Create a podcast that will be a primer for therapists working with a variety of sexual challenges or sexual dysfunctions and how these could be approached using a systemic approach (e.g., not looking at the case/problem from an individual perspective).

Create a podcast that will be a primer for therapists working with a variety of sexual challenges or sexual dysfunctions and how these could be approached using a systemic approach (e.g., not looking at the case/problem from an individual perspective).

Be sure your podcast addresses the following:

Some of the possible sexual dysfunctions that you might encounter

How you might approach working with sexual dysfunctions from a systemic lens

What tools, techniques, and approaches that you would take if you were working with partners who were experiencing sexual dysfunctions.

Length: 5-7 minutes References: Include a minimum of 4 scholarly resources.

Please write me a dialogue that I am able to read verbally that integrates citations appropriately within a sentence Ex: “Christian Reed in 1979 said in an article stating “blah blah blah”. . The podcast needs to be 5 min long so try to write what you can to extend it to that time.

Requirements: 4 pages

ArticleAnIntegrativeModelforTreatmentofSexualDesireDisorders:AnUpdateoftheMastersandJohnsonInstituteApproachMarkF.Schwartz1andStephenSouthern1AbstractAnintegrativemodelfortreatingsexualdesiredisorderswasdevelopedfromtheoriginalworkofMastersandJohnsonInstitute.Sensatefocusexercisesandpsychoeducationwerecombinedwithcoupletherapyforrelationshipconflictsandindividualtherapiesforissueswithtraumaandattachmentdisorders.Theresultingmodelfitstrendsinsystemicandintegrativetreatment.Keywordssexualdesiredisorders,hypoactivesexualdesire,MastersandJohnsonInstitute,integrativetreatment,sensatefocus,coupletherapyMastersandJohnson(1966,1970)wroteverylittleabouttheirapproachtodesirephasedisorders.TheInstitute’sconceptualapproachtoinhibitedsexualdesirefocusedontherelationship.Aswemature,sexualresponseisanaturalmanifestationofattrac-tiontoapersonperceivedasappealing.Thisattractionevolvesintoacasualorcommittedrelationship.Onceapair-bondisestablished,sexualdesireisanaturalwayofexpressingthesenseofintimacythatdevelopswithinacommittedrelationship.Therefore,anythingthatenhancesorinhibitsrelationalintimacymaypositivelyornega-tivelyinfluencetheindividual’slevelsofsexualdesire.Sexisinnatelypleasurable—unlesssomethingmitigatesthatpleasure.Coupleswhoevidencelittleintimacyinthelivingroomusuallywillfeeldistantfromeachotherinthebedroom.Therefore,personswhoarebored,pressured,fatigued,angry,guilty,fearful,anxious,orsuffocatedinarelationshipare“entitled”tolowlevelsofsexualdesire.(M.F.Schwartz&Masters,1988,p.229)Thus,theInstitute’sapproachtotreatinginhibitedsexualdesirewassimilartotheirtreatmentofsexualdysfunction.Therela-tionshipwastheprimaryfocusoftreatmentratherthanthesymptomology.AnupdateonMastersandJohnsonInstitute’smodelfortreatingsexualdesiredisorderstakesintoaccounttheprimacyofthecouple’srelationship,sincethereisaconnectiontointimacyaswellasroadblocksorconstraintsthatmaybeindividualinorigin.Anintegrativemodelfortreatingsexualdesiredisordersbalancesindividualandcoupleissues.SexualDesireDisordersDesiredisordersincludefemalesexualinterest/arousaldisorder(302.72)andmalehypoactivesexualdesiredisorder(302.71)intheDiagnosticandStatisticalManualofMentalDisorders,fifthedition(DSM-V;AmericanPsychiatricAssociation[APA],2013,pp.433–436;440–443).Thereisabroaderrangeofdysfunctionsanddissatisfactionsthatmaybeconsidereddesiredisordersbyexpertsinsexualitytherapy(Kaplan,1995;Leiblum,2010).Forthepurposeofthisreview,desiredisordersincludelowsexualdesireorinterestwithinanindi-vidualorbetweenpartnersinasexualrelationship.Therearemanytheoriesthataccountforlackorlossofdesireincludingbiological,developmental,intrapsychic,relational,andculturalfactors.Whiledesirediscrepancyinacouple,inwhichonepartnerpresentslowerdesirethantheother,isnotsufficienttodiagnoseasexualproblem(e.g.,APA,2013,p.433),suchdifferencesarefrequentlypresentedincouplecounseling.Dis-crepanciesariseasthesexualrelationshipisaffectedbyamyriadofnonsexualissuesorintimacydysfunctioningeneral.FemaleSexualInterest/ArousalDisorderFemalesexualinterest/arousaldisorderblursphasesofinterestandarousalaccordingtotheclassicmodelofthesexualresponsecycle(Kaplan,1974,1979;Masters&Johnson,1966,1970).Lowsexualdesireinthiscontextmaybepre-sentedaslackofinterestinsexualactivity,absenceoferoticorsexualthoughts,reluctancetoinitiatesex,andinabilityto1HarmonyPlaceMonterey,Monterey,CA,USACorrespondingAuthor:MarkF.Schwartz,HarmonyPlaceMonterey,398FoamStreet,Suite200,Monterey,CA93940,USA.Email:[email protected]:CounselingandTherapyforCouplesandFamilies2018,Vol.26(2)223-237ªTheAuthor(s)2018Articlereuseguidelines:sagepub.com/journals-permissionsDOI:10.1177/1066480718775734journals.sagepub.com/home/tfj

respondtoapartner’ssexualinvitations(APA,2013,p.433).Femalesexualinterest/arousaldisordermaybelifelongoracquired,generalizedorsituational,andrangingfrommildtomoderateorseveredistress.Symptomsmusthavepersistedforatleast6monthsduration.Thesymptomscannotbebetterexplainedbyanonsexualmedicalormentalconditionorbysevererelationshipdistresssuchaspartnerviolence.Atleastthreeofthefollowingcharacteristicsarerequiredfordiagnosisofthedisorder(APA,2013,p.433).1.absent/reducedinterestinsexualactivity,2.absent/reducedsexual/eroticthoughtsorfantasies,3.no/reducedinitiationofsexualactivityandtypicallyunresponsivetoapartner’sattemptstoinitiate,4.absent/reducedsexualexcitement/pleasureduringsex-ualactivityinalmostallorall(approximately75–100%)sexualencounters(inidentifiedsituationalcon-textsor,ifgeneralized,inallcontexts),5.absent/reducedsexualinterest/arousalinresponsetoanyinternalorexternalsexual/eroticcues(e.g.,written,verbal,andvisual),and6.absent/reducedgenitalornongenitalsensationsduringsexualactivityinalmostorall(approximately75–100%)sexualencounters(inidentifiedsituationalcontextsor,ifgeneralized,inallcontexts).Femalesexualinterest/arousaldisorderreplaced“hypoactivesexualdesiredisorder”fromthepreviousDSMbecauseproblemswithsexualdesireandarousalfrequentlycoexistandmayreflectdifficultyorinabilitytoidentifycuesforsexualopportunityincludingphysicalchangesinthewoman’sbody.Whiletherearechangesinsexualinterestandarousalacrossthelifespan,sexualdesiremaydecreasewithaging.Thelackorlossofdesireisnotnecessarilyreflectedinfrequencyofsexualactivitiessuchasintercourse.Vaginaldrynessandgenito-pelvicpainconstituteothersexualdisordersorphysicalconditions.Comorbiditywithothersexualdysfunctionsiscommon.PrevalenceandincidencedatawerenotreportedintheDSM-Vbecauseofthenoveltyoftheconsensus-baseddiag-nosis(p.435).MaleHypoactiveSexualDesireDisorderMalehypoactivesexualdesiredisorder(APA,2013,pp.440–443)remainsdistinctfromarousal/excitementandorgasm/eja-culation.Thedisordersharesthefollowingcriteriawithfemalesexualinterest/arousaldisorder:atleast6monthsduration,lifelongversusacquired,generalizedversussituational,andmild–moderate–severedistress.Themajordiagnosticfeatureplaceshypoactivesexualdesireincontext.Persistentlyorrecurrentlydeficient(orabsent)sexual/eroticthoughtsorfantasiesanddesireforsexualactivity.Thejudgmentofdeficiencyismadebytheclinician,takingintoaccountfactorsthataffectsexualfunctioning,suchasageandgeneralandsocio-culturalcontextsoftheindividual’slife.(APA,2013,p.440)Prevalenceofmalehypoactivesexualdesiredisordervariesfrom6%inyoungermen(18–24years)to41%inoldermen(66–74years);however,persistentlackofinterestinsexaffectsonly1.8%ofmenaged16–44(p.442).Bothmalehypoactivesexualdesiredisorderandfemalesexualinterest/arousaldisorderwereassociatedwithfivecon-ditionsintheDSM-V(APA,2013):1.partnerfactors(e.g.,partner’ssexualproblems,part-ner’shealthstatus),2.relationshipfactors(poorcommunication,desirediscrepancies),3.individualvulnerabilityfactors(poorbodyimage,his-toryofsexualoremotionalabuse)and/or psychiatric comorbidity(depression,anxiety)or stressors (jobloss,bereavement),4.cultural/religious factors(attitudes,inhibitionsorpro-hibitionsagainstsexualactivity),and5.medicalfactors(including effects of medication).Temperament,environment,geneticpredisposition,sub-stance/medicationuse,andothersexualdysfunctionscontrib-utetotheemergenceandmaintenanceofthesesexualdesiredisorders.Thereareobviousgenderdifferencesinthecontri-butingfactorsandpresentationsofthedisorders.RecentModelsofSexualDesireDisordersLeiblum(2010)editedanauthoritativetextontheclinicalmanifestationsofsexualdesiredisorders.Inoneofthelastcontributionstoherbrilliantcareer,sheprovidedanoverviewofthefield.Sexualdesireisthemostelusiveofpassions.Whileeasilyignitedinanewrelationshiporaforbiddenencounter,itcanalsoberead-ilyextinguished.Anxiety,hostility,badmemories,orfrighteningflashbackscanthwartit-evensomethingsimpleasthesoundofadooropeningorachildcrying.Andyet,whenarousedbyanimageorscentorfantasyorperson,itcanfeelpowerfullyintense,driven,lively,andlifeaffirming.(Leiblum,2010,p.1)Leiblumandcolleaguestracedsexualdesirefromlibidotosocialconstruction,carefullyexaminingculturalandgenderissuesinvolvedinsustainingjusttherightamountofdesiretofacilitatebondinginanintimaterelationship.Shereportedprevalenceratesrangingfrom8%to55%instudiesofwomenandmenacrosstheagespectrum(Leiblum,2010,p.9).Inter-estingly,while45%ofwomenidentifiedlowsexualdesireinasurveyofsexualdysfunctions,only16%reporteddistresswiththeircondition(Derogatis,Rosen,Leiblum,Burnett,&Heiman,2002).Thisfindingaccountsfortheadaptationtosexualapathyandavoidanceinmanycouplesincluding“sexless”marriage.Kaplan(1974),whoadvancedtheNewSexTherapyasanexpansionoftheoriginalworkofMastersandJohnson(1966,1970),addedthedesirephasetoarousalandorgasminhertriphasicmodelofsexuality.Shedescribedincreasesinsexual224TheFamilyJournal:CounselingandTherapyforCouplesandFamilies26(2)

desiredisordersovera20-yearperiodwithcorrespondinggrowthintheacceptanceofdesirephasediagnosesbysexualitytherapists(Kaplan,1995,pp.7–11).Kaplanandhercolleaguesfounddeepercausesforhypoactivesexualdesireandtreatmentfailuresinothersexualdysfunctions.Inexaminingtheunder-lyingfactorsindeficientsexualdesire,Kaplan(1995,pp.3–4)concluded,…thepathologicaldecreaseofthesepatients’libidoisessentiallyanexpressionofthenormalregulationofsexualmotivationgoneawry.Desiredisordersariseinthecourseofdevelopmentasresponsestosituationsthatinhibiteroticexplorationoropportunityforintimacy.Theinhibitionofsexualdesirehasanextensivehistoryintheliterature.Allofthefollowingfactorsmaycontributetoproblemswithsexualdesire(Leiblum,2010,p.13):Biologicalfactors:hormonalorneurotransmitterimbal-ances,medicationsandtheirsideeffects,andillnessesoraccidents;Developmentalfactors:lackofadequatesexinforma-tion;sexnegativemessages;neglectordeprivation;emotional,physical,orsexualabuse;Psychologicalfactors:fear/anxiety,depression,attach-mentdisorders,personalitydisordersorotherclinicalsyndromes;Interpersonal/relationalfactors:conflictsanddiscordwithapartner,withdrawaloravoidance,partnersexualdysfunction;Culturalfactors:religiousbeliefsandculturalnorms,beliefsregardingsexualityandmarriage;andContextualfactors:comfortandsafetyinsurroundings;relaxingorstressfulenvironments;topicsorsituationsthattriggerthoughts,feelings,andbehaviors.Individualandcouplesdependuponinternalpeaceandrela-tionalharmonytofindpleasureandmeaningthroughinitiatingorrespondingtosexualovertures.Perel(2010)describedtheparadoxinwhichpartnersstriveforthecomfortandconsistencyofintimacywhilecravingtheheightenedpassionassociatedwiththeunfamiliarandunpre-dictable.Eroticismisatypeoflongingbasedonthehumanneedtoexploreandexperiencemysteryandnovelty.Organiz-ingintimacyaroundthenormsandexpectationsdelineatedfromthefamilyoforigincanleadtonumbnessandblockstosexualdesire.Perelchallengedcouplestosustainintimacywhileusingfantasy,imagination,andexperimentationtobreathelifebackintosexualdesire.TieferandHall(2010)expressedaskepticalviewofsociallyconstructednormsthatdefinedsexualdesirecomplaints.TheNewViewofWomen’sSexualProblemsworkgroup(cf.Tiefer,2008)rejectedbiologicalandculturalmandatesindefiningproblemsandprescribingsolutionsforsexualdesireproblems.Traditionalsexualrelationshipsbuiltongenderstereotypes,heterosexist/heteronormativebiases,andoppres-sivepatriarchyextinguishopportunitiesformatchingsexualinterestsandpreferencesinunique,evolvingsexualrelation-ships.TheNewViewfacilitatesexplorationofgenderandculturalinfluences.Thetherapistbecomesacoachfordiscuss-ingandexploringoptionswithoutpreconceivednotionsofwhatis“normal”andwhatisdisorder(Tiefer&Hall,2010).Kleinplatz(2010)describedsexualdesiredisordersasopportunitiestopursueoptimaleroticintimacy.Shenotedthatdesireproblemsanddiscrepancieswerethemostcommonpre-sentingproblemsinherpractice.Sexualitytherapyasexperi-entialtherapyenablesthetherapisttoactasaguidethroughthelandscapeofsexualoptionsandchoices.Partnersareencour-agedtosharetheirfearsandconcerns,preferencesandwishes,andfantasiesanddreamstodeterminewhatispossible.Com-plaintsfrequentlycomefromthehigherdesirepartner;how-ever,thelowerdesireoftheotherisnotapathology.Ratherthedesirediscrepancyheraldstheopportunityforoptimalsexual-itycharacterizedbyeachbeingpresent,authentic,vulnerable,emotionallyaccessible,andconnected.Thebondofthepartneristheplatformforexploringandachievingoptimalsexualdesire(Kleinplatz,2010).Thesymptomofhypoactivesexualdesireisarecordofthepast,analarmofpresentdifficulties,andabeaconforasatisfyingfuture.DynamicsofHypoactiveSexualDesireHypoactivesexualdesireincouplesisfrequentlypresentedinmaritalandcoupletherapy(Leiblum,2010).Whilethecon-structoflowsexualinterestordriveisasoldaspsychotherapy,recentdevelopmentsindiagnosisandtreatmentinviteattention(e.g.,Leiblum,2010).Freud’soriginalpositionsonsexualityaccountedforthecontributionsofneurosistoproblemswithdesire.Hisoriginalviewsontheetiologyofhysteriaantici-patedmodelsofchildhoodtraumatizationandintimacydys-functioninadulthood.Freud(1896/1962)describedthe“sexualscenes”enactedbetweenadultsandchildreninhis1896lectureontheAetiol-ogyofHysteria.Herelatedthepowerlessnessofthechildvictimtohisownfearsoffailureinrelationships,eventhe“impotenceofthetherapist”(Marcel,2005,p.15).Thefollow-ingquote (asinglesentence)highlightsthecombinationofprematureoroverexcitationofachild’svulnerablenervoussystemandbetrayalbyanadultcaregiverinthedevelopmentoftrauma.Allthesingularconditionsunderwhichtheill-matchedpaircon-ducttheirlove-relations-ontheonehandtheadult,whocannotescapehisshareofthemutualdependencenecessarilyimpliedbyasexualrelationship,andwhoisyetarmedwithcompleteauthorityandtherighttopunish,andcanexchangetheonerolefortheothertotheuninhibitedsatisfactionofhismoods,andontheotherhandthechild,whoinhishelplessnessisatthemercyofthisarbitrarywill,whoisprematurelyarousedtoeverykindofsensi-bilityandexposedtoeverysortofdisappointment,andwhoseperformanceofthesexualactivitiesassignedtohimisoftenSchwartzandSouthern225

interruptedbyhisimperfectcontrolofhisnaturalneeds-allthesegrotesqueandyettragicincongruitiesrevealthemselvesasstampeduponthelaterdevelopmentoftheindividualandofhisneurosis,incountlesspermanenteffectswhichdeservetobetracedinthegreatestdetail.(Freud,1896/1962,pp.214–215)Freud’soriginalmodelwasremarkablyconsistentwithcontemporaryviewsarticulatedbysuchcontributorsasVanderKolk(1989,2014).InFreud’s(1914,1920)emergingpsychoanalysis,therepetitioncompulsionmotivatedthereenactmentoftheabuseexperience,literallyorsymbolically,withtheaimofgainingasenseofresolutionormastery.Later,FreudrenouncedtheseductiontheoryinfavoroftheOedipuscomplex,stagesofpsychosexualdevelopment,andfocusonfantasy.Marcel(2005)describedtheevolutionofFreudianpsychoanalysisintermsofFreud’sownhistoryofsexualabuseandstruggleswithhissexualtheoryinthemedicalandscientificcommu-nitiesofthetime.OthersinterpretedFreud’scontributionstounderstandingsexualdysfunction,particularlydisordersofdesire.Kaplan(1979,1995)emphasizedunderlyingpsychodynamicsinunderstandingandtreatingdisordersofsexualdesire.Sheobservedthatearlychildhooderoticexperienceswerehighlyinfluentialinshapingadultsexualdesire(Kaplan,1995,pp.39–49).Theontogenyofsexualdesireincludedmother/childeroticism,conditioningoffantasies,integrationofsensorylovemaps(Money,1986,1989),negativeearlysexualpro-gramming,erotizationofchildhoodtrauma,andemergenceofperversionsorparaphilias(Stoller,1975).Eroticfantasiesturnchildhoodtraumaintotriumph(Money,1986,p.36;Stoller.1975,p.30),similarinconstructtotherepetitioncompulsioninwhichapersonisdriventorecreatepainfulandshamefulexperiencestoattainmastery.Eroticfantasiespreservesexualdesirethatmayotherwisebecodedinthedevelopingpsycheasaturnoff,aversion,orrepulsion(Kaplan,1995,pp.47–49).Kaplan(1979)appliedpsychoanalytictheorytoexplainthecomplexityofcasesinvolvinglowsexualdesire.BasedoncomplicationsintheOedipalsituation,someindividu-alsandcouplesfearsexualandrelationalsuccessorful-fillment.Theycannotenjoysexualsensationsandmaylackpleasureinmanyareasoflifehavingattainedsuccessthatisincreasinglyburdensome.“Winning”elicitsfearsofretaliationorrejectionimmobilizingsomeandcontribut-ingtoavoidanceofintimacyinothers.Freud(1915/1959)describedtwopersonswhowere“wreckedbysuccess.”Kaplan(1979,pp.176–182)reportedcasesofinhibitedsexualdesireandromanticavoidanceassociatedwithsex-ualsuccess,anxiety,andangeroverintimacy.Fearofintimacy(Kaplan,1979,pp.183–192)wasthemostcommoncauseoflowsexualdesireandavoidanceofsexuality.Overtime,cumulativeconsequencesfortheaforementionedpsychodynamicscontributetosexlessmar-riagesandrelationships.IntimacyandIntimacyDisorderAcoupleoftenestablishesreactivedistancerelatedtodepen-dence–independence,closeness–distance,freedomversuscon-trol,andprivacyversusself-disclosure.Onceestablished,thoughbothadapttolowsexualdesire,itisoftenasignthatthisdistanceistoolittleortoomuchandneedsrealignment.Althoughtheattachmentstylesofeachindividualcomplementeachother,anindividualcanfeelengulfed.Asthepartnerexperiencesamovetowardgreaterautonomy,theresultmaybeareactiveresponsetowardgreatercontroltomaintainabracketinginmutualityandconnectedness.TheDevelopmentoftheAffectionalSystemsItisvaluabletoviewsexualdesirethroughthelensofattach-menttheorybecausedesireisoftenanaspectofpairbonding,courtship,attraction,love,affection,andintimacy.Sexualdesireandarousalaretheendpointsofaseriesofdevelop-mentaleventsthatbeginwithgeneticsandtemperament,movethroughthechild’searlyattachmentenvironmentwithcaretakers,andcanbedisruptedbysubsequentexperiencesthataresooverwhelmingthechildisunabletoassimilatethem.Thisdisruptioncanresultinaffectdysregulationandimpairedsocializationandself-development,allactivatedbypubertalhormones.Aperson’sattachmentstyleisestablishedinthefirst2yearsoflifeandremainsstablefrom18monthsto20yearswithabout72%consistency(Main&Solomon,1995).Themother’sattunementtoherchildfacilitatestheexperience-dependentmaturationofthechild’sneurologicalstructure,whichdirectlyinfluencesthechild’sbiochemicalgrowthprocess,aswellasdendriticandaxonaldevelopmentinthefirst2yearsoflife.Whenfeedbackfromcaretakersisabsent,punishing,frustrat-ing,invalidating,orrejecting,theconsequencescanbewrittenintothestructureofthedevelopingpersonality.Childrenmaybeemotionallyconstricted,turnintothemselvesanddisconnectfromothers(avoidant),or become emotionally dysregulated (Main&Soloman,1995).Anemotionallydysregulatedchildwilleitherfailtouseothersforcomfortorbecomeanxious,fearful,andsodependentonothersforcomfort,sopreoccupiedthatheorsherefusestoseparateandexploretheenvironmentthusinterruptingindividuation.Aschildrenage,theyseekfamiliar,consistentenvironmen-talinteraction,evenifitmaybedamagingtotheself.So,theywillrecreateandreenactfamiliarearlyrejectionandfrustra-tions(L.Sroufe,1988).Childrendismissiveofattachmentarepickedonmorebybullies,dislikedbytheirteachers,viewedaslesspopular,anddolesswellinschoolbyage10.Injuredearlyattachmentbonds,likethosedescribed,arehighlypredictiveoflaterrelationaldistressandcreatetheframeworkforhowanadultcouplewillinteractsexually.Individualsratedanxious/ambivalentarebothstarvingforaffectionandfearfulofcloserelationships;avoidantindividualsreportneverhavingbeeninlovenorhavinghadstrongexperiencesoflove.226TheFamilyJournal:CounselingandTherapyforCouplesandFamilies26(2)

