexual relationship rekindled. They both admitted that they had
fallen back in love with each other. In essence,they had gotten out of each
other's way, allowing themselvesto rediscover each other.
Sometimeslow desire is related to a history of sexual abuse.Such was
the casewith Nadia, who, you may recall, felt either numb or nothing at
all when having sex with her husband, Ivan. Not having had sex in 6
months didn't bother Nadia, but Ivan was threateningdivorce,so, after her
gynecologist had told her that there was nothing physically wrong, she
came to Scott for help in solving "her" problem.
Nadia realized that saving her marriage would entail her having sex
more often with lvan, but until Scott asked,she hadn't consideredthe pos-
sibility of actually enjoying it. She said that if pleasurewas possible,then,
yes, she'd like to feel it.
ln gathering a sex history Scott asked about what the couple had tried to
make sex a pleasurableexperience.This discussionwas initially difficult for
Nadia, but she was eventually able to reveal some very important details.
From ages13 to 16, she was sexually assaultedfrequently by an adult male
cousin who was living with her family Entering her bedroom and forcing
intercourse on her, he threatened to hurt her if she ever told her parents.
206 Quickies

Shekept quiet, and the cousin continued to abuseher until he was killed in Nadia --jr-
-rrglll.
a car accident. SeSSiOn. b,:: .le
During these abuse episodes,Nadia would freezeup and go somewhere 6i6[n'1 fsil;, r irr
else in her head. She learned how to have sex without feeling like she was
having it, but her cousin wasn't pleasedwith this. Trying to make her "get him to sFli::: :
into the experience," he would tell her, while abusing her, how pretty or sexual abu.": e* ,iill
sexy she was, and he'd sometimes buy her sexy underwear and tell her to Nadia b::;e,mr
put it on. Scott thanc:: Ttm
After the death of her cousin, Nadia felt great relief. She started dating "Nadia hro :-riir
boys and becamesexually active,but only becausethe boys seemedto like
it. Shecontinued to "go somewhereelse,"so for her, it was something of a
"dead experience." Still, her lack of interest gave her a senseof power. to help. an: :"e
While guys were losing control over her, she was able to remain cool and were hari::= rgrl
collected. to do thl'* :rxr rmfil
When Nadia met Ivan in her early twenties, his solidity and genuine Want tO .f :,*,',,l]lmUllllL
caring for her made her feel secure. She wasn't sure if she ever really would rLr: :ls 'nrmmr,
"loved him," becauseshe never felt romantic and her feelings about sex looked ur :..:
had remained unchanged.Becauseof lvan's disappointment in her lack of going.
interest, she made an effort to warm up to the idea, reading romance nov- Over ih. 1flim*i,,
els that contained sexual material. They might have done the trick, had it sex, so hr :
l:
not been for lvan'shabits in bed. When making love, he liked to talk to her seemed i: :e. wimuml
and tell her how sexy she was. He'd alsobrought her sexy underwear,hop- though ht :.;al
ing it might spark her interest. lovemakl::. r.ruru,
Nadia had told Ivan about being abused,but, afraid she might upset handle ,, r. ,
him, she'd never given him the full details.Shehad askedhim to stop talk- Nadia ani -:ia[
ing during sex and to stop bringing home sexy underwear,but he hadn't After c"::",-Lulil'
really responded. Recognizing that he seemed to enjoy these activities, their dile:::"ru
she'd decided to drop the subject and try to make the best of it. two sess1":i.
After listening carefully to Nadia'sstory Scott reframed her numbness as your abil-:'. ,r.sur
a "secretpower" for disconnectingherselffrom her feelingsof sexualplea- part of tt,: ;r:r:u*u'
sure. This was not only an appropriate way to have handled the sexual fg1 q:gp6;1 ;;'a1q

