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Chapter: Essentials of Psychiatry: Couples Therapy

Couples Therapy: Couples Function and Dysfunction

Members of couples are influenced by past and present re-lationships and tend to form ties that have a distinct character that emerges through regular cycles of conflict and resolution.

Couples Function and Dysfunction


Couples Development


Dym (1993) has described how couples relationships evolve over time. Members of couples are influenced by past and present re-lationships and tend to form ties that have a distinct character that emerges through regular cycles of conflict and resolution. Dym draws attention to broad, normative changes in couples, char-acterizing these developmental shifts as periods of expansion, contraction and resolution. For example, in the early expansive years of a committed romantic relationship, the lives of two are in a sense woven into one. Some refer to this period of optimism, promise and fusion as moving from “I” to “We”.


In the next years of the relationship, Dym describes a predictable stage of contraction and a feeling of betrayal, in which members of the couple reconnect with a need for an “I”. This desire can be marked by experiences of doubts, fears and insecurities, and many couples retreat from their established routines. Partners may find themselves feeling “out of synch” with their own personal ambitions, describe themselves as feeling trapped or lonely, and may believe they are progressing at different tempos from each other. Stormy times may ensue with bitter conflict and blame. During the resolution stage couples may resort to compromise, negotiation, or even a more radical restructuring of their relationship in an effort to make room for both the individual and the relationship. In considering this dialectical movement from expansion to contraction to resolution, this cycle repeats several times over the course of the relationship. Dym notes that many couples have what he calls a “home base” where they tend to reside, in terms of the sense of “We”, “I”, or “working on it”. A home base is the point of the cycle of expansion and contraction where the couples find themselves most often.



Sexual Functioning of Couples


It has been estimated that 50 percent of American marriages have some sexual problems. These can be divided into “difficulties” (such as inability to agree on frequency) which are clearly dyadic issues; and dysfunction which are specific problems with desire, arousal and orgasm, as listed in the DSM-IV (American Psychi-atric Association, 1994). Dysfunctions may be organic or psycho-logical at base, and may be lifelong or acquired, generalized or situational. They may be deeply embedded in relational power or intimacy struggles, or may be the only problem in an otherwise well-functioning relationship. While most family therapists be-lieve that there is no uninvolved partner when one member of a couple presents with sexual dysfunction, that is different from say-ing that the relationship itself is the cause of the dysfunction. The job of the therapist is to ascertain as best as possible the etiology of the problem and to choose the most effective therapy, whether medical, individual, or relational. It is also within the therapist’s purview to inquire about whether the couple would like to improve a technically functional but not very satisfying sexual relationship, in the same way that the therapist can offer methods or directions to increase intimacy in a couple that wishes personal growth.


Diagnosis/Systems Issues


Sexual dysfunction or dissatisfaction is, in a minority of times, caused by a psychiatric disorder (depression and anxiety may often decrease sexual desire). It is commonly caused by igno-rance of sexual anatomy and physiology, negative attitudes and self-defeating behavior, anger, power or intimacy issues with the partners, or medical/physiological problems. Medication side ef-fects are a particularly common cause of sexual dysfunction in patients who are receiving selective serotonin reuptake inhibi-tors (SSRIs). Male erection problems are proving increasingly amenable to medical forms of treatment. It is also important to remember that people vary enormously in the importance they place on sex or eroticism in their lives. For example, in The Social Organization of Sexuality: Sexual Practices in the US (Laumann and Michael, 1994), about a third of the people surveyed have sex at least twice a week, about a third a few times a month, and the rest, sex with a partner a few times a year or not at all. In general, when sex is not part of a marriage over a long period of time, the relationship has less vitality and life. However, even well-functioning marriages may have periods in which sexuality is much less part of their lives (such as after the birth of a first child, or during a family or health crisis). Different people have vastly different tolerance for such periods.


Because sex is a way of each person being vulnerable to the other, it is difficult to have sex when one is angry or not in a mood to be close (although some people can block out other feel-ings and keep the sexual area more separate). In addition, people who feel abused, mistreated, or ignored in a relationship are less likely to want to please the other. For some who feel that they have no voice in the relationship, lack of desire is sometimes the only way they feel able to manifest displeasure.


Couples who continue in marital or individual treatment for long periods of time can resolve some of their marital prob-lems but can still suffer from specific sexual difficulties in their marriage. It is also true that specific sexual problems may be dra-matically reversed after relatively brief periods of sex therapy, even though such problems may have proven intractable follow-ing long periods of more customary psychotherapy. However, sexual functioning which is suffering because the partners do not want to be close is not likely to respond to sex therapy unless other issues are also addressed.


Usually, when a marital couple has a generally satisfactory relationship, any minor sexual problems may be only temporary. Resolution of sexual problems, however, will not inevitably pro-duce positive effects in other facets of a relationship as well.


Marital and sexual problems interact in various ways:


·              The sexual dysfunction produces or contributes to secondary marital discord. Specific strategies focused on the sexual dysfunctions would usually be considered the treatment of choice in these situations, especially if the same sexual dys-function occurred in the person’s other relationships.


·   The sexual dysfunction is secondary to marital discord. In such situations, general strategies of marital treatment might be considered the treatment of choice. If the marital relation-ship is not too severely disrupted, a trial of sex therapy might be attempted because a relatively rapid relief of symptoms could produce beneficial effects on the couple’s interest in pursuing other marital issues.


·   Marital discord cooccurs with sexual problems. This situa-tion would probably not be amenable to sex therapy because of the partners’ hostility to each other. Marital therapy would usually be attempted first, with later attention given to sexual dysfunction.


·   Sexual dysfunction occurs without marital discord. This case might be found in instances where one partner’s medical ill-ness has affected his or her sexual functioning, forcing the couple to learn new ways to manage the change. Another ex-ample might be when one partner has a history of sexual abuse or a sexual assault that creates anxiety related to the sexual experience. While individual therapy can be helpful in both of these cases, couples therapy can be especially useful in creat-ing a safe place to address painful feelings and anxious ex-pectations, and to provide education and guidance for couples undergoing these transitions.


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