Individualdifferencesontheanxietyandavoidancedimen-sionsaccuratelypredictdifferencesinthewaypeopleexperi-enceromanticandsexualrelationships.Peoplewhoranklowonanxietyandavoidance(i.e.,securelyattached)tendtohavelong,stable,andsatisfyingrelationshipscharacterizedbyhighinvestment,trust,andfriendship(Collins&Read,1990;Simp-son,1990).Inthesexualrealm,theyareopentosexualexplo-rationandenjoyavarietyofsexualactivities,includingmutualinitiationofsexualactivityandenjoymentofphysicalcontact,usuallyinthecontextofalong-termrelationship(Hazan,Zeif-man,&Middleton,1994).Secureadolescentsengageinregulardatingandestablishromanticrelationships.Theyaremorelikelythaninsecureadolescentstobeinvolvedinlong-termrelationships,andtheyreporthavingmorefrequentsexualintercoursethanavoidantadolescents(Tracy,Shaver,Albino,&Cooper,2003).Avoidantadolescents,asonemightpredict,tendtoavoidsexualrelationshipsaltogether.Tracy,Shaver,Albino,andCooper(2003)foundthatavoidantadolescentswerelesslikelythantheiranxiousorsecurepeerstohavehadadate,sexualintercourse,oranysortofsexualexperience.Avoidantvirginsscoredhighonmeasuresoferotophobia.Avoidantpeoplearelesslikelythantheircounterpartstofallinlove(Hatfield,Brinton,&Cornelius,1989),andtheirlovestyleischaracter-izedbygameplaying(Shaver,Hazan,&Bradshaw,1988).Tracyetal.(2003)observed“attachmentavoidanceinterfereswithintimate,relaxedsexualitybecausesexinherentlycallsforphysicalclosenessandpsychologicalintimacy,amajorsourceofdiscomfortforavoidantindividuals”(p.141).Avoidantfemalesdistrusttheirbodiesandarenumbduringadolescentexperimentation.Thecostoflivingwithanavoidantstyleofattachmentisnumbing:theabsenceofemotions,includingcompassion,plusaninabilitytoexperiencethefullbreadthoflove,andthesheerbeautyoftheworld.Avoidantpersonsfeelaspiritualdiscon-nectionwiththeplanetanditspeople.Toavoidthepainoflossandgrief,theymustlimitthecapacityforpleasureandplay—bothessentialforsatisfyingsex.Thetypeofinsecureattachmentstylealsohelpstodeter-mineaperson’sbehaviorinromanticandsexualrelationships.Personswhoratehighontheanxietydimensionandlowontheavoidancedimensiontendtobecomeobsessedwiththeirromanticpartners(Hazan&Shaver,1987)andexperiencelowrelationshipsatisfactionandahighbreakuprate(Carnelley,Pietromonaco,&Jaffe,1996;Collins,1996;Collins&Read,1990).Theyaremorelikelythansecureoravoidantpeopletoexperiencepassionatelove(Hatfieldetal.,1989)andexhibitanobsessive,dependentstyleoflove(Collins&Read,1990;Fee-ney&Noller,1990;Shaveretal.,1988).Onaverage,theydisplayastrongerpreferencefortheaffectionateandintimateaspectsofsexuality(huggingandcuddling)thanforthegenitalaspects(vaginal,anal,ororalintercourse;Hazanetal.,1994).Attachmentanxietyisalsoassociatedwithconcernaboutone’sownsexualattractivenessandacceptability,anextensionofanxiousindividual’sgeneralconcernwithrejectionandaban-donment(Hazanetal.,1994;Tracyetal.,2003).DevelopmentofSelfOneoftheremarkablefindingsofL.A.Sroufe,Egeland,Carl-son,andCollins(2005)isthatchildrenwhodevelopedapatternofdisorganizedattachment,withcoexistingavoidantandpre-occupiedstrategiesat18months,weredissociativeinlong-termfollow-up,suggestingsegregatedinternalmodelsofselfandtheattachmentfigure.Theindividualclinicallypresentswithastatementsuchas“Idon’tknowwhoIam,”“Ifeellikeanimposter,”or“IfeellikeI’mbadandpretendtobegood.”Individualswhofeelunlovedandlackadevelopmentalhistoryofcaretakingoftenfailtopresentstructuralcapacitiestocon-nectwithselfandothersbecauseofaninneremptiness.Atthecoreofone’scapacitytobondareself-empathyandthecapacityforself-care.Intheabsenceofvalidatingcare-takers,theindividualdoesnotinternalizeacaringrelationshipwithself.Arejectedorabandonedchildtendstodevelopneg-ativecoreschemasorbeliefsaboutselfandinsomecasesabouttheirgenderorbody.Selectivemodesofprocessingandorga-nizinginformationunfold,suchthatthesebeliefsbecomeself-perpetuating.Thesemodesultimatelyorganizeanindividual’srangeortypeofinteractions,whichconstrainpossibilitiesofnewlearningwithrespecttointimacy.Theselfcomestoexistprimarilyinthecontextofothers,withinanaggregateofexperiencesof“self-in-relationships.”InvariantaspectsofselfandothersareabstractedintowhatBowlby(1969,1973)called“internalworkingmodels.”Newexperiencesarethenabsorbedintoearlierrepresentations,cre-ating,maintaining,andrepeatingcoreschemas.Theinternalworkingmodelsofindividualswithdisordersofintimacymaybefilledwithself-hatred,sothepersoncompensatesbybeingpowerful,controlling,dominatingoralternatively,feelinginadequateandweak.Theresultcanbecomeaself-fulfillingprophesyastheindividualcreatestheabandonmentandrejec-tiontheyfearisinevitable.Perfectionismandself-hatredmanifestedinthebedroomcanresultinobsessivepleasingordepersonalization.Theeffectonsexualdesireisthatsexisusedasaperformancetofeeladequate,desirable,andattractiveandto“keepthepartnersatisfied”ratherthanformutualsatisfaction.Theexperienceisoneof“otherization,”beingoverlyfocusedonothersattheexpenseofself.Sexasaperformancecreatesenormouspres-suretoperformwell,whichcaneventuallydegradeperfor-manceanddesire.Theresultisthesametypeofnumbingnotedintheearlierdescriptionsofavoidantadolescents.Duringthesecondorthirdyearoflife,toleranceforsepara-tionandthecapacityforself-soothingisorganized.Havinga“securebase”allowsforexplorationandthecapacitytomasterandsolveproblems,therebyfeelingeffective,competent,andpowerful.Thesecurechildbeginstointernalizethebeliefof“beingvaluedandloved”anddoesnotneedconstantreassur-ance.Individualswithattachmentinjurydonotformthissecurebaseandrequiretheconstantmirroringofotherstomaintaintheirsenseofself.Theycanbecomesuggestibleandsusceptibletoinfluence.Theybecomehuman“doings,”per-fectionistsalwaystryingnottodisappointothers,feelingonlySchwartzandSouthern227

asgoodastheirlastaccomplishment.Theytendtohavediffi-cultywithcreativeproblem-solving,constantworry,andfeel-ingpowerless.Often,theysuppressaffect,becomingmechanicalandinstrumental.Intheirattempttogainaffection,theyneedtoconquerthepartnerwhoisrejectingthem.Oncetheyconquer,theirsexualarousaldiminishes,andtheirsexualgoalisforphysicalreleaseratherthantrueaffection.Intimacyterrifiesthemduetofearsthattheclosenessmakesthemvulnerabletoabandonment.Toprotectthemselves,theycreatedistancebylosinginterestinthepartnerandusingpornography,affairs,orotherdistractionstostaybusyandtired.Theattachmentsystemevolvedasabiologicalalarm.Itensuresthesurvivalofthespeciesbydetectingpotentialharmandsignalingterrortostimulateaction.Ifthecaretakermovesaway,disruptingthesecurebase,andtheindividualhasaninternalizedworkingmodeltocreateasecurebase,theattach-mentsystemwillbeactivated,andthenaturalresultwillbeterror.Thechildwillseekthecaretakerorcryforattention.Forthepreoccupiedindividualwholacksasecurebase,peoplewantingtohavesexwithhimorherisreassuranceofdesirabilityandreducesfearsofabandonment.Inavoidantattachment,gettingcloseactivatesfearsofdangerorannihila-tion,sincethepeopleachildoncedependedonweredemand-ing,controlling,dangerous,orneglectful.Indisorganizedattachment,bothsystemsalternate,thusneedingsexandneed-ingdistancesimultaneously.Manysymptomsofrelationaldis-tressaswellaspsychiatricsymptomscanbebetterunderstoodwhenseenthroughthelensofattachmentactivation.Helpingtheindividualforminternalandexternalsafetyzonescanneu-tralizefearsrelatedtoclosenessanddistanceandreversesex-ualdesireissues.Mostcriticalfordevelopingasecurebaseareself-coresche-masofsafety,trust,esteem,power,control,andintimacy.Thedevelopmentofthesecoreschemasisalteredwhenearlyeventsengravenegativebeliefsintothedevelopingbrain(e.g.,Iamfat,Iamstupid,andIambad),althoughthethoughtsareirra-tionalandwithoutevidence.Suchself-hatredrequirestheper-sontoperceiveothersconsistentwiththesebeliefs,therebysettingupbiasedfilters.Ifthepartnerisperceivedassmart,beautiful,andthin,thesignaloffearisactivated,increasingapreoccupiedperson’sdesireforreassuranceoranavoidantperson’slossofinterest.Fearandavoidanceareinvolvedintheconstructionoflovemapsortemplatesfororganizingincominginformationandmakingintimatechoices.LoveMapsAnothercriticalcomponentofthedevelopingaffectionalsys-temsiswhatJohnMoney(1986)definesasalovemap:apersonalizeddevelopmentalrepresentationortemplateinthemindthatdepictstheidealizedloverandtheidealizedprogramofsexualeroticactivitywiththeloverasprojectedinimageryandidealizationoractuallyengagedinwiththelover(Money,1986;Money&Russo,1981).Moneybelievedthatactualbiographicaleventsrelatedtoattachmentandtraumainfluencethedevelopmentoflovemapsandthattheycanbe“vandalized”(Money&Lamacz,1989).Toomuchpunishmentassociatedwiththeunfoldingofgenitalsexualityorprematuresexualizationinthefamilycaninterferewithsexualarousaldevelopment.Thedevelopinglovemapincludespartnercharacteristicsthatsexuallyarousethebodytorespondtotouch,andthesenseofselfasattractive,whichindirectlyinfluencestheperceptionofanotherasdesirable.Thelovemapishardwiredtorespondtoavarietyofemotionssuchasillicitness,conquest,fear,intimacy,romanticlove,andchallenge.Earlythemessuchastakingcareofothersorcaretakersbeingoutofcontrol,hostile,orabusivebecometemplatesfor“fallinginlove.”Thewayoneislovedasaninfantcanbecomea“blueprint”foradultaffec-tionalstyle.Pubertythenactivatesthelovemapthatwasestab-lishedthroughoutchildhood.HendrixandHunt(2013)usedthewordimagotodescribethesexualarousallovemapformedbyattachmentfiguresininfancyevenbeforethecerebralcortexisfullydifferentiated.TheimagoisatthecoreofrepetitioncompulsionswhichFreud(1901,1914,1920/1961)described,inwhichanindividualrepeatedlyisattractedtodestructive,self-injuriouspartnership,suchasalcoholicsandrejecting,injuredpartiers.Hendrixofferedaformulathatactuallypredictstheimagebasedonpositiveandnegativeearlychildrenexperiencesandidentifiestheneuralsubstratesforsuchrepetitions.Thefantasyorimageryapersonusestoarouseoneselfinmasturbationcanthenorganizethechoiceofpartner,affec-tionalinterchange,andsexualdesireandarousal.Iftheadoles-centusespornography,theseimagesthenservetooverlearncertainarousalpatterns.Someavoidantindividualsuseitasaformofdisengagement.Fortheseindividuals,morestimulationseemstobecomenecessarytoreachorgasm.Toleranceorhabituationtofrequentstimuliincreasesthroughthebiobeha-vioralrewardsystem.Sexualarousalbecomeschanneledtowardthevisualcomputerscreenratherthanthroughthenat-uralchannelsoftouch,closeness,andaffection.Ifamandevelopsavoidantattachment,forexample,hemightbecomefixatedonthewoman’sbreastsandbecomearousedbytheimageofthebreastsratherthanthewoman,astrategythatallowshimtomaintainadistancefromtheperson.Anothermanmightrequiretheimageofhis“secretary”orascenefrompornographytomaintaindistanceandnotbecometoointimate.Eventually,theimageryalonesatiates,undermininganysexualinteractionwiththepartner.Forpreoccupiedindividuals,sexualactivitycanbecomeameansofreassurancethattheirpartnerdesiresthem,andsexthenbecomesobsessive,mechanical,andoftenreversingthepartner’sdesireforsex.One’ssexualarousalisaffectedbythepartner,soonepartner’slackofpassionoftenresultsintheother’slackofarousal.Asapproachandavoidanceconflictsincreaseinrelationshipsaffectedbyvandalizedlovemapsanddamagedaffectionalsystems,genuineintimacycannotbesustained.Relationshipissuesandconflictscontributetosexualdesireproblems.228TheFamilyJournal:CounselingandTherapyforCouplesandFamilies26(2)

RelationshipIssuesandSexualSatisfactionRelationshipconflictandcoupledistresshavebeenconsideredmajorcontributorstosexualproblemsintheabsenceofdirectphysicalcause.Unresolvedconflictsaffectbothrelationshipsatisfactionandsexualsatisfaction.Dysfunctionalconflictres-olutionstylescontributetosexualdysfunctionanddissatisfac-tionwhileconstructivecommunicationandinteractiondeepenemotionalandsexualintimacy(Metz&Epstein,2002).Whilerelationshipsatisfactionandcouplesatisfactiontypicallychangeconcurrentlyinlong-termrelationships(Byers,2005),sexualsatisfactioncanenhancerelationshipsatisfactioninsomecouplespresentingdifficultyincommu-nicating(Litzinger&Gordon,2005).Adultattachmentstylehadadirecteffectonmaritalsatisfaction,whilesexualcom-munication,asamediatingvariable,waspositivelyrelatedtosexualsatisfactionandmaritalsatisfaction(Timm&Keiley,2011).Differentiationofselfmaycontributetosexualdesire,intimacy,andcouplesatisfactioninheterosexualcouples(Ferreira,Narciso,Novo,&Pereira,2014).Levelsofsexualandnonsexualcommunicationcontributedtorelationshipandsexualsatisfactionincollege-ageheterosexualcouples(Mark&Jozkowski,2013).Itisessentialtorespondtorelationshipissues,maintaincommunication,andsustainsexualintimacywheneverpossible.Emotionalandsexualaspectsofintimacyareimportantcorrelatesofrelationshipsatisfactioninromanticcouples(Yoo,Bartle-Haring,Day,&Gangamma,2014).TheresultsofapathanalysisinthissubsetoftheFlourishingFamiliesProjectindi-catedthatsexualsatisfactionpredictedemotionalintimacyinhusbandsandwives.Emotionalintimacyandsexualsatisfac-tionmediatedappraisalofpartnercommunicationandtheirownrelationshipsatisfaction.Genderdifferencesrevealedthatrelationshipsatisfactionofwiveswasnotassociatedwithsex-ualsatisfactionreportedbytheirhusbands.However,husbandsreportedhigherlevelsofrelationshipsatisfactionwhentheirwivesendorsedgreatersexualsatisfaction.Emotionalandsex-ualintimacyinteracttocontributetorelationshipandsexualsatisfactioninheterosexualcouples(Yooetal.,2014).Achievingandmaintainingintimacythroughgoodcommu-nicationandmakingmeaningintherelationshipcancontributetosexualsatisfaction,withoutregardtoillnessorsexualprob-lems,throughstressrelief,pleasure,playfulness,andspiritual-ity(Metz&McCarthy,2007).TheNewViewofWomen’sSexuality(Tiefer,2008)rejectedanexclusivelybiologicalandillnessmodelofsexualityemphasizinginsteadpolitical,cul-tural,andespeciallyrelationshipfactorsinsexualdysfunctionanddissatisfaction.SouthernandCade(2011)presentedanintimacy-oriented,relationalmodelforsexualhealthtocoun-teracttheovermedicalizationofsexualitycounselingandther-apy.Amodelforintegratingmaritalandsexualitytherapyacrossvariouscontextsinlifehasbeenadvanced(Hertlein,Weeks,&Gambescia,2015).Relationshipdistressandcoupleconflictinterferewithcommunication,intimacy,andsatisfactionintherelationshipandsexuality.Sexualsatisfactionisimportantinrelationshipsatisfactionevenwhenthereareproblemswithcommunica-tion,attachment,orintimacy.Concurrenttreatmentofemo-tionalandsexualintimacyisindicatedincouplesattemptingtoovercomerelationaldistressandestablishasecureandmeaningfulbond.Relationship-orientedtherapyremainsanessentialcomponentoftreatmentofsexualissuesandcoun-teractsthecontemporaryovermedicalizationofsexualproblems.MastersandJohnsonInstituteApproachtoSexualDesireDisordersPriorto1970,treatmentofsexualdysfunctionanddissatisfac-tioninvolvedindividualpsychotherapyorvariousmodelsofmarriagetherapy.MastersandJohnson(1970)establishedacollaborativeprogramfortreatingsexualproblemsbaseduponresearchinitiatedin1954.Theresearchinvolvedobservationandrecordingofthousandsofepisodesofsexualactivity,resultinginthelandmark,HumanSexualResponse(Masters&Johnson,1966).TheMastersandJohnsonInstituteofferedtherapytocouplespresentingparticularsexualdysfunctionsusingtechniquesinnovatedinthelaboratory.Thebasicapproachinvolvedassessment,consultation,andhomeworkrecommendationstothecouplefromadualgen-der,cotherapyteam.Theteamapproachincreasedobjectivity,incorporationofdifferentviewpoints,andmodelingofeffec-tivecommunication.Couplesfreedthemselvesfromthedemandsofordinarydailylife,typicalrolesandresponsibil-ities,andtriggersforconflictoravoidanceathome.Theydevotedthemselvestorecreationandintimatecommunicationwhilereceivingandcompletingdailyhomeworkexercisesovera10-to14-dayperiod.Thisintensiveformatfacilitatedinterventioninaproblemcycleofinteractionandrecoveryofnaturalsexualfunction.Therapysessions,whilebasedonspecificdisorders,weretailoredtotheneedsofthecouple.Occasionally,individualsessionswerescheduledtoaddressroadblockselicitedbythehomeworkexercises.Sexualtherapyinvolvedtheprescriptionofnondemandtouchingexercises,sensatefocus.SensateFocusAcornerstoneoftheInstitute’smodelfortreatingsexualdys-functionwastheintroductionofthesensatefocustechnique.Whilethisinterventionwascriticizedforbeingaseriesofstraightforwardtouchingexercisesthatblockedspontaneityandcreativity,thesensatefocusexercisesassessedthecurrentsexualandintimacyneedsintherelationship,revealingroad-blockstonaturalfunctioningandidentifyingindividualcontri-butionstolackoffulfillmentinsexualoutlet.Apfelbaum(1995,pp.23–24)commentedonthecritiques,observingthatwhilemostsextherapistsusesimilartechniques,theyfailtorealizetherichnessinthesimplicitysincetheywerenottrainedintheinnovativeclimateoftheInstitute.WeinerandAvery-Clark(2017),drawingontheoriginalworksofMastersandJohnson(1970)andtheelaborationbySchwartzandSouthern229