abuse,but it also showed a keen senseof inner wisdom: It was her way of
fighting back. In essence,she'd been able to say,"You can take my body, but tions thai l'na:lL-n
you can't really have sex with me."
Now, as an adult, Nadia had a new need-the need to discover the
power of sexual pleasurein a trusting and loving marriage.Scott, express- Unfonun::--:', rnl$ifil
ing his hope that this could be accomplished,suggestedthat Ivan's in- done sor. -:ru:[,#$i
volvement in therapywould make it possiblefor them all to work together her trigrt:" :rl;ti,[.r
on helping Nadia in this discovery. The dilemma was theirs as a couple,
not simply hers. He also b,r- -,{tlriLtruilm
 A CerervrrcAppnoecHto Bntrr SsxTsenepv 2O7
Nadia thought she might be able to convince Ivan to come to the next
session,but she was uncertain about how it would turn out, becausehe
didn't believe in "shrinks." Scott normalized Ivan's skepticism as a com-
mon reaction among men. He then asked Nadia if it would be okay for
him to spend some time trying to help Ivan understand the impact of the
sexual abuseas away of helping her experiencesexual pleasure.
Nadia brought Ivan for the next session.In an effort to put him at ease,
Scott thanked him for coming and explained his reasonsfor inviting him:
"Nadia has told me about the sex problem that she and you are having. My
goal is to help her to experiencemore sexual pleasureso that you can have
a more enjoyable sex life." Brightening up, Ivan said he would do anything
to help, and he affirmed Nadia'sdescription of his talking to her while they
were having sex and bringing her sexy underwear.Yes,she had told him not
to do this, but he figured she was just being modest. Becauseall women
want to know that they are beautiful and sexy,he thought that telling her
would turn her on. And if she, with her nice figure, could seehow good she
looked in the underwear he bought her, maybe it would be enough to get her
going.
Over the years,Ivan had become impatient with the whole processof
sex, so he'd gotten to jumping into intercourse without much foreplay.This
seemedto be what Nadia wanted. He loved her very much, he said, but al-
though he had adjusted to her lack of interest in sex, the frequency of their
lovemaking had recently gone to such a low level that he just couldn't
handle it. He'd begun thinking that maybe he just wasn't sexy enough for
Nadia and that she needed another man.
After carefully helping Ivan to unfold his side of the story Scott reframed
their dilemma, drawing on the information that he had gathered over the
two sessions:"Ivan, the problem that Nadia is experiencing is not about
your ability as a lover. As you know, Nadia was abused as a young girl. As
part of that abuseshe becameturned off to sex. This is not at all uncommon
for women who have been abused,and in fact Nadia'sreaction was quite ex-
pected. This businessof being turned off has to do with the mental associa-
tions that Nadia has about sex. Mental associationsinclude her fantasiesand
a sense that these fantasiesare pleasurable.Pleasurablefantasieswithin a
very trusting relationship with you are what Nadia needs to feel turned on.
Unfortunately, as a couple, in your efforts to solve this problem, you have
done some things that reinforce Nadia'snegative images of sex. They set off
her triggers. You may not be aware of this, Ivan, but when Nadia was
abused, the abuser talked to her and told her that she was pretty and sexy.
He also brought her sexy underwear. I know that you have done something
208 Quickies

similar totally out of your love, but the problem is that these efforts may be on her on-n
too close to what happened to Nadia for her to stop the negative associa- discovenes
tions that she has with sex. I also know that Nadia's request to have sex After sorne
without foreplay is well intended. Shewants to pleaseyou and get the expe- She was re::::mdl
rience over with; however, this is also too close to what happenedwhen she lsPi6g6lLr. -d$ilmil,
was abused." what it nds::
Scott paused,and Ivan tearedup and began to cry. Nadia, at Scott'sre' excellent ';*rr idl
quest, placed her hand on lvan, who said that he'd had no idea that his her sensua-:r;
wife had been affected in this way. Scott explained that she had tried to Scot t er ;
protect him from her pain, which Ivan understood and appreciated. tercourse R.::
Scott then proceededto unfold a plan for therapy that included many el- one to tn-ifl: l

