At The Tara Hotel, Dublin – 21 September 1996
A Report by Alan A. Mooney
IACT hosted the day and the presenter was Iris Greene FRCOG; MST; IACT. There were about 40 people from a wide variety of backgrounds present. Some were full-time counsellors and therapists, others were interested associate members of the IACT.
Sex begins in the brain! In the hypothalamus to be specific, it involves different glands along the way. The chief of these is the Pituitary gland, various other glands offer their tuppencehapenny worth until the actual business of sex becomes noticeable!
Iris described the normal sexual response as tri-phasic. That is to say there are three main elements: Desire (brain), Excitement and Orgasm (spinal reflex). Dysfunction can occur at any of these levels. Sexual dysfunction can be labelled in two ways: Primary – it has always been present and Secondary – it occurs after a normal period of sexual activity.
She indicated that unless there is a particular pathological reason for dysfunction it can usually be ascribed to anxiety. Anxiety may be generated because of significant trauma like rape or sexual abuse in a person’s history or because of experiences with sex that have left the person feeling inadequate in some way. There may be a power struggle or a worry about performance. In some instances the cause of the anxiety may be deeply buried in the unconscious. Culture and religion may also play their role. The presenter was interested in describing the practical experience of dysfunction and prescribing a behavioural model for its remediation.
How can dysfunction be recognised and attributed to the appropriate stage of the tri-phasic model? Where desire is absent, e.g. in both male and female there is a reduction or absence of sexual interest (libido), a dysfunction at the primary level (hypothalamus) is indicated.
If there is desire but a problem occurs at the excitement stage, e.g. failure to achieve an erection, in men or general sexual dysfunction, including non-lubrication or non-excitement in women, then the problem lies in the nervous system (spinal reflex).
At the third stage (orgasm), problems arise for men in premature ejaculation (the presenter mentioned that there were two million men in America diagnosed as premature ejaculators, someone in the room (a man) remarked; “thank god they’re over there”, the irony was not lost on the group), or retarded ejaculation and for women in the inability to achieve orgasm (inorgasmia). Vaginismus may also feature for women. This is a condition where the muscles in and around the vagina are in spasm so that penetration is impossible and/painful. Iris mentioned that vaginismus may be associated with guilt about real or fantasised incestuous relationships or guilt about sexual pleasure.
She went on to indicate that it is easier to work with dysfunction at the orgasmic phase because it is more readily amenable to a behavioural approach. The behavioural approach does not automatically take into account the fact that there might be an emotional issue to take into account. It was suggested that it is possible to circumvent emotional issues and to deal with the physical problem in isolation. This would not conform to a humanistic and integrative approach that would see the dysfunction and the anxiety as a whole and would approach the client in a way that would hope to integrate change such that the root of the anxiety would be dealt with in tandem with the behavioural anomaly.
Iris did mention that where there were issues of anxiety that required psychotherapeutic intervention, she would not deal with them, preferring to refer the clients on to another counsellor or therapist for that work and to deal only with the practical aspects of the dysfunction herself.
She described a treatment involving a process called “Sensate Focus” where a couple take a step back from the specific sexual problem and begin working at a very basic level of physical intimacy, gradually increasing the level of contact until it becomes possible to address the particular dysfunctional element in a way that is safe for the people involved and secure in the likely positive outcome. She went into some detail about this and the participants had the chance to question and clarify the raison d’etre of her approach.
Iris emphasised the function and importance of initial assessment. The purpose was to assess the suitability of prospective clients for sex therapy, to determine whether the sexual problem presented had more to do with an underlying relationship pathology and to assess any medical or drug related reasons for the dysfunction.
A very detailed history is taken separately, from the man and from the woman. Confidentiality is assured, however, where an item in the separate histories is likely to be significant to the resolution of the problem it is discussed with the client on the basis that it might be better to allow their partner to know about it. Where no agreement is reached on such an issue, a decision to advise the couple that sex therapy is not appropriate may be indicated. How this is communicated is important since the “real” reason cannot be divulged. Assuming therapy will go ahead, a joint meeting with the couple is arranged and the course of therapy is outlined. It is discussed and their commitment is sought.
The group was asked to role-play (in groups of four), a couple, a therapist and an observer. Each “couple” were given an outline of a problem to develop and discuss with the therapist. This was great fun, however, it did have its serious side since most of the groups decided that the sexual problems presented did not exist in isolation from the relationship and so most decided to recommend psychotherapy as well as sex therapy.
I am not evaluating the day in this report. I do know how attractive to the solution of problems is the idea of a quick-fix (relatively). My experience as a therapist tells me that such solutions are rare and that most of the time removing the symptoms of a problem without working on the root at the same time is doomed to eventual failure. The role of expert is also attractive – I know what to do let me help you! -but reality again tells my that I do not know the answers because I am outside the system where the answers lie. As a therapist, what I can offer is the safety and confidentiality of the relationship between my clients and me to enable them to come to their own resolution of their difficulties. At the same time it is good to be able to offer a scheme or template that may help along the way.
In passing, I thought about the fact that IACT offer regular seminar days during the year on various subjects. Whatever the quality or depth of these days, they do offer counsellors and therapists an opportunity to meet and to network. This is good in a profession that so often sees its members working in isolation. Perhaps IAHIP is established enough now to consider sponsoring such days. They might even generate some small income to further the work of the Association and thus, keep membership fees down!