Kaplan(1987),developedanillustratedmanualforsensatefocusinsextherapy.WeeksandGambescia(2009)analyzedsensatefocusexercisesfromasystemicperspective,simulta-neouslyaddressingsexualandmarital/coupleissues.Thefol-lowingfunctionsmakesensatefocusafundamentalinterventionintreatingsexualdesiredisorders(Weeks&Gambescia,2009,pp.348–353).1.helpeachpartnerbecomemoreawareofhisorherownsensations;2.focusonone’sneedsforpleasureandworrylessabouttheproblemorthepartner;3.communicatesensualandsexualneeds,wishes,anddesires;4.increaseawarenessofthepartner’ssensualandsexualneeds;5.expandtherepertoireofintimate,sensualbehaviors;6.learntoappreciateforeplayasagoalstartratherthanameanstoanend;7.createpositiverelationalexperiences;8.buildsexualdesire;and9.enhancetheleveloflove,caring,commitment,intimacy,cooperation,andsexualinterestintherelationship.WeinerandAvery-Clark(2017)ultimatelyadvocatedsen-satefocusasameansbywhichtheclinicianisabletofocusonawholepersoninthecontextofachangingrelationship.Sen-satefocusovercomesscriptsforsexualbehaviorandexpecta-tionsthatcontributetoanxiety,frustration,avoidance,anddisinterest.Inaveryconcrete,immediatemanner,thetherapistassiststhepartnersinreturningtofundamentaltouchandexplorationofopportunitiesforintimacyanddesire.SensateFocusisaseriesofstructuredtouchinganddiscoverysuggestionsthatprovidesopportunitiesforexperiencingyourownandyourpartner’sbodiesinanon-demand,exploratorywaywith-outhavingtoreadeachother’sminds.Non-demandexplorationisdefinedastouchingforyourowninterestwithoutregardfortryingtomakesexualresponse,pleasure,enjoyment,orrelaxationhap-penforyourselforyourpartner,orpreventthemfromhappening.Touchingforyourowninterestisfurtherdefinedasfocusingonthetouchsensationsoftemperature,pressure,andtexture.Tempera-ture,pressure,andtextureareevenmorespecificallydefinedascoolorwarm,hardorsoft(firmorlight),andsmoothorrough.(Weiner&Avery-Clark,2017,p.8)Sensatefocusleadseachmemberofthecoupletoreturntotheimmediateexperienceofone’sbodyinthecontextofclosenesstoanotherperson.Dr.Mastersdescribedthetechniqueasshar-ingmuchwiththechild’snaturaltendencytoexploretheworldthroughthesenseoftouch.Healsoremarkedthattheartistdiscoversandappreciatesthebeautyandmeaningofthecrea-tiveworkthroughtheexperienceoftextureandform.Sensatefocusaffordsasecurefoundationforadditionalconstructionofanintegrativetreatmentmodel.RelationalComponentsoftheTreatmentModelTheoriginalmodelofMastersandJohnsonInstituteinvolvedintensivetreatmentinanidealsituation,removedfromthedemandsandconflictsofdailylifeathome.Asthecoupleplacedthemselvesinsocialisolationandfolloweddailysug-gestionstoincreasecloseness,connection,communication,andintimacy,theroadblocksthatinterferedwithsexualdesirewouldbecomeobvious.Directiveformsofpsychotherapywereusedto“neutralize”theseroadblocks,andthecouple’snewfoundlevelsofintimacyelevatedtheirsexualdesire.MastersandJohnsonconcludedthattherewasnosuchthingasanuninvolvedpartnerandmaintainedtheirtreatmentfocusontherelationship.Acommoncoupleissueinfluencingsexualdesireisexplicitandimplicitcontracts.Forexample,atraditionalcouplemightmakeanimplicitcontractthatthemanwillbetheprovider,thewomanthehomemaker.Ifeitherfailstoholduptheirendofthebargain,sexualdesirecanbeaffected.Manyofthesecontractsaredoomedfromthestart,sincesuchrolesmaycontaininher-entcontradictions.Apartnermightexpectthespousetobeasuccessfulsurgeon,yetalsowantanengagedandequalpartnertoassistinraisingthechildren.Whenthespousecannotdoboth,thepartnerbecomesfrustratedandmaylosesexualdesire.Inotherheterosexualcouples,whenawomanearnsmoremoneythanherhusband,themanmayfeelthreatened,insecure,andlosesexualinterest.Multiplerelationalfactorsmayinfluenceattractionanddesiresuchasthepartners’responsiveness,theintimacyandclosenesstheycreated,anddistractionssuchaswork,parenting,andhomemaking.MastersandJohnsoninsistedontheintensivetreatmentformattoconstructa“honeymoon,”withtimeandspacetobeclose,repairrelationshipissues,andenjoyintimacy.Psychoeducationandauthoritativepronouncementdisruptedoldbehaviorpatterns,creatingopportunitiesforlearningnewskills.Therewaspressuretocarryoutratherthanavoidspecifichome-workthatcouldtakehourseachday.Thedemandcharacteristicsandexpectanciesengenderedbytheintensivetreatmentformatfacilitatedovercomingtheroadblocksthatinterferedwithnatu-ralfunctionssuchassexualdesire.Thisfocusontherelationshiphaslimitationsandshortcom-ings,sincemanyroadblockscanexistforyearsinanindividualwhichmaypredatethecurrentrelationshipinwhichadesiredisorderismanifested.Hormonalinsufficiency,certainmedi-cations,andotherphysicalconditionscancauseapersontohavegenerallylowinitiatorybehaviorandlowarousal.Butpresentthisindividualwithanewpartner,ordisinhibithimorherwithsmallamountsofalcohol,thentheremaybeheigh-tenedinterestandpotentialforsexualrelations.Thus,disposi-tionalandsituationalfactorscanaffectdesire.Ifanindividualmanhasbeenenmeshedwithmother,sexuallyabused,ordevelopedbodydysmorphiaoranyotherinjurytosexualunfolding,theremaybeemergenceofhypoactivesexualdesire.Therefore,treatmentofinhibitedsexualdesiremustvaryrelativetoitscontributingfactors,usingdifferentinter-ventionstoachievesuccessfultreatment.230TheFamilyJournal:CounselingandTherapyforCouplesandFamilies26(2)

Awomanexperiencingdyspareunia,vaginismus,anorgas-mia,ormenopausalhormonalchangesmayfinddesiredecreas-ingprecipitously.Womenwithahistoryofsexualassaultcandiscoverthatincertainsituationssuchasdating,desirecanincreaseanddecreaseunpredictably.Inaddition,sinceindividualsoftenchoosepartnerswhohavecomplementaryorcompoundingissues,thecoupletogethercancreateamorecomplicatedproblem.Whenonepersonsaysnotosex,theothermayfeelunlovedorrejected.Thecouplethenmanifestsmaritaldistressandconflictinotherareasoftheirrelationship.Thisstartsadominoeffect:aseriesofdeleteriousinfluencesonlevelsofsexualdesireintherela-tionship.Bothpartnersmaylabelthepersonmostavoidantashyposexual.Theotherpartnerfeelsundesirableandfrequentlyreactsbyincreasinghisorherdemandforsexualinteraction.Thiselevatedlevelofsexualdemandincreasesperformanceanxietyintheinhibitedpartnerandmayleadtosexualdysfunc-tion,whichfurtherlowersdesireTable1.Moredominosfalliftheindividualwithlowdesireattri-butesthelackofdesireto“fallingoutoflove.”Feelingsoflowself-esteem,insecurity,guilt,andothernegativeemotions,suchasdepression,follow.Addthesideeffectsproducedbyaserotoninreuptakeinhibitortotreatthedepression,whichcanfunctionasthe“icingonthecake”forserioussexualandrela-tionshipdamage.Themostfrequentrelationalissuecontributingtolowsex-ualdesireisignorance.Weconsiderthelackofknowledgeaboutsexandphysicalintimacy,aswellascommunicationandproblem-solving,apublichealthcrisis;whilethereisalotofmediaattentiontosexuality,fewpersonsknowadequatetech-niquesformutuallypleasurablelovemaking.Thiscanbemoredifficultwithrepetition,boredom,lackofcreativity,fatigue,andamyriadofdemandsofdailylife.Frequently,wehearaboutacompulsivelydriven,mechanicalinteractionfocusedonorgasm,ejaculation,andtensionrelease,whereinintimacy,connection,tenderness,andaffectionarelimited.Thewidespreadavailabilityofpornography,withimagesofsexactsthatrewardsize,stayingpower,anddehumanizingtechniques,hasaddedtothecrisis,sincemanypeople“learn”aboutsexualitythroughtheseimages.Youngergenerationsareshowingatendencytobeevenmoremechanical,lessaffec-tional,andunresponsivetotouch.Thisproblemiscomplicatedwhenanindividualischild-likeandnever“growsup”toformacoherentcohesiveembodiedsenseofself.Insuchinstances,heorshecanfeelobjectified,depersonalized,andnumbnesswhentouched.Theirpersonalityisoftenfocuseduponanticipatingothers’reactionsandwishingnottodispleaseothers.Focusingexcessivelyuponpleasingone’spartnerleadsto“spectatoring,”performancepressure,andavoidanceoranxiety.Anotherfactorcontributingtolowsexualdesireistheinabilitytoexpressemotionstothepartnersuchashurt,frus-tration,oranger.Sometimesthepartnersdonothavethetools,resolutionskills,ortrainingtodealwithdisagreements.Apart-nerunabletofeel,label,orexpressemotionsmayinsteadrelyonsextofeelloved,placingextraordinarydemandsontheotherpartner.Passiveandactiveexpressionsofangercanslowlyincreaseorbeprojectedontothepartnerfromtheunfin-ishedbusinessofchildhood.Unexpressedorunacknowledgedfeelingsmaintainastran-gleholdonintimacy,eventuallychokingthespontaneityandlifeoutofeventhemostoriginallyvibrantrelationship.Insuchinstances,triangulationoccurs(cf.Bowen,1978).Ongoingconflictrequiresthetriangulationofathirdobjectoractivitytobindthetroubledrelationship.Preoccupationwithmaterialpossessions,workorsuccess,parenting,andespeciallyaddic-tivesubstancesorbehaviorsenablethecoupletostaytogether:distant,detached,andresentful.Onepartnerassumestheroleof“hero”whiletheothersuffersasthe“martyr.”Couplesareabletogrow,negotiateboundaries,resolveconflict,andcreatealternatives.Whatcannotbespokenstiflesratherthanseedsgrowth.Suchdifficultiesstealtheenthusiasmandcuriosityrequiredtomaintainsexualdesire.Forthesereasons,maritalandrelationaltherapiesthatincludecommunication,problem-solving,andconflictresolutionarealmostalwaysintegratedintothesextherapy.Somerelationshipinterventionsfocusonfacilitatingdiffer-entiationfromthefamilyoforigin,individuation,andtolerancefortheothernessofone’spartner.Stuckpointsindevelopmentduetoneglect,abuse,trauma,andadversechildeventsimpedethecapacityforgenuineintimacyandposeroadblocksintheemergenceofhealthysexualdesire.Individualpsychotherapyon“deeper”issues”isusedtoteachdissociativeindividualstobepresentintheirownbodyandaccentuatethesensesinvolvedinattemptingsensatefocuswiththepartner.Oftenfearoranxietytriggeredbycloseness,intimacy,ortouchcanresultinanumb-ingresponse.Exposure-basedtherapiesandmeditationcanaddressemotionalreactivityandaffordbiobehavioralhealing.Afinalmajorfactorcontributingtolowdesireisthereduc-tionorabsenceofcourtingbehavioroncemarried.Acouplefailstogiveahighprioritytohavingfun,playing,orbeingromanticoncetheyareestablishedinmarriage.Lifecanbecomeredundantandtaskdriven.Theyforget,orneverdis-cover,howtobeplayful,spontaneous,andenjoynongoalinter-actions.TheirsexualexpressionmirrorstheirserioushardworkinglifestylesandbecomesroutineororgasmfocusedTable1.DominoEffectsinSexualDesireDisorder.Malelowdesireduetohypogonadism,hormonalinsufficiencyFemalehistoryofassault,trauma,andlowself-esteemDepressionandwithdrawalSideeffectsofSelectiveSerotoninReuptakeInhibitorsLowfrequencyofinitiationFeelingundesiredbypartnerOnepartnerlabelstheotherasinhibitedPartnerescalatesdesiresPerformancepressureemergesSexualdysfunctionsNoorgasmFrustrationandangerRelationshipconflictsSexualdissatisfaction,relationshipdissatisfactionSexlessrelationshipSchwartzandSouthern231

ontensionrelief.Perfectionismcanalsoleadtotheroadblockofgoalorientation.Unfortunately,theharderoneworksatsex,thelessspontaneous,playful,andenjoyableitultimatelyis.Althoughimmediatefactorscontributetomaintaininglowdesire,asKaplan(1974)noted,“deeper”issuesarefrequentlyatthecoreofdesireandarousalproblems.WhileMastersandJohnsonfocusedontherelationship,eachpart-nermaybring“baggage”tothepairbondinterferingwiththecapacityforintimacyandblockingthedevelopmentofsexualsatisfaction.Bondingdisordersoriginateinthedevel-opingattachmentsystemwithintheindividualthatissub-sequentlyexpressedintherelationship.IndividualComponentsoftheTreatmentModelMateselection,asdrivenbyattachmenttheory,wouldoftenfindtheavoidantpersonpairingwithapartnerwithpreoccu-piedattachment.Thiscouplingestablishesamerger–seekerrelationshipinwhichthesexdriveishighforthemergerandlowfortheseeker.Thecouplepresentswiththeseekerlabeledashavinglowsexualdesire,withsubsequentdamagingdominoeffectstotherelationship,whentheactualproblemistheircomplementaryattachmentpatterns.Ifeitherhadchosenapartnerwithsecureattachment,heorshemighthaveavoidedsexualdifficulties.Thefocusoftherapeuticinterventioninthesecaseswouldbeonindividualissues,perhapsconcurrentwithcoupletherapyorgrouptherapyapproaches.OurworkondeeperissueshasfocusedonshorterterminterventionstomoveindividualstowardwhatMainandHesse(1990)definedas“earnedsecureattachment,”whichreferstorepairinginsecureattachment.Table2liststhecomponentsofourworktosupportsecureattachmentandprogressiontowardintimacy(M.F.Schwartz&Southern,2017)Table2.Thetreatmentconsistsofhelpingtheindividualrevisittheirmemoryofsequentialdevelopmentalexperiences….becomemoreawareofhisorherimmediatementalstate,learningtoaccuratelymark,label,andunderstandaffectivestatesandcognitivestatus,suchasmaladaptivebeliefsandschemas,becomingsensitizedtothelimitationsofknowledgeandbeliefs,learningtoidentifystatesofmind,andbecomingabletomentalizeaboutothers’stateofmindandaboutthetransferenceintherapy.(Brown&Elliot,2016,p.323)Theultimateaimisareappraisaloftheirlifeexperiencesandreconsiderationoftheirfixedbeliefsandconclusionsaboutself,others,andtheircapacitiestomasterandresolveprob-lems.Coreschemasrelatedtotrust,safety,power,control,andintimacyarereconsideredandbecomemorerationallybasedintheiradultworld,asopposedtofrozen,fixedbeliefsbasedonpasttraumasoradversedevelopmentalevents.Atthecoreofone’scapacitytobondareself-empathy,thecapacitytobealone,andself-care.Intheabsenceofvalidatingcaretakers,thedevelopmentallyimpairedindividualdoesnotinternalizeacaringrelationshipwithself.Achildwhoisrejectedorabandonedmaydevelopnegativecoreschemasorbeliefsaboutself,whichorganizewaysofrelatingtoothers.L.A.Sroufe(2016,p.6)reportedthatahistoryofmaltreatmentasachild,inalongitudinalfollow-upof170childrenfrombirthofadulthood,“almostneverhasapositiveoutcome.”Theindividualattemptstocre-atesafetyandconsistencyinmaladaptiveways,suchasfindingotherswhoneedtakingcareof,tocreateanillusionofsafetyandcontrol.Sroufealsofoundthatthelong-termresultofearlydisorganizedattachmentpatternsleftindividualsvulnerabletofragmentationordissociation.Suchfragmentationleadstothe“addictivepersonality”orinternallyfeltemptinessinwhichtheindividualneverquitefeelsconnectedorsafe.Thecriticalfeatureofrecoveryislearningtoexperienceotherpeopleasareliablesourceofcomfortandsafety.Todothis,weintegratetrauma-resolutiontherapiesandgriefworkintotheprocess,withafocusonchallenginginappropriatefamilyloyalties,fixedbeliefs,orshame-basedfamilyrules.Astheclientexperiencesgreaterself-compassionandresolvespast“unfinishedbusiness,”theyarelesslikelytoprojecttheirinternalconflictsontotheirpartnerandusesextofeelsafeandconnected.Repairingvandalizedlovemapsrequiresrevisitingthecriticalexperienceandreactivatingtheaffectinthesafetyandcontainmentofthetherapist’soffice,allowingforrecon-structionandrevisionofcoreschemas.Ourexperienceisthatfantasyandsexualarousalpatternsshiftastheclientestab-lishessecureattachmentandbecomeschanneledtowardtouch,closeness,andaffection.Insummary,thetherapybecomesavehicletocatalyzestructuraldeficitsfromchildhoodaswellasindividualrela-tionalissuesblockingintimacy,bonding,arousal,desire,andpassion.Beingnudewithapartnermindfullyand“inone’sbody”createsanxietyandfear,whichblocksdesire.MastersandJohnsoningeniouslyusedanintensiveformatof2weeksofdailytreatment,socialisolation,tofosterpositiveexpectations,learnnewbehaviors,andenjoyfledglingintimacy.Theinno-vationsthathaveunfoldedoverthepast30yearsintraumaresolutionandgriefworkallowafocusonindividualblockstointimacywithinthecontextofthecouples’work.Weoftendooneindividualsession,withthepartnerobserving,andonesessionofcouple’stherapyeachdayfor2weeks.Rapidchangeandincreasedcompassionforselfandotherscreateevengreatermotivationforhealing.Individualtreatmentcompo-nentsfreeeachpartnertobenefitfromcouple’stherapyandTable2.ConditionsforSecureAttachment.1.Senseoffeltsafety/protectionfromdangerandthreats2.Senseofbeingseenandknown(attachment)3.Unconditionalloveandsupport4.Experienceoffeltcomfortwithsoothingandreassurance5.Asenseofbeingvalued,delightintheindividual6.Asenseofpotentialfornewpossibilitiesforgrowthandbecomingoneself7.Self-compassion,self-soothing,andself-efficacy8.Venturingforthtowarddifferentiationandindividuation9.Increasingcapacityforbondingandintimacy232TheFamilyJournal:CounselingandTherapyforCouplesandFamilies26(2)