ements of MastersandJohnson'swork. He explained to Ivan that the course power of at":

of treatment would involve a sacrifice from him. He was giving them an ini- The cc'r.-:,rrE
tial prohibition against intercourse while they engagedin a program of pro- month laxr:
gressivepleasuring, and this could take a few months. It would be key that and rnith T-,''a:r
Nadia not engagein intercourse just to relieve his sexual tension, because two conLe::s,
this could reinforce her negativemental associationswith sex. Masturbation ing orga:r,*.-ummlffiL
would be perfectly appropriate, though, if he got too frustrated. okay to hu'--':
The couple's progressivepleasuring started with one-on-one talking, usuallr- g-'*;s
without touching, for 15 minutes a day, and it continued, with assign- sometimes a"rdL
ments given every 2 or 3 weeks, for sitting together and touching hands, posite eff;:: lum'
then hair, and then face and other nonerogenouszones.They progressed each othe: .-s
to doing this without clothes on and then to giving massages, also without guide v.-'u :
clothes. Scott stressedthat Nadia should always take the lead so that she The marL --i n,
could feel in control and reversethe processthat had brought on her neg- for one's f-a::Tuml
ative sex images.Shewas to direct lvan's hands when he was touching her Regarul:E
and to practice touching him. Scott asked them to talk about which types any \\-a\- --:""a:flMtflw
of touchesfelt better and what they liked most. In subsequentsessionsthe .o1116 u]5; 3eil&rlr
three of them talked about the couple'sattitudes and what kinds of sex done a r.'-u-:;fo*dMlL
they were most comfortablewith. pect thai v*-[Trnruil

Nadia beganto enjoy sexualpleasureand sensation,but she also had an others.-F,;

experience,for the first time in her life, of feeling intensely jealous. It came grocen-sI-r*
upon her as she watched Ivan talking to an attractive woman at church, sex life. i:,trr
and she didn't know what to make of it. Scott framed it as an indication of test to the -ru:
-rfr'lfi]iff[
their budding romance,and he warned lvan of the need to reassureNadia [1[1e. evdl

of his love for her. Her jealousy meant that she was making herselfvulner- pressedho: n
able to him, and she would need protection so that she could continue allou- her :-
opening up.
As a parallel development,Scott askedNadia if she would feel comfort-
able exploring how to experiencesexual stimulation, pleasure,and arousal
 A Cerervrlc Appnoecs ro BrunnSrx THnnepv 2O9
on her own. She would be in control, and, eventually, she could share her
discoveries with Ivan, thus opening a new sexual relationship together.
After some hesitation, Nadia agreedto take some steps in this direction.
She was referred to the book and video Becoming Orgasmic (Heiman &
LoPiccolo, lgBB) and asked simply to review the materials and consider
what it might mean to her to open this part of herself back up. She made
excellent use of the materials and exercises,using them to slowly explore
her sensuality.
Scott eventually suggestedthat they were ready to take the step into in-
tercourse.Recommending that Nadia be on top, Scott.directedher to be the
one to insert lvan's erect penis into her vagina so that she could feel the
power of eventually reducing it to a withering pulp."
The couple were doing well when they returned for a follow-up a
month later. Nadia was experiencing pleasure with sex (both on her own
and with lvan) and Ivan was no longer contemplating divorce. They had
two concerns. First, Ivan had noticed that Nadia wasn't consistently hav-
ing orgasmswith him. Second, they were wondering whether it would be
okay to have intercoursewith lvan on top. Scott offered some ideas: "Sex
usually goes better when the objective is pleasure. Orgasms will happen
sometimes and sometimes not for Nadia. Trying too hard can have the op-
posite effect for her. There are many ways for you to reach orgasm with
each other. As Nadia continues to discover these herself, she can help to
guide you in helping the two of you to experience this with each other.
The mark of a good lover is the ability to nurture a pleasurable experience
for one'spartner. Unfortunately, the movies rarely get this right."
Regarding their second concern, Scott said they were free to have sex in
any way that they chose, as long as it produced mutual pleasure. They
could also trade off on initiating. Scott ended with a caution: "You have
done a wonderful job of learning to make love. Even so, you should ex-
pect that sexual interest will be stronger at times and less strong at
others." He invited the couple to check out the women's magazinesat the
grocery store, noting that they all include features on how to spice up your
sex life. Apart from any useful ideas these articles might contain, they at-
test to the fact that all couples ebb and flow in sexual interest from time to
time, even when sexual abuse is not a factor in a person's life. Nadia ex-
pressedher gratitude to lvan for helping her to open herself to him and to
allow her to discover her own ftue sensuality.Ivan cried.