ultimatelyparticipatefreelyintheintimatejourneytosexualfulfillment.AnIntegrativeModelRecentdevelopmentsinpsychotherapyintegrationandsys-temictherapyaffordastructurefororganizingcomponentsoftreatmentofsexualdesiredisorders,basedupontheoriginalmodelofMastersandJohnsonInstituteandincorporatingcon-temporaryviewsoncultural,contextual,andindividualfactors.Psychotherapyintegrationinvolvessystematicortechnicaleclecticism,implementationofcommonfactorsforbeneficialchange,andassimilationofcomponentsfromvarioustheore-ticalmodelsintoapromisinginnovation.Whiletherearecom-monfactorsthataccountforeffectivetherapy,therearealsoempiricallysupportedtreatmentsknowntoproducetargetedoutcomesinevidence-basedpractice.Systemictherapyorigi-natedinmarriageandfamilytherapybutincorporateslevelsofinfluencefromcellularbiology,throughindividualandcouplefactors,tocommunityandsocietalinfluences.Integrativesystemictherapy(IST;Pinsofetal.,2018)grewoutoftheintegrativeproblem-centeredmetaframeworksapproach(Breunlin,Pinsof,Russell,&Lebow,2011;Breunlin,Schwartz,&MacKare-Karrer,1997).ISTaffordsacompre-hensive,integrative,multisystemic,andempiricallyinformedprocessforhypothesizing,planning,andimplementingsolu-tionsequenceswithinthecontextsofproblemsequencesofinteractionsandconstraintsthatarisetorestrictchange.TheISTapproachbuildsoncollaboration,therapeuticalli-ance,strengths,andguidelines.Thehypothesizingmetaframe-worksordomainsofhumanfunctioningconsistindevelopment,organization,mind,biology,spirituality,culture,andgender(Pinsofetal.,2018,pp.99–142).Theplanningmetaframeworksincludeaction,emotion/meaning,biobeha-vioral,familyoforigin,internalrepresentation,andself(pp.143–192).Aplanningmatrix(p.145)incorporatescon-textsoftherapyandguidelinesthatmovefromdirectactioninfamilysystemstoincreasinglycomplexinterventionsinvolv-ingcoupledynamicsandintrapsychicmechanisms.Direct,action-orientedinterventionsinvolvingatleasttwomembersofafamily(e.g.,thecouple)arefavoredtoreplaceoldproblemsequenceswithnewsolutionsequences.However,constraints,frequentlybasedonfamilyoforiginissuesandlifetrauma,mayshiftthefocustoindividualsystemsincludingbiology,mind,andselfhood.Sexualdesiredisordersreflectcultureandgenderissuesthatrequireattentiontoreleaseconstraintsandmovetowarddirecttechniquesforrekindlingdesire.Thefirstofthesevenmetaframeworksisorganization,anessential,multilevelconstructinIST.Organizationcorre-spondsinmanywayswithMinuchin’s(1974)structural,cross-generationalstructuralfamilytherapymodel.Keynoteintheorganizationmetaframeworkareboundaries,whichvaryonacontinuumfrominclusiveorjoinedtoexclusiveordetached.Leadership,thesecondofthedimensionsoforgani-zation,referstotheallocationofresources,rights,andrespon-sibilitiesorfunctions;mediationofconflictingneeds,goals,andpreferences;andmaintenanceofbalance,fairness,andequity.Hypotheseswithintheorganizationmetaframeworktypicallylookatrelationships.However,boundariesandlead-ershipapplytoalllevelsofsystemsfromcellsinthehumanbodytomovementsinasocietalcontext.Developmentisanothercentralmetaframeworkimplicitinexaminingchangeovertime.Macrotransitionsoverthefamilylifecycleaddressdevelopmentofthefamilysystembutaffectindividualswithinthegroup.Microtransitions,evenatthebiopsychosocialleveloftheindividual,affordopportunitiesforgrowthinpersons.Ascompetenciesemergeintheindividual,relationshipswithinfamilyandsocialsystemsareaffected.Similarly,theculturemetaframeworkaddressesindividual,family,andsocietalchange.Cultureappliestosharedidentityingroupsandaffordsvariouscontextsthroughmembership.Frequently,discussingandunderstandingthecontextsofmembership(Pinsofetal.,2018,pp.113–114)revealconflict,distress,andconstraint.Theconceptofintersectionality,occurringatthejunctionofvariousidentitiesormemberships,facilitateshypothesizingrelatedtomeaning,relevance,andsignificance.Persons,couples,andfamiliesattempttofashionagoodnessoffitfrommultiplecontextsormemberships.Thesemaycontributetostucknessastheyoperateasconstraints.Acculturationandsocialjusticeissuesapplytotheculturemetaframework.Mindisametaframeworkcentraltoanindividual-orientedtherapyinwhichcausalityislocatedwithinaperson.Inpar-ticular,depthapproachestopsychotherapyandbiologicalinterventionsframeaproblemasintrapsychicorphysiologicaltotheexclusionofhypothesesframedatotherlevels.ThereareatleastthreesubsystemsorlevelsofmindaccordingtoICT(Pinsofetal.,2018,pp.117–123).Thefirstlevelreferstonarrativeaccountsofpersonalityandlifeexperience,aswellasthoughts,emotions,andattributionsassociatedwitholdproblemsequencesandnewsolutionsequences.Thesecondlevelofmindaccountsforpartsorobjectsexperiencedwithinapersonorexpressedoutwardlythroughinteractions.Second-levelhypothesesareespeciallyhelpfulinaddressingcon-straintsincouples’work.Thethirdlevelinvolvesdeeperorcoredynamicsinpersonalityorselfhood.Distortionsrelatedtonarcissisticvulnerabilitiescanaffectthecapacitytoprocessinformation,makingdifficultyinnegotiatinginterventionsatothersystemlevelsorthroughothermetaframeworks(Pinsofetal.,2018,pp.121–122).Genderremainsakeymetaframeworkinwhichcontempo-raryissuesareassessedandunderstood.Whengenderrolesandidentitiesarenotprescribedordeclaredsomehowfixed,oppor-tunitiesforchangeandadaptationarise.Today,thelesbian,gay,bisexual,transgender,andqueer/questioningcommunitieshavecalledintoquestionwhatconstitutes“real”malenessandfemaleness.Genderisnotviewedasbinary.Infact,manyofthemetaframeworks,includinggender,donotexistaspolesoronlyacontinuum,ratheroneshouldexaminetheentirefieldorarrayinordertounderstandandrespectthelivedexperiencesofothers.FeminismmadethepersonalpoliticalandexaminedthegenderedlensofpatriarchalinstitutionssuchasSchwartzandSouthern233

psychotherapy.ISTtakesseriouslythemeaning-makingfunc-tionofgenderexplorationandrecognizesexternallyimposedconstraintsthatmaystillinhabitsystems.Thepatriarchalandheteronormativebiasesofmanyearlyformsoftherapy,includ-ingsexualitytherapy,canbeinformedandrevisedthroughanintegrative-systemicfocus.Biologywouldbethecentralmetaframeworkinneu-roscienceandmedicallyinformedinterventionsforhumanproblems.Whileitisessentialtoexaminethecyclesandsequences,theproblemsandsolutionspresentedbythebiolo-gicalfactorsofpersonsincontext,theISTmodelplacesitamongtheothermetaframeworksinordertoavoidreduction-ism.Thebiologymetaframeworkaffordsassessmentandinter-ventionregardingillnessandmedicationandinavarietyofotherdomains:wellness,mindfulness,sleephygiene,sexualhealth,andaging.Recentadvancesinunderstandingaddiction,mentalillness,brainfunctioning,hormonalinfluence,andgeneticsprovideperspectivesrelevanttounderstandingandresolvingproblems.Spiritualityasametaframeworkcouldseemotherworldlyandlessscientificorempiricalthanbiologicaladvances.Yetthereappearstobeatrendtowardexploringpersonalmean-ings,emotions,andbehaviorswithinthecontentofspirituality.Spiritualitycanbefundamentaloressentialinovercomingill-nessandrespondingtosuffering(Pinsofetal.,2018,pp.137–142).Mainstreampsychotherapymayavoidpotentialstrengthsandresourcesorfailtorecognizeconstraintsassociatedwithspiritualityandreligion.Havingusedthemetaframeworkstoassesswithinandacrosssystemiclevelstheproblemandconstraintsequences,theISTmodelnextpositsamatrixfortherapyplanning,imple-mentation,andevaluation(Pinsof,Breunlin,Russell,&Lebow,2011;Pinsofetal.,2018,p.145).Thereisanarrayofplanningmetaframeworks,incorporatingcommonfactorsinpsychotherapyintegration,tofindthebestfitforeachidenti-fiedconstraint.Eachplanningmetaframeworkcontainspoten-tiallyeffectivestrategies.Theactionplanningmetaframeworkisespeciallyhelpfulinaddressingbehavioralconstraintssuchasnotknowingwhattodoorlackingnecessaryskills.Constraintsbasedonproblemswithorganizationanddevelopmentcanbeaddressedthroughdirectaction.Thenextplanningmetaframeworkinvolvesmeaning/emotion.Whileactionaddressessequences,organiza-tion,anddevelopmentinhypothesizing,meaning/emotionplanningaddressesaspectsofculture,gender,spirituality,andsequencesofmind(Pinsofetal.,2018,p.145).Thereareplanningstrategiesthataddressthoughts,feelings,andnarratives.Someofthestrategiesorcommonfactorsinthemean-ing/emotionplanningmetaframeworkaddresscomplexmeaningsandemotions,someofwhicharerelatedtounder-lyinglossortrauma.Thebiobehavioralplanningmetaframeworkhasreceivedalotofattentionincontemporarytreatment.Someofthestrategieshavebeenviewedasprimaryoressentialwithothertherapystrategiesbeingviewedasadjunctiveordevalued.“Overmedicalization”oftherapycanresultinineffectiveortemporaryoutcomeswithrelapseorfailuretomaintaintreatmentgains.Thefollowingstrategiesfitthebiobehavioralplanningmetaframework.Thebiobehavioralplanningmetaframeworkfiguresprominentlyinbehavioralhealthcare,especiallytheemphasesonpsychopharmacolo-gicalinterventionandaddictiondetoxificationandtreat-ment.Inrecentyears,afocusonwellnessandfitnessbalancestheunderlyingillnessordiseasemodelwithhealthinitiatives.Thefamily-of-originplanningmetaframeworkenablesmeaningfulhypothesizingespeciallyforadultclients.Family-of-originproblemsoperateasconstraintsindirectinterventions.Family-of-originstrategiesincreasetherangeofoptionsforsolutionsequences.Thefamily-of-originper-spectiveinterfaceswithinternalrepresentationplanningmetaframework.Aftersomeattentiontothefamily-of-originissues,itiseasiertoaddressinternalfamilysystemsandobjects.Themind,gender,culture,anddevelopmenthypothesizingmetaframeworksarecommonlyaddressedthroughinternalrepresentationstrategies.ThisisalsothejunctureinwhichinternalsystemsandpsychodynamicsofindividualsandcouplesinformISTpractice.Theplanningmetaframeworksconcludewiththeself.Self-planningaddressesvulnerabilityandrigidityinthepersonalitythatconstrainssolution.Theself-planningmetaframeworkincreasesawarenessofthedemandsofrelationshipincludingsustainingorrepairingthetherapeuticalliance.Baseduponthepervasivenessofsexualdesiredisorders,whethermanifestedindesirediscrepanciesincoupletherapyorpresentedasanindividualproblemofhypoactivesexualdesire,anintegrativemodelbasedonISTcanbeappliedtotherapyandcoachingmodalities.TheintegrativemodeltakesintoaccountthestrengthsoftheoriginalMastersandJohnsonInstituteapproachbutupdatestheinterventionswithindividualandrelational,contextual,andculturalinsights.Thecompo-nentsoftheintegrativetreatmentofsexualdesiredisordersarepresentedinTable3.AsdepictedinTable3,integrativetreatmentinitiallyfocusesondirectinterventionwiththecouplesexualsystem.Asconstraintsareidentified,interventionsmovetothecouplerelationalsystemand/orindividualsystemsincludingorganizationofmindanddevelopmentofselfmetaframe-works.Biobehavioralinterventionsshouldbeaddressedeitherconcurrentlywithcouplesexualinterventionsorruledoutthroughacomprehensiveassessmentcompletedduringtheintakeplanningphaseoftreatment.OurintegrativemodelfortreatingsexualdesiredisordersbuildsuponthefundamentalsoftheMastersandJohnsonInsti-tuteapproachwithinitialattentiontosensatefocus.Psychoe-ducationisofferedtothecoupletohelpthemunderstandchangesindesireovertimeandtoencourageexplorationoferoticintimacy.Ifeithermemberofthecouplehasnotcom-pletedarecenthistoryandphysicalwiththeirphysician,itmaybewarranted.Medication,especiallyantidepressants,maydemandevaluation.Otherwise,thepartnerswillbeencouraged234TheFamilyJournal:CounselingandTherapyforCouplesandFamilies26(2)

toexercise,practicefitnessandrecreation,andintroducespiri-tualdisciplinessuchasmindfulnessoryoga.Shouldtherebeenmeshmentoroverinvolvementinthefamilyoforigin,individual,couple,andfamilytherapiesmaybeneededtofacilitatedifferentiation.Coupletherapymaybeindicatedforrelationshipconflictsimpingingonthesexualrelationship.Inmostcasesoftraumahistory,someintensiveindividualtherapywillbeneededtoovercomeanxietyandavoidanceassociatedwiththedemandsofintimacy.Wehavefounditbeneficialtoalternateindividualsessionsinwhichthepartnerispresent.Severalmodelsofpsychotherapypermitempathy,understanding,andinsightinthismatter.Bibliotherapyandhomeworkexercisesextendthevalueoftherapybeyondtheformalsessionsinkeepingwiththeinten-sivemodeladvancedbyMastersandJohnson(1970).ConclusionRepairingsexualdesireiscomplexandrequiresafocusondeepercapacitiesforintimacyandconnectiontoselfandoth-ers,aswellaschoiceofpartnerandsubsequentrelationaldynamics.Allofthisisinfluencedbybiochemistry,factorsshapingtheCNSstructureduringcriticalperiodsofsexualunfoldingandthemind’sdevelopmentoflovemaps.Theory,research,andpracticeinattachmentdisordersfacilitateunder-standingofconstraintsonintimacyinpairbonds.Sustainingsecureattachmentisnecessarytobenefitfullyfromsexualtherapytechniquestoenrichdesire.Therapeuticinterventionisnowmoretargetedandeffective,astheconceptualmodelhasshiftedfromsextoloving,secureattachment.Theultimategoalofsuccessfultherapyandhealthysexualfunctioningistostrengthentheindividual’scapacitytobefullypresentandavailableinasafeandtrustingrelationship.Advancesinevidence-basedandintegrativeapproachespromisetoupdateandexpandtheoriginalmodelforintensivetreatmentinnovatedatMastersandJohnsonInsti-tute.Dr.Mastersparticipatedintheextensionofthemodeltotreatsexualtrauma,sexualcompulsivity,andotherintimacy-baseddisorders.Effectiveinterventioninsexualdesiredisor-dersharkensbacktotheoriginsofpsychotherapyandsexualitytherapy.Welookforwardtopresentingsomecasesinwhichthisintegrativemodelisapplied.Table3.IntegrativeModelforTreatmentofSexualDesireDisorders.HypothesizingMFPlanningMFContextInterventionOrganizationActionEquityTeaching/coachingCoupleSensatefocusBehavioralexposureCoupleHomeworkCouplePsychoeducationCoupleGoodenoughsexaGenderActionFlexibilityPsychoeducationCoupleNewviewbTeaching/coachingCoupleOptimaleroticintimacycBiologyBiobehavioralMedicationMedicationevaluationIndividualPhysicianreferralWellnessExercise/fitnessIndividualSport/recreationCoupleOutdoorsharingDevelopmentFamilyoforiginTransitionDifferentiationFamilyCouple/familytherapyEmotionLoss/traumaCoupleEmotionfocusedtherapydMindInternalrepresentationThoughts/feelingsInhibitingvoicesCoupleVoicestherapyePartsPartsworkIndividualorcoupleInternalfamilysystemsfSchematherapygSelfDistortionsTherapeuticallianceIndividualDepthorientedtherapyRupturerepairIndividualDepthorientedtherapyProjectionCoupleImagotherapyhCoupleorindividualObjectrelationsPsychotherapyiSpiritualitySelfBalanceSpiritualdisciplineIndividualSpiritualteacherordirectorIndividualAddictionrecoveryNote.MF¼metaframeworkfromintegrativesystemictherapy.aGoodenoughsex(Metz&McCarthy,2007;forbibliotherapy,alsoseeMcCarthy&McCarthy,2013).bNewview(Tiefer,2008).cOptimaleroticintimacy(Kleinplatz,2010).dEmotionallyfocusedtherapy(Johnson,2015).eVoicestherapy(Firestone,Firestone,&Catlett,2006).fInternalfamilysystemstherapy(R.Schwartz,1995).gSchematherapy(Young,Klosko,&Weishaar,2006).hImagotherapy(Hendrix,2007).iObjectrelationspsychotherapy(Scharff,1995).SchwartzandSouthern235

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CoupleGoodEnoughSex:AnInterviewWithBarryMcCarthyStephenSouthern1BarryW.McCarthyhasmademajorcontributionstosexualityeducationandtherapy.McCarthyteachescoursesinhumansexualityandpsychologicalwell-beingattheAmericanUni-versitywherehewasrecognizedasanoutstandingprofessor.Dr.McCarthypublished20books,32chapters,and112journalarticlesfocusingonintegratingsexualityandmaritaltherapy,advancingsexualhealth,andenhancingsexualdesire.Healsocontributedtotheliteratureonsexlessmarriages,extramaritalaffairs,andsexualabuse.HecoauthoredwithEmilyMcCarthyseveralaward-winningself-helpbooksonsexualhealthtopics,especiallyforcouplesneedingsupportinsustainingsexualdesire.Twooftheirtop-rankedbookswereRekindlingDesire(McCarthy&McCarthy,2014)andDiscoveringYourCoupleSexualStyle(McCarthy&McCarthy,2009).McCarthyreceivedfromtheSocietyforSexTherapyandResearchthe2016MastersandJohnsonawardforlifetimecontributionstothesexualityfield.Dr.McCarthyreceivedthediplomateinclinicalpsychologyfromtheBoardofProfes-sionalPsychology.Hepracticedindividual,couple,andsextherapyasapsychologistanddiplomateinsextherapy(AASECT)inWashington,DC.FollowingthesageadviceofhiscolleagueMichaelMetz,Dr.McCarthyretiredfrompracticetodevotehimselftowrit-ing,presentingprofessionalworkshops,andenjoyinghisfam-ily.MetzandMcCarthy(2007,2012)collaboratedinthedevelopmentofthe“Good-EnoughSex”(GES)model,aninte-grationofpositivepsychology,genderequity,andrelapsepre-vention.Arecenttextbook(Metz,Epstein,&McCarthy,2018)summarizedcognitivebehavioralinterventionsforsexualdysfunction.Dr.McCarthytranslatedresearchfindingsintousefulrec-ommendationsforenjoyingsexualfulfillment.InSexMadeSimple,McCarthy(2015)sharedhisinsightswithagroupofcliniciansingeneralmentalhealthpractice.Sexualityisasignificant,yetneglected,areaofcoupletherapy.WearefortunatetolearndirectlyfromBarryMcCarthyhisperspectivesonsexuality.Inaddition,thefollowinginterviewrevealedpersonalqualitiesinvestedincollaborationwithEmilyMcCarthy,hispartnerinlife,andMichaelMetz,hisfriendwhofinallylosthisbattlewithcancer.TheInterviewThefollowinginterviewwasconductedbytelephoneonMarch15,2018,followingaseriesofe-mailsinwhichIwasfact-checkingsomeinformationforabriefbiography.Wecontin-uedthediscussionbye-mail,andDr.McCarthywaskindenoughtosubmitamanuscript,completedwithLisaRoss,forTheFamilyJournal.Thepurposeoftheinterviewwastosecurehisperspectivesondevelopmentsincontemporarysexualityandsexualityther-apy.Inparticular,IwasinterestedinMcCarthy’sworkontreatingsexualdesiredisordersandenhancingsexualhealth.Dr.McCarthyemphasizedtheimportanceofrelapsepreven-tionandrealisticexpectationsfortherelationshipinsexualsatisfaction.Southern:Dr.McCarthy,thankyousomuchforagreeingtothisinterview.Ihavefollowedyourworkforyearsanduseyourbooksonsexualdesireinmypractice.Aftercompletingabiographi-calsketchonyoufortheEncyclopediaofCoupleandFamilyTherapy,Ithoughtitwouldbegreattorecordsomeofyourper-spectivesonsexualitytherapyforourreader-ship.How’severythinggoingforyou?McCarthy:I’msemiretiredbutstillveryactivewithwritingandusuallyIgotoAU(AmericanUniversity)onWednesdaytoteach.Andgrandparenting,soit’safairlybusyschedule.Southern:Soundslikeit.I’mjustgladwehavealittlesunhereinEvanston.McCarthy:Yes,Chicago’sagreattown,IgrewupinChi-cago.SpringthroughfallinChicagoarewon-derful.Toolongandcoldawinter.1CenterforAppliedPsychologicalandFamilyStudies,NorthwesternUniver-sity,Evanston,IL,USACorrespondingAuthor:StephenSouthern,815BOceanViewBlvd.,PacificGrove,CA93950,USA.Email:[email protected]:CounselingandTherapyforCouplesandFamilies2019,Vol.27(1)5-10ªTheAuthor(s)2018Articlereuseguidelines:sagepub.com/journals-permissionsDOI:10.1177/1066480718804792journals.sagepub.com/home/tfj

Southern:Right,Iappreciatethechange.IknowIsentalotofstuff,andIdon’tknowwhichtopicsyoumightliketoaddress,butmygoalwiththisistoinformourmembership.InTheFamilyJournal,we’vealwaysdoneinterviews,andthey’reverywellreceived.Wehaveagoodcirculation,espe-ciallythroughtheSAGEfull-textdatabaseandonlinesearchengines.So,itgivesanopportunityforyoutomakesomestatementsthatprovideafoundationforpeopleunderstandingyourwork.Youmaydosomemodelingandofferguidancetoourreadersintermsofpursuingacareerinvolvingsexualitytherapy.Icangothroughthelistofquestions,orifyouwouldjustliketosharesomethingswithmeingettingstarted,whateverisyourpreference.McCarthy:I’llbegladtospeakandifIamnotontarget,youbringmebackin.WhenIthinkaboutmycareer,thethingthatstrikesmethemostisbeingverylucky.I’mthefirstoneinmyfamilytoevergraduatecollegeandIwenttocollegeatLoyolaUniversityinChicago.Therewasthisnewassistantprofessorwhosaid,“Psychology’sagrowingnewfield,youshouldbeinterestedinit;itgivesyouallkindsofopportunities.”AndthenIdidmyPhDatSouthernIllinoisUniver-sityinCarbondale,andIreceiveditin1969.In1970,MastersandJohnsonwroteHumanSexualInade-quacy,whichreallychangedtheworld.AndIthinkofthebeginningofsextherapy,modernsextherapy,is1970,thepublicationofHumanSexualInadequacy.IwenttoteachatAmericanUniversity,andAUhadthis,whatwascalledan“intersession,”inwhichyoucouldteachacoursethathadneverbeentaughtbeforeandyouwerepaid$1,200.Forayoungpsychologistthatwasalotofmoney,andIactuallytaughtacourseinhumansexualbehavior.Thestudentsabso-lutelylovedit.Andbackthen,believeitornot,therewasnotextbookonhumansexuality.So…itreallywasaninterestingkindofbackwayofgettingintothefield.Thenin1971,LeeDoyle,whowasthefirstfemaleclinicianthatMastersandJohnsonhadtrained,shewasbasedinDallasandcametoWashingtonfourtimesduringtheyear—forlongweekends—todotrainingwithabout30peopleinsextherapy.Probablythethingthathadthemostimpactonmylifeandcareerwasin2000,MikeMetzsentmeane-mail(IknewhimfromtheSSTARorganization).Hesaid,“Idon’tknowwhattodo,Ireallywanttowriteabookaboutprematureejaculation,butI’vebeenrejectedseveraltimes.”So,Isaid,“Doyouwanttowriteaprofessionalbookthat’slikelytoselllessthan1,000copies,ordoyouwanttowriteabookforthepublic?”thatcouldmakesomedifference.Hesaid,“Let’stryalaypublicbook.”So,thatwasthefirstofthefourbookswewrotetogether.OneofthemoreinterestingphenomenaisthatIthoughtthefirstone(CopingWithPrematureEjaculation),whichsoldthemostcopies,about30,000,wasourleasthelpfulbook.Andourmosthelpfulbookwasthelastone,EnduringDesire,abouthowtokeepdesirealiveinongoingrelationships.ItwonanAASECTaward,butitsoldlessthan3,000copies.So,Ithoughtthatwasaninterestingparadox.Southern:I’dliketolearnmoreaboutyourcollaborationwithMikeMetz.McCarthy:Oneofthethingsthatwedid,itwasactuallymuchmorehethanme,wasthisconceptof“goodenough”sex.Thattheessenceofsexual-ityisnotindividualsexualperformance,itisacouplesharingpleasurethathasmultipleroles,meanings,andoutcomes.Michaelhadcancerandabonemarrowtransplant.Sixyearsago,hedevelopedbileductcancer,fromwhichhedied(in2012).Beforehedied,hesaid:“There’stwothingsIwantyoutodoformeasI’mdying.AndoneisthatIwantyoutopromisemeyou’regoingtoretirefromclinicalpractice,”whichIdidin2012,soIcouldhaveabetterqualityoflife,writemore,anddomoreworkshops.Andsecond,hesaid,“Let’sgetthisbookpublished.”HisbookwaspublishedinNovember2017,Cog-nitiveBehaviorTherapyforSexualDysfunction,whichisatributetohisprofessionallegacy.Southern:Oh,that’swonderful.McCarthy:So,Ithinkofmyselfaskindoflucky.It’salonganswertoashortquestion.Southern:No,that’sexcellent.Thankyou.IreallywantedtoknowalotmoreaboutyourrelationshipwithMikeMetz.Imethim,whenIwentuptoMin-nesotatherewithEliColemanandhiscrewafewtimes,butIdidn’tknowMetzverywell.McCarthy:YouknowIalwaysthoughtofMichaelasboththesymbolofthebestinsextherapybutalsothebestinbeingahumanbeing.Hewasnotatallaself-promotingguy,buthedidveryseriousworkandthoughtverycarefullyaboutit.AndIthinkofhimasthepersonwhoputtogetherverydisparatefields:thefieldofcoupletherapy,thefieldofsextherapy,andthefieldofspiri-tuality.Ithinkthatisauniquecontribution.Thewholeideaof“goodenoughsex”isthisideaofthinkingaboutsexualitythroughthelensofitsrolesandmeaningsinpeople’slives.Whenyoudogoodtherapywithpeoplearoundsexissues,you’vegotfiveclientsintheroom.You’vegoteachperson,that’sthefirsttwo;you’vegotthegeneralrelationship,thethirdclient;thefourthclientistheirsexualrelationship;andprobablythetoughestclientistheirhistoryasanemotional-sexualcouple.Becausepeopledon’tgototherapywhenthey6TheFamilyJournal:CounselingandTherapyforCouplesandFamilies27(1)

shouldgo,whenit’sanacuteproblem,theygowhenit’sachronic,whentheproblemisbecomingmoresevere.ButMichaelwasalwaysaveryoptimisticguy,intermsofpeople’sabilitytogrowandtochange.AndIthinkhewasawonderfulmodelofthat.Idon’tknowifthisisappropriateornot,butI’mgoingtotellyou.Youknowwhenhediscoveredthathewasn’tgoingtobeatthislastcancer,medicallyhehadaterribledyingprocess.Butpsychologicallyandrelationally,hehadawonderfuldyingprocess.Hesaidtohiswife—hewasveryveryfondofher,thiswasbothoftheirsecondmarria-ges:“Youknow,firstoff,ourchildrenaregrown;youneedtosellthehouseinthesuburbsandmoveintodowntownMin-neapolis.”Andshesaid,“I’lldothatafteryoudie,”andhesaid,“No,no,I’mgonnadieinthatcondo.”Southern:Wow,wow.McCarthy:Andthenhealsosaidtoher:“Youknowmar-riagehasreallybeengoodforyou,it’sbeengoodforus.AndIhopeyougetremarriedagain.Ireallythinkmarriageworksverywell.Whenitworkswell,andit’sworkedwellforus.”Andthenthethirdthinghesaidtoherwas:“You’vechangedyourcareer,sothatyoucouldgethealthinsuranceasI’mdealingwithmycancer.”(Afterhisfirstcancer,hehadaboutthreeorfourrelapses.)Hesaid,“Youbecameacorporatelawyer,whichyoureallydidn’twant,andyouhadbeenalitigator.Whatyoureallywanttodoisbeajudge.Whydon’tyouretireandbecomeajudge.”?Whichshedid.Lawyersandjudgesareverydifferentthanpsy-chologists,theyhavethesebigrituals.Whenshewassworninasajudge,oneofthepeoplewhocametoherswearinginwasanoldfriendfromlawschoolwhosewifehadjustdied…Andtheyhavenowremarried.Southern:Mygoodness.Whatagift!McCarthy:It’saverynicestory.Southern:Howaboutthat!McCarthy:It’satruestoryandaverynicestory.Italsodemonstratedwhohewas.Southern:DoyouthinkitwouldbeappropriateorwoulditbeokayifIcouldsomehowsharethatstoryinthisinterview?McCarthy:Yeah,sure.Ithinkthenotionthatsays,“Youwanttoleadagoodlife.Andpartofleadingagoodlifeishavingagooddeath.”Andpartofhavingagooddeathissayingtopeople,“Here’smylegacy,andhere’smyhopesanddreamsforyou.”Southern:ThankyouDoc.McCarthy:Ipracticedfor42yearsandIreallycaredverymuchaboutclinicalpracticeandtryingtobehelpfultopeople,butclinicalpracticeisverydraining.AndsinceI’veretired,I’vedonemoreworkshopsandmorewritingthanI’veeverdoneinmylife.Hopefully,it’shadsomepositiveimpactonthefield.Southern:Oh.Verymuchso.Verymuchso.Wellthankyouforthat,that’sverymeaningfulsharing.Itsaysalotaboutone’slifecareer.Alongthatline,Iwantedtoinquireaboutwhatitisliketohavewrittensomeofthosegreatbookswithyourwife,Emily.Ifyouwouldn’tmindsharingsomeofyourcollaboration,Ithinkthatagainwouldbeveryinterestingtoourreadersandwouldmakeamarkonthefield.McCarthy:Oneofthemostinterestingthingsaboutmeasawriteristhatit’saverybigchallengebecauseIhavethisperceptualmotorlearningdisability,soIcannottypeorusecomputersverywell.Andastheworldmovesmoreonline,itbecomesmuchmoreofanissue.Whenwewrotethefirstbook,SexualAwareness—thefiftheditionnowout—Emilywasveryinvolvedinitfromthebegin-ning.It’snotjustdoingtypingthings,butalso,youknow,herbackgroundisspeechtherapythathelpedthewriting.Shegaveakindofhumanisticapproachtomyoftenverydrywriting.Andrepetitivewriting,frankly.Icertainlydoreinforcethings,probablyoverly.Ithinkitwasagoodbalance,anditwasfun.She’salwaysgivengreatfeedbacklike“Thisisofftrack;thisistoomuchjargon;thisistoolong;you’renotreallytalkingaboutrealpeopleandrealissues.”OneofthethingsthatEmilyandIconstantlytalkabout,andMichaelandItalkedabout,isthatthereisaninterestingthingaboutbeinginthesexfield,inthatyou’reoftenaddressingtwoverydifferentaudiences.AndIthinkthat’sthechallengeofmodernsextherapyin2018.Itishowyoutalktothetraditionalpeople,youknowpeoplewhovaluetraditionalmarriages,tra-ditionalmonogamy,andtrytokeepsexhealthyandalivewithinthatframework,andatthesametime,youwanttorespectdiversity—andIthinkthesexfieldhasdonebetteratthisthananybodyelse—howyouhonorpeoplewhoarenottraditional.Howyouhonornotjustsexualorientationorgenderpresentationbutotherswhochooseconsensualnonmonogamy,orpeoplewhovaluesexualfriendshipsratherthanlifecom-mitments.Anditisn’tuptome.ThewayIdescribeit,itisn’ttherightorwrongapproach,itis:“Whatistherightfitforthatpersonandtheirrelationship?”AndIdon’tknowwhoselinethisis(IthinkIusedtosayitwasEstherPerel’sline,butshesaysitisn’t,soI’mnotsurewhoIstoleitfrom)butIlovethelinethat“Sexually,onesizeneverfitsall.”So,whenIthinkofthesethingsthatEmilywasextremelyhelpfultome,becausewehave,inmostways,atraditionalapproachtoourlifeorganization.Inthat,wemar-riedattheexactageofourcohort,Iwas23andshewas21.Shehelpedmewithmyconceptsandwritingaboutmaintainingavitalsatisfyingsexualityinongoingrelationships.Andagain,Michael’sbestbookinmyhumbleopinionforthelaypublicwasEnduringDesirebecauseitdoesreallylayoutthoseSouthern7

challengesandhowpeoplecanmeetthosechallenges.Andsooftentheydon’t.Southern:That’sgood.I’mworkingwithMarkSchwartznow,we’retryingtoworkonamanuscriptaboutdealingwithsexualdesirefromtheoriginalMastersandJohnsonstandpointbuttakingintoaccountthecontemporarydevelopments.McCarthy:Ithinkthatthekeyissuenowintermsofsexualdesireinongoingrelationshipsisthisissueabouthowyouintegrateintimacyanderoticismintothesamerelationship.What’stherightbal-anceforthatcouple?Ireallybuythisnewideathatthecorethinginsexualityisdesire,plea-sure,eroticism,andsatisfaction.Andthatdesire’sacoreissue.Andthatsatisfactionisthesecond.AndthenIthinkthatoneofthebadthingsthat’sgoingoninthecultureisthatthere’sbeenarealemphasisonroleenact-mentarousalasthekeytoeroticism.LikewhenIaskmycollegestudents“Howdoyoukeepdesirealiveinongoingrelationships?”theyalwaysputtheirhandsupandtheysay,“It’ssharingeroticfantasiesandwatchingporntogether.”Andthere’snoscienceatallthatIknowofthatsupportsthat.Ithinkthatformostpeople,whatreallykeepsthemgoingasasexualcoupleisthiscombinationofpartnerinteractionarou-salandself-entrancementarousal.Anotherbigthingformostcouples,trueforbothpartneredandmarriedcouplesandles-biancouples,too.Itmightnotbetrueofgaymalecouples,but…Ithinktheidea,andSueJohnsonbuysthis,andsodoesGottman,isthatformostpeople,thebestrelationalstyleisthe“bestfriend”relationship.AndSuehasthislinethateverybodyloves,bothprofessionalsandclients,andthat’sthatyoutrustthatyourpartnerhasyourback.Southern:Right.McCarthy:ButwhatIemphasizeisthatformostcouples,thebestfriendsexualstyleisnottherightsexualstyle.Thatformostcouples,thecomplementarycouplesexualstyleismuchbetterfitthan“bestfriend.”Idon’tthinkthatthat’sdiscussedeitherinmarriageclassesorinsexclasses.AndIthinkthemarriagepeopleandthesexpeopleneedtotalktoeachotherandcomeupwithsomethingmoreintegrativeandmorecongruent.That’soneofthebestwaysofunderstandingwhatisgoingon.Healthyrelationships,especiallyhealthymarriages,aresatisfyingfirst,securesecond,andthattheroleofsexisthatenergizing15–20%role.Asyoucantell,Ihavealotofstrongideasaboutthings.Southern:That’sgood.It’sveryimportanttointegratesexandmaritaltherapyinwaysthatconsidertradi-tionalcouplesandemergingformsofrelation-ships.IwantedyourperspectivesoncoupleandmaritaltherapybecauseotherthanmaybeGer-aldWeeks,youareoneofthefewsextherapiststolookcarefullyattherelationship.Andsomeofthemaritaltherapists,likeSueJohnson,theycanaddresssexuality,butit’sreallytheintegra-tionofthosetwothatIthinkwouldmakeforthebestoveralltherapy.McCarthy:Thisideathatonesizedoesn’tfitalliscrucial.Themostimportantthinginarelationshipisthatitshouldbesatisfying,notperfect,butsatis-fying.Thatbeinginthatrelationshipbringsoutsomethinghealthyinyou.IthinkGottmanactu-allyhasitright,thatagoodfriendshipisacoreofhealthytraditionalrelationship.Andthenthesecondisthatit’ssecure.Notstable,butsecure.YouknowEmilyandIbothcomefromfamilieswheretherewasalotofstabilitybutnothealthyorsatisfying.Asecurebondmeansthatit’sahealthybondandyoureally,youaccepteachother,intermsofyourstrengthsandvulnerabil-ities.Youdon’texpecttobeperfect.Imeanthejokethatwealwaysmade—EmilyandImade—isthatIsaid,“I’llover-comemylearningdisability.”(Icouldn’tovercomemylearn-ingdisability.)AndEmilywasfivefoottallwhenwemet,shesaid,“I’llgrowforyou.”(“Nowshe’sfourfootsevenandahalf.”)Southern:(laughter)McCarthy:So…accepteachother.Beinginthatrelation-shipishealthyforyou.Andthat“secure”notionisthatyou’rereallyvaluedforwhoyouare.Youknow,Ithinkoneofthethingsthathasalwaysstruckmeclinicallyisthatsomanypeoplehavethiscontingentsenseofpersonalself-esteem,andespeciallysexualself-esteem,thatsaid,“Ifyouknewthisaboutme,youwouldn’trespectmeandloveme.”Ithinkthat’saveryhardwaytolive.AndIthinkinahealthyrelationship,youdofeelacceptedforwhoyoureallyare,yourauthenticsexualself.Includingyourvulnerabilities.Theroleofsexwithinthatrelationshipisnotthecoreissue.It’smatteroffeelingdesired,desirability,andfeelingenergizedasacouple.Atleastthat’smytakeonit.Andthat’swhatImeanbythe15–20%role.It’sawayofsharingpleasure,ofenergizingyourself,feelingintimatelyconnected,notsomuchwhenyou’rebeingsexual,butbeforeandafterbeingsexual.Ithinkwereallyunderestimatetheideaofsexasatensionreducer,tohelpyoutodealwiththestressesofsharingyourlife.Southern:Throughoutyourcareer,youhavecultivatedsomeexcellentcollaborations.Couldyoutellusmoreabouthowthoserelationshipsdeveloped?8TheFamilyJournal:CounselingandTherapyforCouplesandFamilies27(1)

McCarthy:Right.Mostofmycollaborations—otherthanwithEmilyandwithMichael—especiallynow,iswithgraduatestudentsatAmericanUniver-sity.Graduatestudents—andIthinkthisisatrendinpsychologyandit’snotagoodtrend—theydon’ttakeanycouplecourses,theydon’ttakeanysexcourses.Andthewaytheycomeintomylifeisthey’remyteachingassis-tantsforthehumansexualbehaviorclassinthefallandthepsychologyofwell-beingclassinthespring.ThosearetheonlysubjectsIteachundergraduates.Formanyofthestudents,it’sareallygoodlearningexperience,andoneofthethingsthatIalwaystellmystudentsis:Yourprimaryprofessionshouldnotbesextherapy,butsextherapyandthesexfieldisawonderfulsecondaryprofession:aspecialtyfield.Southern:Right.McCarthy:Whetheryou’reapsychologist,asocialworker,amarriageandfamilytherapist,that’sagoodwayofthinkingaboutthesexfield.Asasub-specialtyskill.AndI’vereallyenjoyed—andIthinkthestudentshaveenjoyed—workingontheseprojectstogether.Southern:Youseemtobeverygenerous.McCarthy:They’realsotremendouslycompetentintech-nology.Theyhelpme.Southern:Yes,that’swhatIlike,too,fortheeditorialassistantsI’vehad,andtheteachingassistants.Theyreallyhelpmetoaccesssomeofthetech-nologythatfranklyiskindofscaryforme.Andtheyintroducemetonewideas,particularlyrelatedtoculturalissues.McCarthy:Right.Southern:You’vebeengenerouswiththem,itappears,workingwithoneoverseveralarticles.Doyoufeellikethatthereisarolethereintermsofmentoringandmodelingaspectsofyourlifeandyourcareerfortheseyoungerprofessionals?McCarthy:Wellyouknow,IthinkoneofthethingsthathasbeenabsolutelyfascinatingishowthementalhealthfieldhaschangedinthetimethatI’vebeeninit.Icanremember,again,whenIwasan18-year-oldcollegestudent,wherethepro-fessorwassaying,“Thereasontogetintograd-uateschoolisit’seasiertofindjobs.”It’sjust…IrememberwhenIgotmyPhDpeoplecallingmeonFridaynightsandSaturdaynightsofferingmejobs.Andnowit’sjustbecomeamuchmorecompetitivefield.ButIdothinkit’safieldthatallowspeopletofindtheirniche.I’mabigbelieverthatpeoplehavetofindtherightnicheorrightfitforthem.Southern:Yes.McCarthy:Whetherit’sbeingaclinician,orbeingateacher,it’sbeingawriterorbeingaresearcher.So…Ialwaysencouragepeopletotrytofindwhatistherightnicheforthem.Southern:Okay.Wellthankyousomuch,letmeseeifthere’dbesomethingelseherefrommylistofquestionsinthee-mail.Obviously,relapsepre-ventionhasbeenamajorcomponentwithevidence-basedpractice,dealingwithmentalhealthandaddictionissues.Howdidyousortofcometoemphasizerelapsepreventionintermsofdealingwithsexualconcerns?McCarthy:Basically,clinicalknowledge,youknow.Themostdemoralizedpeoplewhowouldsitinmyofficewerepeoplewhohadsuccessfullychangedwhetherwithmedication,coupletherapy,andthenrelapsed.They’rethemostdemoralized.Southern:Mmm.McCarthy:Andtheywouldcomeinandsay,“Youknow,IreallylikethetherapistIsaw,IreallylikedtheclinicianIsaw,theywereveryhelpful.”Andtheywouldsay,“It’sobviouslymyfault,”or“It’smypartner’sfault,”or“Wehaveafatallyflawedrelationship.”AndIwouldsay,“Thisclinicianwhoyoulikedandrespected,didtheyhelpyoudeveloparelapsepreventionplan?”Whentheywouldsay“No,”Iresponded,“Blametheclinicianbecausetheydidnotdocomprehensivecoupletherapy.”Southern:Okay.McCarthy:Ithinkit’snotonlytrueaboutsex,butit’strueaboutanyotherkindoftherapyforanxiety,depression,compulsivesexualbehavior.Anyofthoseproblems.You’regoingtohavenega-tiveexperiences.AndIthinkthat’spartofthevalueofthe“goodenoughsex”model.Theylearntoacceptalloftheirsexualexperiences.Thewholeideaismaintainingpositiveandrea-listicexpectationssexually.Ithinkthisisoneoftherealkeystokeepingdesirehealthy.Becausesomuchofsexisportrayedasdramatic,whetherit’spornsexorit’ssexinR-ratedmovies,it’salwaysdramaticandlovingandfunctional.Andthat’sjustnotthetruthofpeo-ple’slives.So,Itrynottoterminatewithclientsuntilthey’vehadatleastoneexperiencewithsexthatdidn’twork.IremembersomecommentsfromWilliamMasters.IwenttoaworkshopinPhiladelphiaandaskedhimaboutanarticleonerectionproblems.Masterssaid,“Doyouknowforsurethatamaniscuredoferectiledysfunction?”Hewaslikeagodspeak-ingtothisyoungpsychologist.Southern:(laughter)McCarthy:Hesaid,“Whetherithappensonceamonth,onceevery10times,oronceayear,whenhedoesn’thaveanerectionsufficientforSouthern9