* This suggestion, taken from a casemade famous by Milton Erickson, reflected a reversal of the abuse
situation.
21O Quickies

Although the guiding ideas for this case,as for all of our work, derive chapterde:,,:
from systemic and social constructionist theory the interventions were pists n-hc :l
similar to those used by mainstream sex therapists working with desire abdicaun'E--:em
problems (Pridal & LoPiccolo, 2000) and issuesof sexual abuse (Maltz, grounded--
-:,-ut,s
2001a, b). What was different in this case,as in each of the others before As rre
it, was the therapist'scloseattention to first- and second-orderchangeand can be int:E:wruudi
the respectgiven to the relativity of realitiesin social relationships.Nadia believe rh;: -.r
and Ivan had been locked in a solution-generatedproblem cycle of well- constmc:l:ns;
meaning attempts to negotiate their sexual relationship. The more they'd ally enricn*
struggled, the worse it had become.With their worldviews honored in a for sexua, :
therapeutic setting, they were able to make small yet significant shifts in
their ideas,knowledge, and solutions, initiating the progressiveresolution
to their shared difficulty.

IN SEXTHERAPY
FOR CFTANGE
A CATALYST
The "new sex therapy" has always been a relatively brief therapy,but it has
been criticized for lacking an underlying theory. In this chapter, we articu-
lated and illustrated the social constructionist and systemic ideas that in-
fluenced the deveiopment of the MRI and solution-focused schools, as we
believe that they can offer sex therapy the theoretical foundation it has
been lacking. A social constructionist view honors clients' contexts and tra-
ditions, while also acknowledging the influence of the therapist's back-
ground. Such an appreciation helps therapists avoid the tendency to
perpetuate dominant and implicit sexual myths, while also avoiding associ-
ated gender-biased,phallocentric, and heterosexist assumptions.
Becausethe theoretical framework of a catalytic approach is fund.amen-
tally systemic,its biopsychosocial set consistently places people in the
larger contexts of their relationships.Thus, even biologically based diffi-
culties and interventions are framed within the clients' social and inter-
personal relationships.Instead of focusing on parts (a criticism, you may
remember, that has been ieveled at mainstream sex therapy), a catalytic
approach to sex therapy considers the context of relationships to be of cru-
cial importance. As can be seenfrom the caseswe've discussed,such con-
textual sensitivity proves very helpful when therapists are addressing
couples'problemswith desire.The nature of the dilemma becomesclearer,
making available a number of effective interventions.
This chapterhas been a blend of both theory and practice.The editors of
this book, Shelleyand Douglas,told us that they wanted to "get inside our
heads and our hearts," to learn how we work from our point of view. This
 A CereryrrcAppnoecsro Brurr SrxTHnnepy 211
chapter demonstratesour thinking and our passion.We believe that thera-
pists who practice without a guiding theory risk losing their direction and
abdicating their professional responsibility. Alternatively, theory that isnt
grounded in effective clinical practice is lifeless and useless.
As we have demonstrated, the innovations of traditional sex therapy
can be integrated with those from MRI and solution-focused therapy. We
believe that in bringing the two fields together, using systems and social
constructionist ideas as the bridge, practitioners from both can be mutu-
ally enriched. The result is an exciting catalyst for effective brief therapy
for sexual difficulties.

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