intercourse—andhedoesn’tpanic.That’showyouknowhe’scured.”Southern:That’sagoodpoint.McCarthy:BecauseIthinkit’sthiskindofnotionofself-efficacyaboutyourselfasaperson,asasexualpersonevenwheneverythingisnotgoingwell.It’sbasedontheideayoudeservesex,thatyoucanlookforwardtosex,andwhensomethinggoesbadly,whetherit’sonceayearor10%ofthetime,youdon’tapologizeandyoudon’tpanic.Southern:Okay.Keepeverythinginperspective.McCarthy:Ithinkthat’showyoustaysexualinahealthywayinyour60s,70s,and80s.ThephysicianStaceyLindau,she’sbasedatUniversityofChi-cagoMedicalSchool,wroteaboutbeingsexualbetween58and85,inTheNewEnglandJournalofMedicine,Ithink.Basically,thepeoplewhocontinuetobesexualhaverealisticexpecta-tions,andtheylearnhowtoavoidrelapse.Southern:That’sthegood-enoughsexperspective.McCarthy:AndIthinkthat’sahellofanimportantmes-sage.Whenitcomestodesire,sometimesyou’renotgoingtofeelspontaneous.Ithinkthat’strueofmenandwomen.Thisideaofresponsivesexualdesire.Andthatonceyoufeeldesire,thatyouhavechoicesabouthowyou’regoingtoplayitoutratherthanallsexhastoendinintercourseandorgasm.Demandsquelchesdesire.Themorevariableandsexualtheirsex-ualrepertoire,thebetterofftheyare.Southern:Yes.IrememberDr.Masterssayingitwaslikeasmorgasbordorgoingthroughthecafeterialine,andyouhavesomanydifferentchoices.Youmaygotothesamerestaurant,butyoudon’talwayswantthesamething.Freedomofchoiceissuchanimportantcomponent.McCarthy:Iabsolutelyagreewiththat.Ithinkthatthehealthiestindividuals,thehealthiestcouples,areabletohavethisideaofpersonalresponsibilityforsexualityandbeinganintimatesexualteam.That’sthebalance.Southern:Okay.Letmeshiftgearshereforjustasecond.IjustcamebackfromourSocietyforAdvance-mentofSexualHealthboardmeetingtheyhadhereinChicago.Theconferenceisgoingtobeherein2019,sowhileIwasattheboardmeet-ingastheeditorofSexualAddictionandCom-pulsivity,wearetryingtoemphasizesexualhealthinthesexualaddictionfield.Yourmodelofenhancingdesireisbasedonacceptanceofgood-enoughsexandhavingopportunitiestoenjoypositiveandmeaningfulsexuality.McCarthy:Weneedmorepositivesexuality.Southern:Thecriticsofthesexualaddictionfieldareprobablyright,it’sexcessivelypathologizingandlimiting,andit’sfullofallkindsofrestrictivelabelsanddiagnosesandtreatmentprograms.Ibelieveyourworkisopeningupthefieldofsexualaddictiontreatment.McCarthy:IdidapostconferenceworkshopattheSASHmeetinginAustin.Ithoughtitwasprettywellreceivedbymostofthepeople,notallofthepeopleforsure.Mywholeideaofanintegrativeapproachisyou’vegottoconfrontthesexualpoisonsofsexualcompulsivityandsexualshameforsure.It’seasiertoconfrontthosepoi-sonsifyoualsohaveapro-sexapproach.Southern:Apro-sex,integrativesexualhealthmodelholdsthemostpromisefortreatingsexualproblemsandpreventingrelapse.Allright,doc,I’mabouttodosomesupervision,butthishasbeenatreatforme.Ienjoyedeverythingthatyouhadtosay,andIlookforwardtoworkingonfutureprojectswithyou.McCarthy:Okay,soundswonderful.WelookforwardtoreceivingsomeadditionalinformationandinsightsfromDr.McCarthyinupcomingissuesofTheFamilyJournal.HeandLanaWaldRosswroteanexcellentarticle,“MaintainingSexualDesireandSatisfactioninSecurelyBondedCouples,”forourjournal.Ihopereaderswillfollowupthisinterviewbyreadingthearticle(McCarthy&Ross,2018)andprepareforthenextarticleonhealthysexuality.DeclarationofConflictingInterestsTheauthor(s)declarednopotentialconflictsofinterestwithrespecttotheresearch,authorship,and/orpublicationofthisarticle.FundingTheauthor(s)receivednofinancialsupportfortheresearch,author-ship,and/orpublicationofthisarticle.ReferencesMcCarthy,B.(2015).Sexmadesimple:Clinicalstrategiesforsexualissuesintherapy.EauClaire,WI:PESI.McCarthy,B.,&McCarthy,E.(2009).Discoveringyourcouplesex-ualstyle.NewYork,NY:Routledge.McCarthy,B.,&McCarthy,E.(2014).Rekindlingdesire(2nded.).NewYork,NY:Routledge.McCarthy,B.,&Ross,L.W.(2018).Maintainingsexualdesireandsatisfactioninsecurelybondedcouples.TheFamilyJournal,26,217–222.Metz,M.,Epstein,N.B.,&McCarthy,B.W.(2018).Cognitive-behavioraltherapyforsexualdysfunction.NewYork,NY:Routledge.Metz,M.,&McCarthy,B.W.(2007).The“good-enoughsex”modelforcouplesexualsatisfaction.SexualandRelationshipTherapy,22,351–362.Metz,M.,&McCarthy,B.W.(2012).The“GoodEnoughSex”(GES)model:Perspectiveandclinicalapplications.InP.Kleinplatz(Ed.),Newdirectionsinsextherapy(2nded.).NewYork,NY:Routledge.10TheFamilyJournal:CounselingandTherapyforCouplesandFamilies27(1)

GROUPCOUPLES’INTERVENTIONTOIMPROVESEXUALHEALTHAMONGMARRIEDWOMENINALOW-INCOMECOMMUNITYINMUMBAI,INDIAShubhadaMaitraTataInstituteforSocialSciencesStephenL.SchensulUniversityofConnecticutSchoolofMedicineBenjaminD.HallowellUniversityofGeorgiaSchoolofPublicHealthMarieA.BraultYaleSchoolofPublicHealthBonnieK.NastasiTulaneUniversityThisarticledescribesthedesignandimplementationofagroupcouples’interventionfocusedonimprovingwomen’ssexualhealthasacomponentofamultilevelcommunity,clinical,andcounselinginterventionprojectconductedinassociationwithagynecologicalserviceinamunicipalurbanhealthcenterinalow-incomecommunityinMumbai,India.Thegroupcou-ples’interventioninvolvedfoursingle-genderandtwomixed-gendersessionsdesignedtoaddressthedynamicsofthemaritalrelationshipandestablishamoreequitablespousalrela-tionshipasameanstoimprovewomen’ssexualandmaritalhealth.Involvementofmenpre-sentedamajorchallengetocouple’sparticipation.Forthosecouplesthatdidparticipate,qualitativefindingsrevealedsignificantchangesincoupleandfamilyrelations,sexualhealthknowledge,andemotionalwell-being.INTRODUCTIONThenatureandformofmarriageisrapidlychanginginAsia(TheEconomist,2011),asanincreasingnumberofmiddle-andupper-classwomenaredelayingmarriage,choosingtostaysin-gleorevendivorcing.TheaverageageatmarriageinIndiahasrisenbytwoandahalfyearsbetween1970and2000(Jones,2010),withlargeregionaldifferences.Womenmarryrelativelylaterinthemoreaffluentsouthernstates,particularlyKerala,andrelativelyearlierinthelowerincomeShubhadaMaitra,PhD,isaProfessorintheCentreforHealthandMentalHealth,SchoolofSocialWorkattheTataInstituteforSocialSciences;StephenL.Schensul,PhD,isaProfessorofCommunityMedicineandHealthCareintheDepartmentofCommunityMedicineandHealthCareattheUniversityofConnecticutSchoolofMedicine;BenjaminD.Hallowell,MPH,isadoctoralcandidateattheUniversityofGeorgiaSchoolofPublicHealth;MarieA.Brault,PhD,isanAssociateResearchScientistattheYaleSchoolofPublicHealth;BonnieK.Nastasi,PhD,isaProfessorintheDepartmentofPsychologyatTulaneUniversity.Atthetimeofthestudy,MarieA.BraultwasadoctoralcandidateintheDepartmentofAnthropologyattheUniversityofConnecticutinStorrs,CT,andBenjaminD.HallowellwasanMPHstudentintheDepartmentofCom-munityMedicineandHealthCareattheUniversityofConnecticutSchoolofMedicineinFarmington,CT.Thisarticlehasnotbeenpreviouslypresented.TheworkreportedinthemanuscriptwassupportedbytheNationalInstituteforMentalHealth(grantnumberRO1MH075678;2007–2013).WewishtoacknowledgetheRISHTAinterventionteamfortheirworkinfacilitatingandcollectingthedatapresentedinthisarticle.AddresscorrespondencetoShubhadaMaitra,TataInstituteforSocialSciences,Deonar,Mumbai400088,India;E-mail:shubhada@tiss.eduJanuary2018JOURNALOFMARITALANDFAMILYTHERAPY73JournalofMaritalandFamilyTherapy44(1):73–89doi:10.1111/jmft.12248©2017AmericanAssociationforMarriageandFamilyTherapy

statesofthenorth,particularlyBihar,MadhyaPradesh,Rajasthan,andUttarPradesh(Visaria,2004:62).Yet,forlow-incomesectionsofIndiansociety,marriageandthecontinuityofthemaritaldyadisanearuniversalphenomenon(Jones,2010).Despitethestereotypesportrayedintheliterature,marriagesinlow-incomeruralandurbancommunitiesshowarangeofvariationincompatibility,communication,andgenderequity(Mai-tra&Schensul,2002).Thereare,however,asubsetofrelationshipsthatsufferfromanumberofchallenges.Althoughtheaverageageatmarriageisincreasing,50%ofwomen,primarilyfromlow-incomeormarginalizedcommunities,marrybelowthelegalageof18(InternationalInstituteforPopulationSciencesandMacroInternational,2008).Mostmarriagescontinuetobearrangedbyparentsorotherrelatives,andinthemostconservativefamilies,themanandwomanmaynotmeetpriortotheirwedding.Thislackofpremaritalcontactcoupledwithmen’sandwomen’slim-itedknowledgeandexperiencewithsexoftenresultsinunpleasant“firstnight”experiencesthatsetthetoneforthesubsequentsexualrelationship.Maritalcommunicationpresentsanotherdifficultyforsomecouples.Manynewlymarriedcouplesmoveinwiththehusband’sfamilywheretheyoungwifeassumesajuniorposition,andmayhavelimitedopportunitiestocommunicatewithherhusband.Thetensionsbetweenthenewwifeandherin-lawsandpoorcommunicationwithherhusbandplacewomenatriskforintimatepartnerviolence(Maitra&Schensul,2002).Neolocalresidencedoesnotseemtosolvetheseprob-lemsifthewifeandhusbandhavenotestablishedeffectivemodesofcommunicationandgenderequity.Inacontextofinflationandtherisingcostofliving,financialstressinlow-incomecommu-nitiesalsocreatefrustrationsinthemaritalrelationship,ashusbandshavedifficultyinmeetingthetraditionalroleofproviderandwomenasaresulthavedifficultyintheirculturallyprescribedroleofmaintainingthehousehold.GlobalevidenceindicatesthatsexualintercoursewithinmarriageorwithapermanentpartnerputswomenatriskforHIVinfection,mostcommonlyfromtheirpartners’extramaritalliaisons(JointUnitedNationsProgrammeonHIV/AIDS&WorldHealthOrganization,2007).InIndia,men’sengagementinunprotectedsexualrelationships,bothcommercialandnoncommercial,out-sidemarriage,putwivesatincreasedriskofacquiringHIV/STIinfection.Womenaremostofteninfectedthroughsexwiththeirhusbands,despitetheirperceptionthattheirownmonogamyispro-tective(Santhya&Jeejebhoy,2007).Asaresult,researchersandinterventionistsneedtomovebeyondafocusontheindividualtoaddresstheissuesofsexualhealthandgenderequitywithinthemaritalunit.Thisarticledescribesaninterventionconductedwiththemaritaldyadtoreducewomen’ssex-ualriskandimprovewomen’ssexualhealthinalow-income,officiallydesignated“slum”commu-nityinMumbai,India.Theinterventionwaspartofalargermultilevelcommunity,clinicalandindividualcounselinginterventionprogramconductedinassociationwithagynecologicalserviceinamunicipalurbanhealthcenter.Thecouples’interventionwasdesignedandimplementedtoenablemenandwomentoaddressthedynamicsofthemaritalrelationshipandestablishamoreequitableandegalitarianrelationshiptoimprovewomen’ssexualandmaritalhealth(WorldHealthOrganization,2010).Thecouples’interventionwasinformedbythefeministperspectivethatinequitywithinmar-riageshouldbechallengedandaddressed.Feministshavelongcriticizedtheinstitutionofmarriageasinherentlyunequal,inequitable,andhierarchicalintermsofthepowerdifferentialofthe“hus-band”and“wife”roleswithwomenintraditionalmarriagesassubordinate,economicallydepen-dent,anddeferent(Johnson,1988).Inmostifnotallcountries,womencontinuetohavethemajorresponsibilityforhouseholdandcaringduties(VanEvery,1995).Intermsofeconomics,womenarestillexpectedtoprovideunpaidlaborinthefamily(Delphy&Leonard,1992)andaredisad-vantagedbothwithintheirmarriages(Pahl,1989)andinpaidemployment(Witz,1993).Feministdiscoursehasengagedwithconceptsofpatriarchy,power,genderrelations,sexuality,andmas-culinitytoexplaintheseinequities.Thisdomination–subordinationdynamicisdisplayedinasignificantnumberofmaritalrela-tionshipsinIndia(Maitra&Schensul,2002).Feministsandtheirallieshavearguedforworkingwithmenandmasculinitiesinordertoaddressviolenceagainstwomenandbringaboutachangeinwomen’slives(Vermaetal.,2006).Engagingmenininterventionsthatfacilitatereflectionandchallengethedominantnotionsofgenderrelationswithinmarriagearecritical,particularlyina74JOURNALOFMARITALANDFAMILYTHERAPYJanuary2018

contextwherewomen’shealth,well-being,andsafetyarecompromised(Barker,Nascimento,&Ricardo,2007;Dworkin,Treves-Kagan,&Lippman,2013;Jewkes,Flood,&Lang,2015;Jewkes&Morrell,2010;Pulerwitz,Michaelis,Verma,&Weiss,2010).Thisapproachissupportedbytheculturalnormthathusbandsareresponsiblefortheprotectionandwell-beingofthefamily.Thus,thecouples’interventiondescribedheresoughtashifttoamoregenderequitablerelationshipthatwouldincreasethecapacityofthemaritalunittodealwiththechallengesofanurbanpoorcom-munityandprotectthehealthandwell-beingoffamilymembers.Couples’InterventionsCouples’interventionsrepresentamajorstepforwardinHIVpreventionefforts(El-Basseletal.,2003).Traditionalinterventioneffortsthatdonotaddressthepartnerdynamichaveoftenfailedtodemonstrateimprovedbarrieruseamongwomeninintimaterelationships,becausetheyneglectthecrucialrolepartnersplayinsexualbehavior(Burton,Darbes,&Operario,2010;El-Basseletal.,1995;Ickovics&Yoshikawa,1998;Misovich,Fisher,&Fisher,1997;O’Leary,1999,2000).Bringingcouplestogetherandimprovingtheircommunicationskillsinasafe,cultur-allysensitive(Ahmad&Reid,2016)environmentpermitsthediscussionofawiderangeofdifficultissues(El-Bassel,Gilbert,etal.,2010),andenablescouplestomorerealisticallyappraisetheirsex-ualrisk(El-Basseletal.,2003;Remien,1997).However,couples’approachestosexualriskreductionremainrare.Areviewoftheliteraturehasonlyidentifiedthreecouples’interventionsthatworkedtoreduceHIV/STIriskbehaviorand/orpreventtransmissionamongserodiscordantcouplesconductedintheUnitedStates(El-Basseletal.,2003;El-Bassel,Jemmott,etal.,2010;Koniak-Griffinetal.,2008),oneinZambia(Jones,Ross,Weiss,Bhat,&Chitalu,2005),oneinKazakhstan(El-Basseletal.,2014),andoneinSouthAfrica(Pettiforetal.,2014).Whileotherstudieswereidentifiedthatprovidedinterventionsatthecouple’slevel(Allenetal.,1992;Chombaetal.,2008;Coates,2000;Kamengaetal.,1991;McKennaetal.,1997;Musaba,Morrison,Sunkutu,&Wong,1998),thesestudiesdidnotaddresstheinteractionalanddynamicforceswithinthecouplethatcontributetosexualrisk.Incouples’interventions,researchersworktoaddresstheinteractionalanddynamicforcesthatcontributetosexualrisk,includingmartialcommunication,genderroles,genderequity,preg-nancyintentions,andotherrelationshipissues(Burton,etal.2010).Couple-focusedinterventionshavebeenemployedattheindividuallevel(El-Basseletal.,2003,2005;El-Bassel,Jemmott,etal.,2010)whereindividualcounselingisfocusedonthepartnerrelationship,atthedyadiclevel(El-Basseletal.,2003,2005;El-Bassel,Jemmott,etal.,2010)inwhichbothmembersofthedyadarepresentforcounselingandeducation,orthegrouplevel(El-Bassel,Jemmott,etal.,2010;Jonesetal.,2005;Koniak-Griffinetal.,2008)wheremultiplecouplesmeetinagroupsettingtodealwithgenericissues.TodateinIndia,therehasonlybeenoneothercouples’interventiondescribedintheliterature(Yoreetal.,2016),andthatinterventionfocusedongenderequityandfamilyplanning.Theinterven-tionreportedhereisthefirstinIndiatoaddresstheinteractionalanddynamicforceswithinthemari-taldyadthatcontributetosexualrisk.ThisinterventionfocusedongroupsofmarriedcoupleswiththepropositionthatimprovingthemaritalrelationshipwouldenablewomentoachievebettersexualhealthstatusandavoidHIVrisk.Thisarticledescribesthemethodology,abriefoverviewofthequan-titativeresultsfromeachoftheprojectinterventioncomponents,andthenfocusesontheresultsofqualitativeevaluationfrombothmenandwomenengagedinthecouples’interventionprocess.METHODSThedataandinterventiondescribedinthisarticleweredrawnfromtheNIMHproject,“ThePreventionofHIV/STIamongMarriedWomeninUrbanIndia(2007–2013;RO1MH075678;S.Schensul,PI).”Thisprojectwasapartofadecade-longIndo-U.S.collaboration(Maitraetal.,2015).Throughthiscollaboration,theprogram,ResearchandInterventioninSexualHealth:The-orytoAction(RISHTA,meaning“relationship”inHindiandUrdu),wasestablished.TheRISHTAmarriedwomen’sprojectutilizedarandomizedcontrolledtrial(RCT)whoseobjectivewastodeterminetheefficacyofmedicaltreatment,pairedwitheitherindividualcounseling(IC),groupcouples’(husbandandwife)intervention(CI),oracombinationofindividualcounselingJanuary2018JOURNALOFMARITALANDFAMILYTHERAPY75

andgroupcouple’sintervention(IC+CI),toimprovewomen’shealthoutcomes.Inadditiontoindividualcounseling,groupcouples’intervention,andmedicaltreatment,theRISHTAmarriedwomen’sprojectalsoincludedacommunityeducationcomponentthatworkedwithImamsandnongovernmentalorganizations(NGOs)topromotegenderequitablenormsinthestudycommu-nity(seeSchensuletal.,2009forfurtherdesigndetails).TheStudyCommunityTheRISHTAprojectwasconductedinacommunityof600,000innortheastMumbai,India.ThecommunityincludesoneofthelargesttrashdumpinggroundsinIndia.Inthe1970s,migrantsfromthestatesofUttarPradeshandBiharinthenorth,andruralareasofMaharashtra(thestateMumbaiislocatedin),settledinthecommunity,andthemajorityofthesemigrantswereMuslims.Thecommunityisnow80%Muslim,16%Hindu,and5%BuddhistandChristian.Themeanlengthofresidenceinthecommunityis14years.Approximately80.4%ofthepopulationlivesinasingleroom,withamedianhouseholdsizeofsixindividuals;96.6%ofthemenareemployedandworkprimarilyasdailywageworkers,salariedprivateworkers,autorickshawdrivers,indus-trialworkers,andpettytraders,withamedianmonthlyincomeof4,000rupees(U.S.$63.96).Theemploymentrateforwomenis25.4%,with60%ofthosethatgeneratecashincomeinvolvedinhome-basedpiecework.SampleSelectionTheRISHTAprojectestablishedaWomen’sHealthClinic(WHC)inthestudycommunity’smunicipalUrbanHealthCenter(UHC).TheWHCwasstaffedwithresourcesandpersonneltoprovidegynecologicalexaminations(previouslyunavailable)towomenwhocametotheclinic.AllwomenweretriageduponarrivalattheUHC.Iftheyhadnonreproductivehealthproblems,womenweredirectedtotheoutpatientdepartmentintheUHC.Ifthewomenpresentedreproduc-tivehealthproblems,theyweredirectedtotheWHCformedicalcare.Inclusioncriteriaforparticipationinthestudywereasfollows:womenaged18–40yearsold,womenlivingwiththeirhusbands,residinginthestudycommunityforatleastayear,notpregnantatthetimeofenrollment,andhavingatleastoneofsixgynecologicalorrelatedsymptoms(vaginaldischarge,genitalitching,burningmicturition,lowerabdominalpain,geni-talulcers,andinguinalswelling).IfitwasdeterminedthatthewomenbeingseenattheWHCmetthecriteriatoparticipate,theyweregivenadescriptionoftheRISHTAprojectandaskedforwrittenconsentiftheychosetoparticipateintheRCT.Allwomenirrespectiveoftheireli-gibilityand/ortheirrefusaltoparticipateintheRCTwereprovidedwithmedicalcare.TheprojectwasapprovedbytheIndianCouncilforMedicalResearchandtheIRBsofallthepar-ticipatingpartners.WomenwhoconsentedtobepartoftheRCTwerethenrandomlyassignedtooneoffourcon-ditionsthatwerepairedwithmedicaltreatment.Ofthe1,125womenwhowereenrolledintheRCT,285womenwereassignedtothecontrolgroup(medicaltreatmentonly),275womenwereassignedtoindividualcounseling(IC),284womenwereassignedtothegroupcouples’interven-tion(CI),and281womenwereassignedtoindividualplusgroupcouples’intervention(IC+CI).Thisarticlefocusesonthegroupcouples’interventionprocess,structure,andresults.RISHTACouples’InterventionDevelopmentThecouples’interventionaddressedthepsychologicalandsocioculturalfactorsrelatedtothesexualhealthconcernsofbothwomenandthecouple.Thecouples’interventionprogramwasbasedontheNarrativeInterventionModel(NIM).Usinggenderequityasthecoreoftheinterven-tionprogram,theNIMprocessintegratedprinciplesandstrategiesfromnarrativetherapy,cogni-tivetherapy,andcognitive-behavioralapproachestosexualriskpreventionandreduction(Nastasietal.,2015).ThethemesfortheCIsessionswerestandardizedandbasedonthedatafromtheformativeresearch,whichincluded39in-depthinterviewswithwomen,21in-depthinterviewswithmen,and15in-depthinterviewswithcouples.ThetranscriptsfromtheseinterviewswerethenanalyzedinAtlas.ti(v.7.0;Muhr,2013)toidentifythefactorsinthemaritalrelationshipthatimpactedwomen’ssexualhealthandHIV/STIrisk,andsubsequentlyusedtodeveloptheCIprogram76JOURNALOFMARITALANDFAMILYTHERAPYJanuary2018

curriculumandtheCImanual(Nastasi&Maitra,2013;seesupplementaryfile1).Theanalysisofthesedatageneratedsixsessions:rolesandresponsibilitiesinmarriage,tensionsinmarriage,mari-talsexandsexuality,sexualriskanditsprevention,violenceinthemaritalrelationship,andhealthymaritalrelationships.TheCIsessionswerecomposedof5–8couplesthatmetfor2hr,onceaweek,for6weeks.Thefirstfoursessionsweresingle-gendergroups,withwivesandhus-bandsmeetingseparatelywithtrainedfacilitatorsmatchedbygender.Sessions5and6weremixed-gendersessions,andwereco-facilitatedbymaleandfemalefacilitators.Furtherdetailsonthetrainingofthefacilitatorsandcontentofthesessionsareprovidedinthemanual.EachoftheCIsessionsbeganwithabriefintroductionbythefacilitator(s).Thesessionswerestructuredarounddiscussionandroleplaysrelatedtohypotheticalscenariossuchasadisagree-mentbetweenacouple,suspiciousness,differentialexpectations,householdresponsibilities,andsexinmarriage.Eachmoduleprovidedthemechanismforintroducingeducationalmessages,reframingbeliefsthatsupportsexualrisk,andprovidingskillstrainingonthetopicunderdiscus-sion.Sessionswereconcludedwithplansforapplyingthecontenttodailylife.Facilitators,primar-ilywithmaster’sdegreesinsocialworkandrelatedgraduatetraining,wereprovidedextensivetraining,regularrefreshertraining,andweeklyconsultationfromprojectPIs.EvaluationAvarietyofmethodswereusedtoevaluatethefidelityandoutcomesofthecouples’interven-tioncomponent.EveryfourthCIgroupwasobservedandfollowedoverthecourseoftheirsixses-sions.Ofthetotalof69groupsthatmetforallsixsessions,16groupswereobservedanddocumentedbyRISHTAevaluationteammemberswhowerenotinvolvedinfacilitatingthecou-ples’intervention.Theevaluationteammembershadpostgraduatetraininginsocialsciences.Ses-siondocumentationfollowedaprocess-recordingformatwithdetaileddescriptionsofparticipants’seatingarrangement,nonverbalcuesandverbatimrecordingofthefacilitator–partic-ipantinteraction.Aftereachsession,selectedparticipantswereinterviewedindividuallyandaskedtoprovidefeedbackonthesession.Theinterviewsfocusedontheactivitytheylikedthemost,onetheylikedtheleast,theiropiniononthedurationandlocationofthesession,andsuggestionsformakingthesessionsbetter.Eachinterviewlastedbetween15and30min.Eighty-ninecouplesparticipatedinallthesixCIsessionsand200womenattendedaminimumofthreeCIsessions.AttheendofthefinalCIsession,in-depthinterviewswereconductedtodocu-menttheirexperiencesandreflectionsontheCIprogramandtorecordtheimpactthatCIhadontheirlives.Atotalof14coupleswhohadattendedallthesixsessionsparticipatedinthein-depthinterviews.Postfinalsessioninterviewsexploredparticipants’viewsoftheirCIexperiences,thebehavioralchangesinthemselvesandtheirspouses,andwaysinwhichthemaritalrelationshipitselfhadchanged.Thereportsofeachsession(whichincludedthediscussionsandresponses)wereorganizedbygenderandenteredintoAtlas.ti,coded,andanalyzedtoidentifycommonthemes,conceptions,andnormsreportedbyparticipants.AnalysisofQualitativeDataTheproceduresfortranscription,storage,andanalysishavebeenestablishedbytheIndo-U.S.collaborativeteamacrossadecadeofcollaborativeresearchandintervention.Allqualita-tiveinterviewswereconductedinHindiorthestatelanguageofMarathi.Detailedhandwrit-tennotesweretakenduringtheinterviews,andwithin2hroftheinterview,theresearchinvestigatorfullytranscribedthesenotesintofullEnglishsentencesandparagraphs,maximiz-ingquotesandretainingkeyHindi/Marathitermsusefulininterpretation.TheresultingWordfilewasthenenteredintoAtlas.ti,v7.2(Muhr,2013)acomputer-basedtextmanagement,search,andanalysisprogram.Thekeytoeffectivequalitativedataanalysisisthecodingsys-tem,basedontheproject’skeyvariables.Codesweredevelopedutilizingatreediagrammethodallowinganalysistooccuratthedomainfactorandthevariablelevels(Schensul,1993)consistentwiththeprojecttheoreticalmodel.Asdatawerecollected,thecodingschemewastested,modifiedandfinalized,withcodesdefinedandcoderstrained.Aninitialfiveinter-viewswerecodedbythreestaffandthecodingmatchedtofinddiscrepancies.Thisprocesswasrepeateduntil85%ofthecodingwasconsistent.Thisstepwasrepeatedperiodicallyasaqualitycheck.Codedsegmentswerethenassessedforprimaryandsecondarypatterns,January2018JOURNALOFMARITALANDFAMILYTHERAPY77

exemplaryquotesidentified,andhypothesestestedthroughtheassociationofmultiplecodes,afeatureavailableinAtlas.ti.RESULTSSummaryofQuantitativeInterventionResultsThequalitativeresultsofourstudy,ourprimaryfocusofthisarticle,provideanin-depthper-spectiveonwhatthecouples’interventionmeanttotheparticipants.Atthesametime,toprovidecontext,webrieflysummarizeourquantitativeinterventionresultsbelow.Thequantitativeresultsforeachofthestudycomponentsdemonstrateapositiveeffectofcommunityeducation,couples’intervention(CI),andindividualcounseling(IC;Maitra,etal.2015;Mehrotra,Schensul,Sag-gurti,Burleson,&Maitra,2015;Schensuletal.,2015).Therewasastatisticallysignificantchangeingenderequityperceptionsinthestudycommunity,drivenlargelybypositivechangesinmen’sattitudes(Schensuletal.,2015).WomenwhoreceivedCIshowedsignificantpositivepre–postinterventionchangesinsexualhealth(p<.001),physicalhealthsymptoms(p<.001),andemo-tionalhealth(p<.001)comparedwithwomenwhodidnotreceiveCI.Asignificantimprovementwasfoundincomparingpre–postsexualhealth(p<.001)andphysicalhealthsymptoms(p<.001)forwomenwhoparticipatedinIC.DemographicInformationfortheCIParticipantsThemeanageofwomenwhoattendedatleastoneofthecouples’interventionsessionswas28.71years,andtheaverageageatmarriagewas17.5years.Thewomenaveraged3.7pregnancies,2.7livingchildren,and5yearsofeducation.Consistentwiththereligiousmake-upofthestudycommunity,thewomeninthesamplewhoattendedCIwerepredominantlyMuslim(90.6%),with9.0%Hindu,and0.4%Buddhist.Onaverage,husbandswere5yearsolderthantheirwives.Amajorityofhusbands(97.1%)wereemployedatthetimeoftheintervention,withamedianmonthlyincomeof4,500rupees(U.S.$76.79),andameaneducationlevelof5.5years.Theemploymentrateforwomenwas28.4%andameaneducationlevelof5years.CIAttendanceMenandwomenwereexpectedtoattendatotalofsixCIsessionseach,consistingoffoursin-gle-gendersessionsandtwomixed-gendersessions.Oneofthemajorhurdlesatthebeginningoftheinterventionwasobtainingthehusband’sconsenttoparticipateinCI.Thisproveddifficultassomewomendidnotknowtheiraddress(newtothecommunityorhadlimitedmobility),providedthewrongaddress(particularlyintheillegalsettlementareas),ormovedduringthecourseoftheinter-vention.Ifthehomecouldbefound,itwasoftendifficultforRISHTAstafftomeetthehusbandasmanymenworkuntillateintotheevening.Oncethehusbandconsented,thecouplewasinformedofthemeetingtimeandlocationofthefirstCIsession,generallyheldattheWHC.Thenoveltyoftheconceptofcouples’interventionmadesomehusbandsreluctanttoattend,despiterepeatedfol-low-upvisits.Whilemostwomenwerepositiveaboutparticipation,whenthemendidnotattendthesessions,neithercouldtheirwives.Duetothesechallenges,ofthe565couplesthatwereassignedtothecouple’sintervention(CIorCI+IC),45.1%ofthewomenand49.4%ofthemenneverattendedasinglesession.The4.3%differentialinmen’sandwomen’sentryintoCIhadtodowithwomencomingwiththepromiseofmen’sparticipation,whichwasnotrealized.Table1WomenandMen’sAttendanceatEachCISession(percentagesbasedon565couplesassignedtoCI)SessionS1S2S3S4S5S6Women284(50.3%)252(44.6%)224(39.6%)202(35.8%)138(24.4%)143(25.3%)Men249(44.1%)216(38.2%)197(34.9%)190(33.6%)138(24.4%)143(25.3%)78JOURNALOFMARITALANDFAMILYTHERAPYJanuary2018

ThesecondhurdlewithCIattendancewasthedeclineinparticipationthatoccurredoverthecourseofCI,asattendancepeakedinsession1,andthenslowlydeclinedthroughsession6(Table1).AfterattendingthefirstCIsession,coupleswerecontactedthroughmobilephonecallstoinformthemofthetimingofthenextCIsession.Issuesarose,however,whentheirphonewasturnedoffornotpickedup,orwhenthemessagewastransmittedthroughathirdparty(childorrelative)andwasnotdelivered.Iftheindividualdidrespond,thosewhodidnotattendoftengavenumerousreasonswhytheycouldnotattend.Otherissuesarosewhenindividualswouldconfirmtheirattendanceandthennotattend,orshowupverylateorwhenthesessionwasover.Despitethesechallenges,eachsessionwasattendedbyatleast25%oftheassignedsampleand17%ofthesampleattendedallsixsessions.CISessionAnalysisThissectionpresentsanoverviewofthecontentofeachsessionandparticipants’responses.Additionalinformationonthestructureofeachsessioncanbefoundinthemanualprovidedinsupplementaryfile1.Session1:Rolesandresponsibilitiesinmarriage.Theobjectiveofsession1wastoidentifydif-ferencesinexpectationsasapossiblesourceofconflictinmarriageandfacilitatetheprocessofcommunicationandnegotiationregardingrolesandresponsibilitiesinmarriage.Participantsinboththemen’sandwomen’ssessionsdescribedsimilarresponsibilitiesandexpectationsformeninthemaritalunit,whichincludedtakingcareofandeducatingtheirchil-dren;lookingafterthehealthandwell-beingoftheirwife,children,andparents;andprovidingadequatefinancialsupportfortheirhousehold.Inadditiontotheseresponsibilities,however,womenexpectedgreatersharingofhouseholdresponsibilitiesbythehusbandbeyondfinancialprovisioning,andsupportwhentherewerefamilydisagreements.Ifwifehasanyproblemthenhusbandshouldsupporther,ifawomancandoitandtakecareofhusbandthenwhycannotthehusbanddo?(Woman,Session1)Women,contrarytomen,alsoexpressedexpectationsthatfocusedoncompanionship,husbands’noninvolvementinextra-maritalrelationships,andattentiontotheiremotionalneedsthroughexpressionofloveandrespect:Heshouldgivetimetohiswife;myhusbandgoesoutevenonholidays.(Woman,Session1)Ialsoexpectthatheshouldrespectme.(Woman,Session1)However,therewasamatchwhenbothgroupsidentifiedthewife’sresponsibilitiesandexpec-tations:thattheymaintainagoodrelationshipwithin-laws,lookafterchildrenandin-laws,man-agehouseholdexpenseswithintheavailableincomeofthehusbandandmeetthehusband’ssexualneeds.Awomanshouldthinkabouthusband’sizzat[honor].AsItoldearlieraftermarriage,giveonefullyeartowifetounderstandthehouseholdanditismuchmoreimportantifmarriageisarrangedmarriage.Incaseoflovemarriage,husbandandwifeknoweachotherpriortomarriage.Forarrangemarriagebothareunknown(ekdusareseanjan).Awifeshouldacceptin-lawswayoflife(Patnikosasuralkesanchemendhalnachahiye).(Man,Session1)Amancanleavehiswife.Ifawomanisnotcapableofdoingit,thenamancangooutsideforsex.(Man,Session1)Thisquestionisrelatedwithrelations[sex].Wheneverahusbandwants[sex],wifeshouldsatisfy.Sometimeshusbandwanted[sex],butwifedoesn’t.Thenalsowifehastofulfilthewishofhusband.Ifitdoesn’thappenlikethis,thenfighting-violencestartsathome.(Man,Session1)Manyoftheparticipantsmentionedthatthesessionhelpedthemunderstandtheimpor-tanceofdiscussingexpectationswiththeirspouse.ParticipantsrecognizedthatunfulfilledorJanuary2018JOURNALOFMARITALANDFAMILYTHERAPY79

unrealisticexpectationswereoftenthecauseforconflictanddisagreementsbetweenthecou-ple.Therewasrecognitionthatcommunicationplayedavitalroleinmarriageandcouldreducedisagreements.Session2:Tenshun(tension)inmarriage.Theconceptoftenshun(theHinditermderivedfromtheEnglishwordtension)hasbecometheculturalexpressionforanxiety,stress,andpooremotionalstatus,usedcommonlyamonglow-incomeindividualsinIndia(Chatterjeeetal.,2008;Karasz,Patel,Kabita,&Shimu,2012;Maitraetal.,2015;Weaver,2017).TheobjectiveofSession2wastoidentifycommonsourcesoftenshunforwomenandmenandidentifyeffectiveandineffec-tivetenshuncopingstrategies.Women’ssourcesoftenshunincludedbeingover-burdenedwithhouseholdresponsibilities,tenuousrelationshipswithin-laws(particularlythemother-in-law),children’shealthandeduca-tion,obtainingwater,managinghouseholdexpenses,husband’searnings/jobstatus,andrelation-shipwiththehusband.Severalwomenreportedthatmarriageitselfwastheissue:Marriageitselfisonebigtenshun.ManyatimesIfeelIwasfarhappierbeforemarriage.Aftermarriage,onehastoworryabouthusband,children,expensesetc.Then,menfightwithus;allthisgivesalotoftenshun.(Woman,Session2)Ifeellikecrying.IfeelthatIwasinabetterconditionwhenIwasalone,whydidIgetmarried?(Woman,Session2)Men’ssourcesoftenshunincludedpayingbills,findingworkandgeneratingadequateincome,payingfortheirchildren’seducation,obtainingwater,maritalconflict,andthehealthoftheirfam-ilymembers.Bothmenandwomenreportedhusband’sperceivedunmetsexualneedsandhus-bands’demandsforsexasasourceofmaritalconflict.Manyoftheparticipantsidentifiedthetenshuncopingstrategiesdiscussedduringthesessionandtheroleplayastheirfavoritepartofthesessionaspartoftheirfeedbackonthesession.Ilikedthe[second]role-playverymuch.Boththehusbandandwifetalkednicelywitheachotherinthesecondrole-play,theytookadvicefromeachotherandtriedtofindasolutionfortheproblem.(Man,Session2inpostsessioninterview)Angermakestheproblemmoresevere.Wecanachieveeverythingbylove;nothingcanbeachievedbyfights.(Man,Session2inpostsessioninterview)OneoftheemergingthemesinSession2wasthathusbandsandwivesrarelycommunicatedtheconcernsthatproducedtheirtenshun,andtheparticipantsreportedasenseofisolationandper-ceivedlackofspousalsupportinaddressingtenshun-relatedissuesasacouple.Session3:Sexualityandsexinmarriage.TheobjectiveofSession3wastoprovideinfor-mationonmaleandfemalesexualandreproductivehealth,discussmisconceptionsaboutsexu-alityandidentifyfactorsthatleadtoandinterferewithapositivesexualrelationship,andbrainstormstrategiesthatcouldbeusedtodiscusssexandsex-relatedmatterswiththeirspouse.Atthestartofthissession,womenwerereluctanttodiscussmattersrelatedtosexduetosoci-etaltaboosandacultureofsilencethatsurroundssuchissues.However,theyopenedupgradually,anddescribedsex(jismaanisambandh,anUrdutermusedtodenotesex/sexualrelationship)inthefollowingways:Talkingwithhusbandandspendingqualitytimewitheachother.Whenhusbandwantssexthattimetheytalkverysweetlybutwhentheirneedsareovertheyevendon’trememberwhatalltheytalked.Sexisdirty.Sexispainful.Itishusband’sneedandwifeisresponsibletosatisfythem.Violenceandcoercivesex(Maar-peetaurjabardasti).80JOURNALOFMARITALANDFAMILYTHERAPYJanuary2018

Sexandfear.WheneverIthinkaboutsex,thefearofcoercivesexcomestomind(Women,Session3)Duringthesession,womenrevealedalimitedunderstandingofreproductivehealthandsoughtclarificationonseveralissues:Howisthebabyconceived?Whatisthebestwaytoavoidpregnancywithoutusingcontraceptives?Isswellingintheabdomenrelatedtoregularforcedsex?Whydowomenexperiencepainduringsex?WhatistheconnectionbetweenusingCopper-T(Intra-UterineDevice)andmenstrualproblems?Whydowomenhavewhitedis-charge?Menfocusedonthelackofprivacyforsex,anddescribedthisasareasonforengaginginsexoutsidemarriage.Womenoftendiscussedtheirhusband’scontinualreadinessanddemandstoengageinsex,andtheirreasonsforrefusal,includinglackofprivacy,poorhealth,andthefearofpregnancyduetononuseofcontraception,andcoercionandviolence.Bothmenandwomenexpressedlimitedknowledgeofsexuality,reproduction,andanatomy.Duringthediscussiononwhataretheingredientsofagoodsexualrelationship,womensaid,Understandingthepartner’sproblem,sexualdesires,satisfyingthem,goodcommunica-tion,leadtohappysexualrelationship(Woman,Session3)Illhealth…lackofprivacy,[and]havingmanychildrenisthebarriertoahappysexualrelationship.(Woman,Session3)Whensexualrelationshipsarestrained,itleadstodissatisfactionintherelationship.Itleadstofighting,quarreling,violenceandsometimesitmayleadtodivorce,too.(Woman,Session3)Whilewomeninitiallyfeltinhibitedtalkingaboutsexandsexualbehaviors,bytheendofthesession,theyreportedthattheyhadenjoyedthesession.Men,however,demonstratedimmediatecuriosityandaneagernesstohavetheirdoubtsclarified.Likethewomen,theytooappreciatedthesessionandthefacilitators’opennessindealingwithsuchtopics.Inthepost-CIevaluation,partici-pantsreportedthatSession3wasthehighlightofCI.Myinformationrelatedtothistopicincreased.Thereweremanypoints,whichIdidnothaveanyinformation,butIcametoknowaboutitbycominghere.Ididnothaveinfor-mationaboutphysiology,contraception,etc.TherewasnothingaboutthesessionthatIdisliked.(Woman,Session3postsessioninterview)Ilikedtheinformationaboutsafeperiod,becauseIdidnotknowaboutit.Soweusedbeafraideverytimewhilehavingsex.Allpeopleusedtosaythatpregnancyoccursifsextakesplaceimmediatelyafterthemenses.BecauseofsuchmisconceptionsItookpillsforthreeyears.(Woman,Session3postsessioninterview)Theroleplaywasverygood.Peopledobehaveinsuchaway.Itcommonlyhappensinthehouses.Myinformationalsoincreased,Icametoknowthathowwomangetspreg-nant,howafemalegetsmenses.NowIcantellthisinformationtoothersalso.(Man,Ses-sion3postsessioninterview)Ihavegottheinformationaboutovaandsperm.EarlierIwasnotawareaboutit.Firsttime,Ihaveunderstoodthesafeperiodconceptaswellaswomanisnotresponsibleforfemalechild(Man,Session3postsessioninterview)Session4:Sexualriskanditsprevention.TheobjectiveofSession4wastoreviewriskbehav-iorsandpreventivemeasuresrelatedtoHIV/STIs.ThesessionbeganwiththefacilitatorsplayinganeducationalcardgamewiththeparticipantstoassesstheirinitialknowledgebaseandteachthemaboutthesignsandsymptomsofSTIs/RTIs,emphasizingtheimportanceofrecognition,treatment,andpreventivepractices.Reflectingonthesession,manyoftheparticipantsidentifiedtheinformationtheyreceivedonHIVtransmission,sexduringpregnancy,andgeneralknowledgetheyobtainedaboutsexasthemostvaluablepartsofthesession.January2018JOURNALOFMARITALANDFAMILYTHERAPY81

IthinkwegottheinformationaboutHIVveryopenly,thatwasgood;thecarethatshouldbetakentomaintainasafesexualrelation,importanceofmaintainingsexualrela-tionswithonlyonepartner.SoIthinkIgotoverallgoodinformationaboutsex.(Woman,Session4)Forbothwomenandmen,thesessionprovidedasafespacetodiscusstheirpersonalviewsandattitudes.Formanyparticipants,thesessionalsovalidatedtheneedformutuallypleasurablesexwithinmarriage,contrarytotheculturallydominantparadigmofsatisfyingmen’ssexualdemandswithoutattentiontowomen’sneeds.Session5:Violenceinmaritalrelationships.Session5wasthefirstofthetwojointsessionsinwhichhusbandsandwivesmettogetherinagroupco-facilitatedbyboththemaleandfemalefacil-itators.Thissessionwasdesignedtohelpcoupleshaveabetterunderstandingofviolenceinitsvar-iousforms,understandthefactorsthatleadtomaritalviolence,anddevelopskillstoresolvecontentiousissuesinthemaritalrelationshipthroughnonviolentcommunication.Whendiscussingviolence,menprovidedavarietyofsituationsthatledtoviolenceinthehousehold,includingalackofincome,husband’sdrinking,mother-in-lawproblems(mothercom-plainingtosonabouthiswife),birthofafemalechild,andargumentswithwivesaboutunfulfilledhouseholdresponsibilities.Womenlinkedmen’sfrustrationsoutsideofthehomeascommoncausesofdomesticviolence.Verbalabusehurtsmuchmorethanphysicalabuse.Thewoundscausedfromphysicalviolencedisappearwithtime,buthurtthatiscausedbecauseofverbalabusenevergoesoff.(Man,Session5)Verbalabuseismorepainfulthanphysicalviolence.Becausephysicalviolencecanbetreatedbymedicineorrestbutemotionalviolencegivesdeeppaininsoul.Noonecanunderstandtheseverityofemotionalviolence.(Woman,Session5)Initially,severalmeninsistedthatbothpartnersareresponsibleforviolencewhilesimultaneouslyemphasizingtheneedforspousalcommunicationasthemainwaytoresolvehouseholdviolence:Clappingisonlypossiblewhentwohandscometogethersimilarlymenandwomenareequallyresponsibleforviolenceandtheyshouldsittogetherandsolvetheissues.Thisistheonlysolutionofviolence.(Man,Session5)However,anin-depthdiscussionontheuseofviolenceasanexpressionandassertionofpowerandmasculinitywasgeneratedwhenmenwerechallengedtoreflectontheformsof“violence”and“power”usedbymen.Mendominatedthemixed-gendersessionsalthoughwomenwerequitevocalandparticipativeinthesingle-gendersessions.Thefacilitatorshadtomakeanefforttoelicitresponsesfromwomenandgetthemtovoicetheirviewsratherthanletthemenspeakforthem.Aspartoftheend-of-the-sessionfeedback,onemanhadthistosay,Today’ssessionisverygoodbecausewebothhusbandandwifeweretogetherintheentiresession.Nowourunderstandingincreases.Sessionsarehelpingalotforourmaritalrelationship.(Man,Session5postsessioninterview)Session6:Towardahealthymaritalrelationship.Session6wasthefinalsessionandthesec-ondofthetwojointsessions.Theobjectiveofthesessionwastounderstandtheimportanceoftrust,communication,andlisteninginmarriageandtodefineandidentifyfactorsthatledtoapositivemaritalrelationship.Thefacilitatorsworkedwiththegrouptodefinewhatconstitutesapositivemaritalrelationshipandidentifytheessentialqualitiesandtraitsthatcouplesneededtoachieveit.Thefacilitatorsthenaskedeachofthecouplestochooseonemembertobeblindfolded.ThenonblindfoldedparticipantshadtoleadtheirblindfoldedpartnersaroundtheUHCwithver-baldirectionsonly.Theblindfoldingprocesswasthenreversed,andtheactivitywasrepeated.Fol-lowingtheexercise,thegroupdiscussedtheactivityandfocusedontheimportanceoftrustduringtheexerciseandinmarriage.Throughthisdiscussion,thefacilitatorsworkedwiththegroupto82JOURNALOFMARITALANDFAMILYTHERAPYJanuary2018

brainstormwaysinwhichcouplescouldbothfosterandunderminetrustintheirmaritalrelationships.Commoncausesofmistrustidentifiedbymenwereinteractionoftheirwiveswithotherwomen,neighbor’sgossip,beingcaughtinalie,andsuspectingthattheirwifehadanextramaritalaffair.Causesofawife’smistrustincludedneighbor’sgossip,decreasedcommunicationbetweenthecouple,andhusband’sbehaviorwhenthewifeisvisitinghernatalfamily(forpregnancyorextendedvisitstodistantruralareas).Menassociateddistrustwithincreasedfights,divorce,andlossofloveandaffection,whilewomenmostoftenassociateddistrustwithlossoflove,andincreaseddislike,suspicion,andlonelinessbetweenthecouple.PostinterventionReflectionsAttheendofthefinalCIsession,coupleswereinvitedbyevaluatorstoanswerquestionsandreflectontheintervention.CoupleswhodidnotmindwaitingafterthefinalCIsessionandwerewillingtoprovidefeedbackonallsixofthesessionswererequestedtospareapproximately30minforthisreflection.Thekeyareasthatparticipantscitedcouldbecategorizedasinformational(thosepertainingtoachangeinknowledge),relational(thosepertainingtoachangeinmaritalandfamilyrelationshipsbecauseofenhancedunderstandingofspousalexpectations),oremo-tional(thosethatimpactedparticipants’psychologicalwell-being).Informationalchanges.Participantsreportedanincreaseinknowledgerelatedtoanatomy,fertility,contraception,sex,andHIV/STIs.Participantsspecificallyreferencedincreasedknowl-edgeofmaleandfemaleanatomy,properbirthspacing,factorsthatdeterminethesexoftheunbornchild,menstrualcycle,contraception(includingcondomuse),masturbation,sexduringpregnancy,sexuallytransmitteddiseases,therisksofunprotectedsex,andgeneralknowledgeonHIV/AIDSanditstransmission.Relationalchanges.Participantsalsoreportedimprovedrelationshipswiththeirspouses,mother-in-law,andchildren.Whilewomenoftenreferencedanimprovedrelationshipwiththeirmother-in-law,menoftentalkedaboutchangesinthehusband–wifedynamicsandthebalanceintheirrelationshipwiththeirwifeandmother.Bothmaleandfemaleparticipantsnotedanincreaseincommunication,andareductionintenshun,fights,andmistrustintheirmarriage.Menandwomenoftenreferencedchangesintheparent–childrelationship.Menreferredtotheireffortstobecomebetterrolemodelsfortheirchildrenandreflectedonanincreasedinvolve-mentintheirchildren’slifeandeducation.Women’sresponsesfocusedonanimprovedrelation-shipresultingindecreasedangerandconflict.Aspartofthechangeinthemaritalrelationship,manymaleparticipantscommentedonincreasedparticipationinhouseholdresponsibilitiesandwife’sfulfillmentofhouseholdresponsibilities.Psychologicalwell-being.AsaresultoftheCIsessions,bothmaleandfemaleparticipantsreportedchangesintheirtenshunlevels.Forwomen,thischangewasoftenreflectedindecreasedangerandresentment.Menreporteddecreasedangerandirritationwhensolvingconflictswiththeirspouse,children,orotherfamilymembers.Effectivespousalcommunication,particularlyrelatedtotheday’seventsandfrustrationsexperiencedbybothspouses,wasseenasthekeytothereductionintenshun.DISCUSSIONFindingsofstudiesonmaritalinteractionandwell-beingsuggestthatitisthequalityofthedyadicinteractionthatiscrucialforindividualwell-being,andthattheeffectsofmaritalqualityareastrongerconcernforwomenthanamongmen(Qadir,Khalid,Haqqani,Zille,&Medhin,2013;Schmitt,Kliegel,&Shapiro,2007;Williams,1988).ThedynamicsofthemaritaldyadinIndiaplayakeyroleinsexualhealth,sexualrisk,andemotionalwell-beingforboththehusbandandwife.Patriarchy,genderinequity,violence,coercivesex,poorcommunication,andlackofknowledgecontributetoincreasedsexualriskandpoorsexualandpsychologicalhealthamongasignificantsubsetofmaritalcouples.Inacontextwherethedominantnormssupportpatriarchyandgenderinequity,whywouldmenwanttochange?Wesuggestanumberoffactors.Menasfathersandhusbandsinurban,eco-nomicallymarginalcommunitieshavenowbeguntorecognizethefinancialadvantagesofmoreJanuary2018JOURNALOFMARITALANDFAMILYTHERAPY83

educationandacquisitionofskillsleadingtoemploymentforwivesanddaughters.Inturn,thisrecognitionhasledtolatermarriage,increasededucationalattainment,morecontributionsbywomentohouseholdincome,andagreaterdegreeofempowerment.Thesetrendsaresupportedbyglobalizationofmedia,thechangingimagesportrayedbyHollywoodandBollywood,thebuildingofwomen’snetworksthroughthecellphone,accesstotheInternet,thegrowingwomen’smovementsinIndia,andtheworkofcommunity-basedorganizations(CBOs)thathavepromotedvocationaltrainingandincreasingwomenandgirls’empowerment(Ghosh,2011;Mankekar,2004;Mishra,2011;Netting,2010;Tenhunen,2008).Whilethereisnodoubtthatnormativepatri-archystillexists,andwasresponsiblefortheinitialanddecliningparticipationofmen,andconse-quentlyofwomen,theimplementationofCIandtheparticipationandresponseofthosemenwhoparticipatedisarecognitionofthesesocialandculturalchanges.Toourknowledge,thiscouples’interventionisthefirsttoaddressmarriage,dynamicsofthespousalrelationship,andsexualhealthinIndia.Unlikemanyofthecouples’interventioneffortsinternationallyordomesticallyintheUnitedStates,theinterventionreportedherewasconductedinalow-incomecommunitywithageneralpopulationofmarriedcouples,ratherthanwithhigh-riskbehaviorgroupssuchassexworkers,drugusers,andpersonswithHIV.Perhaps,forthisrea-sonandthefactthatCIwasconductedinacommunitysetting,theratesofinitiationofthefirstsessionwasalittleover50%,despitetheinitialconsentprovidedbythewomen.Thispercentageisinsharpcontrasttothatforwomenwhowereassignedtoindividualcounseling.Whileindividualcounselingwasequallynewandunfamiliar,80%ofwomenattendedatleasttheinitialICsession.Clearly,thedifferenceinthelevelofparticipationinthetwomodesofinterventioninvolvedtherequirementthatwivessecurehusbands’consenttoalsoparticipateinCI.Thebarrierstomaleparticipationinwomen’sreproductivehealthhavebeenwelldocumented(Dudgeon&Inhorn,2004;Msuyaetal.,2008;Mullany,Becker,&Hindin,2007).Inthiscase,men’sreluctancetobeinvolvedincouples’interventionincludedthelackoffamiliarityandunderstandingoftheobjec-tivesandprocessoftheintervention,thecommitmenttolonghoursofwork,andthelackofsup-portfromotherfamilyandcommunitymembers.Severalpossiblestrategiesformoreeffectiverecruitmentandretentionofmenshouldbecon-sideredforthefuture.TheRISHTAstaffsupplementedwomen’seffortstoinvolvetheirhusbands,butmoreemphasisonprogrammaticcontactsmighthavehelped.OrganizationalmeetingsformenpriortothestartofCIsessionsmighthavebeeneffectiveinmakingmenmorecomfortablewiththeconceptofCI.EndorsementandencouragementbyMuslimreligiousleadersfromthecommunityforparticipationinCImighthaveprovidedanadditionalincentiveforparticipation.Individualsessionsorsomeformofmale-specificcounselingmayalsohavebetterpreparedmentoparticipateintheCIintervention.Fewersessionsmayhavealsohelpedwithretentionwithoutsac-rificingtheefficacyoftheintervention,asnotedinpreviousstudies(Bradford,Mock,&Stewart,2015;Pettiforetal.,2014).Thesestrategiesandothersthatmayberelevanttospecificculturesandcommunitiesneedtobedevelopedandimplementedpriortoinitiationofcouples’intervention.PractitionersattemptingtoimplementCIelsewhereshouldalsoconsiderthechallengesassociatedwithsustainabilityandsupportforcouplesaftertheinterventionends.TheWHCintheUHCcouldsustainindividualcounselingbutcouples’interventionwouldneedsupportwithintheNGOorreligioussectors.RISHTAisstillseekingopportunitiestobuildcapacityforCIinthestudyarea.Thedocumentationofthesessionsindicatedthatwomenweremuchmorevocalandpartici-pativeinthesingle-gendersessions,whilementendedtodominatetheinteractioninthemixed-gendersessions.Itmaybepossibletobetterpreparewomenforthejointsessions,andfacilitatorscouldprovidemorespaceforwomentocommunicatetheirviewsinthejointsessions.Thisgenderdifferencehasimplicationsforconsultationandcoachingwithfacilitatorslinkedtoformativeeval-uation;forexample,programstaffcouldobserveparticipantaswellasfacilitatorcommunicationandprovidefeedbackandcoachingonhowtoaddressdisparitiesincommunicationbetweenmaleandfemaleparticipants.Thereareformidablebarrierstotheinvolvementofmen,aswehaveseen;however,men’scommunication,knowledge,andemotionalstatusplayasignificantroleinthedynamicsofthecouple.Itisimportanttocontinuetheeffortstoengagemeninsexualandreproductivehealth84JOURNALOFMARITALANDFAMILYTHERAPYJanuary2018

interventions.Asonemanstatedinthepostsession6feedback,“Iwasneversoabletosee,whenIhadtheblindfoldonandwasguidedbymywife.”Inapatriarchalsociety,wheremarriageasaninstitutionishighlyvaluedandpromoted,women’swell-beingandhealthisoftensacrificedfortheprioritiesofothermembersofthefamily.Whilewomen’sexpectationsofmarriagecallformutualunderstandingandrespect,manymendonotmovebeyondtheir“bread-winner”role.Often,womenacceptthehusband’sauthorityandmayjustifymen’suseofviolenceaspartofmarriage.Thus,men’spatriarchalvaluesandbehaviorsandwomen’ssubordinationwithinthemaritaldyadneedtobechal-lengedandshifted.Theevaluationresultsindicatethatcouples’interventionprovidesanopportunityforspousestounderstandeachother’sperspectivesandaddressissuesofpower,violence,andtrustinamaritalrelationshipwiththegoalofstrengtheningandinvestingintherelationship.CIwaseffectiveforbothmenandwomeninimprovingsexualknowledge.Womenreceivelittleornoinformationaboutsexuality,anatomy,orsexualrelationshipsinmostIndiancom-munities.Thegreatmajority(90%inthissample)haveearly(<18yearsofage)andarrangedmarriagesinwhichtheyhavelimitedfamiliaritywiththeirprospectivespouses.Consequently,theyentermarriagewithoutthebasicinformationforsexualhealthandmaycontinuethatpatternevenafterchildbirth.Withstrongsegregationofthesexes,mostmenhavelimitedinteractionswithwomenpriortomarriageandlimitedsexualexperience.Men’sknowledgeofsexualitymaybedrawnfrommisguidedpeers,pornography,orvisitstosexworkersasanentryinto“manhood”andpreparationforthe“firstnight”ofmarriage.Thesessionsdealingwithreproductiveanatomyandsexualriskwerethemostpopularsessions,addressingmiscon-ceptionsanddiscussingpositivesexualrelationshipswithanemphasisonmutualityandnon-coercion.TheseresultssuggestsexualityeducationisneededformarriedcouplesandmaybebestachievedinaformatsuchasCI.Forasubsetofmarriedcouplesinlow-incomecommunities,communicationbetweenhus-bandandwifeislimitedtothebasiclogisticsofdailylife,devoidofshareddecision-making,andnegotiatingperspectives.Thislackofcommunicationparticularlycharacterizesthosearrangedmarriagesthatstartedpoorly,wherethecouplehasnotgrowntogether.TheCIpro-cessemphasizedtheimprovementofthemaritalrelationshipaswellasrelationshipswithchil-drenandotherfamilymembers.Qualitativefeedbackfromparticipantsattheendofeachsessionandfrommenandwomenwhorespondedtotheformalpostsessionandpostgroupevaluationindicatedrecognitionoftheutilityofimprovedcommunicationwiththeirspouse.Theimprovedspousalcommunicationalsohadafurthereffectofgeneratingbetterrelation-shipswithchildren,mother-in-law,andotherfamilymembers,contributingtooverallwell-beingforwomenandmen.Lifeinalow-incomecommunityinMumbaipresentsmanychallengesincludinginfrastructure(water,sanitation,androads),financial(inconsistentemployment,insufficientfinancestomaintainthehousehold,andchildren’seducation),andrelationaldynamics(maritaldyadandthefamily)inlimitedresidentialquarters.Thesestressorscontributetotenshunandcopingstrategieswerefoundtobefrequentlydysfunctional,producingevengreatertenshun.Participantsreportedthat,asaresultoftheCIsessions,theywereusingbettercopingstrategiesthatbeganwithimprovedspousalcommunication.Asubsetofmarriagesinthestudycommunityfacemanychallenges,bothinternalandexternaltothecouple.Thesechallengesnegativelyimpactonsexualhealthandcontributetoemotionalandsexualriskofhusbandsandwives.Formiddle-andupper-incomeIndiancou-pleswhocannotresolvetheseissues,themostproductivealternativemaybeseparationordivorce.Forlow-incomeurbanwomen,thisalternativeisonlyavailableinthemostextremecasesduetoissuesrelatedtoabsenceofshelterandlivelihoodoptions,inadequatesupportofthenatalfamily,andstigmaattachedtobeingdivorcedorseparated.Insuchcircumstances,oneoftheapproachestoaddressawiderangeofissuesistostrengthenthemaritaldyad.Couple’sinterventionprovidesanempiricallytestedapproachtostrengthenthemaritalrela-tionshipbycreatinganopportunityforwivesandhusbandstoaddresschallengestogether,discussmutualexpectations,andresolvedifferencesinacollaborativeandnonviolentwayinasafeenvironment.January2018JOURNALOFMARITALANDFAMILYTHERAPY85

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