Addressing Relationship Issues in the Context of Illness

As we suggested earlier, aging, illness, and/or disability may have changed the client’s level of interest in sex. Level of desire, especially a discrepancy in desire, should be closely examined. Attempts should be made in therapy to reconcile this difference in the couple. The desire discrepancy may have predated the physical problem or be compounded by it. The therapist will need to perform a complete sex history for the couple and also explore the impact of the illness on the couple and sexual dynamics. For example, one partner may become the caretaker to the other, thus creating a parent-child relationship dynamic that affects more than the sexual relationship.

Another concern is how the couple deals with the medical/physical impact on attractiveness, affection and sensuality, sexual functioning, and so on. How is the asymptomatic partner affected and how is the couple is compensating sexually? Sometimes the compromised partner will have incorporated a negative sexual self-image and might not be communicating with their partner about their feelings. If the therapist suspects this dynamic, each partner’s view of their sexual selves can be explored as well as the couple’s view of themselves as a sexual couple. One or both partners might need permission and time to mourn the loss of sexual functioning, express anger, rage, embarrassment, fears, and so on.

Some of our clients are not partnered and will need to discuss their concerns about dating and sexual expectations. We reduce reluctance to dating by allowing for discussion of expectations and by reinforcing the notion that dating can be treated as an opportunity to spend time with another person without pressures related to sex. Some individuals may have developed a virtually phobic avoidance of trying to develop a relationship. The therapist will need to process their avoidance feelings and their negative beliefs about their sexuality and value in a relationship. For example, a man in his 40s developed herpes in his marriage. It had probably been dormant for decades. He was a man with high morals who believed he was being punished for acting-out as a young man, and believed that no woman would ever want to be with him sexually nor would he ever want to give the infection to another. He presented with depression and an avoidance of any contact with women that could lead to a sexual relationship. The development of a more positive sexual selfimage can occur through cognitive interventions discussed previously.

Expanding the Sexual Repertoire

A sexual act that does not culminate in penetration or orgasm is often viewed as falling short of an essential sexual goal. The couple can be helped to appreciate a greater variety of pleasurable sensual and sexual activities. Each physical activity can be enjoyed and valued as an expression of pleasure, intimacy, caring, and so on depending on the meaning of sex for the individual or couple. The pressure to experience goal-oriented, penetrative sex is discouraged in all of our clients; instead, they are helped to be mindful of the sensations they are feeling in the moment and to communicate these feelings to the partner, if partnered. Expanding the sexual repertoire can incorporate exploring new positions, techniques, devices, or sexual aids. Nonetheless, the therapist can help to explore the possibility of penetrative sex after first learning the intrinsic value of affectional and sensual interactions.

The therapist should support an attitude of trial and error, with an emphasis on the pursuit of pleasurable activities. Couples who are looking for easy answers, fixed performance-oriented goals, or for the therapist to simply tell them what to do will be disappointed. Emphasize creativity in an effort to inspire them to find their own solutions. Table 12.2 provides some factually based resources about sexuality that will help correct myths and misinformation and supply scientifically based information. These resources also suggest new and different techniques for enjoying sexual expression and expanding the sexual repertoire.

Enhance Couple Communication

The onset of illness, disability, or age-related decline may significantly influence couple dynamics, producing impaired communication, changes to sexual intimacy, unwelcome role changes, and challenges in adapting to the new situation (Dankoski & Pais, 2007). The more functional partner might feel guilty about having sexual feelings toward someone who is ill or in pain from a disability. Couples may be very reluctant to discuss these concerns, particularly in the presence of the partner with

Table 12.2 Sexuality Resources for Physical Disabilities

the illness or disability. Sometimes it will be necessary to meet with each partner individually to get a sense of what they are experiencing and help them develop a plan for discussing their concerns in the couple session. We often prescribe incremental sensate focus assignments to be performed at home with the stipulation that the partners communicate about what they are feeling (see the chapter on sensate focus). These exercises will also reveal underlying obstacles to the couple having better sexual expression. Additionally, accessing the client’s sense of humor, fun, and creativity will afford a sense of empowerment to keep the focus on sexual enjoyment, not dysfunction.

Attend to Issues in the Therapist

The therapist must be informed about and prepared to discuss accurate information in a nonanxious and direct manner. Some health and mental health practitioners have circumvented the critical discussions involving sexual needs and proceeded with a singular focus on treatment as though sex is unimportant in illness, aging, and disability. Therapists may lack knowledge, not feel comfortable talking to older or disabled clients, and share some of the client’s mythological thoughts about sex. Some clients have never been asked directly about their levels of sexual interest, activity, and desire to improve their sexual lives. Therapists need to understand how their countertransference issues can hamper treatment and increase embarrassment, stigmatization, and vulnerability in the client. The therapist may actively or passively avoid discussing sexual issues or discuss them in a superficial way. Anxiety in the therapist can be readily detected by the client(s) who then avoid bringing up or pursing the topic of sex. The therapist may give simplistic advice and move on to topics with which they are more comfortable. Additionally, older therapists may be reluctant to discuss sexual problems with a client who is the same age as their child or grandchild. The reverse is also true. A younger therapist may have trouble talking about the client's sexuality when they are older or about their parent’s age.

Finally, therapists may experience countertransference issues with this population based on cultural stereotypes that chronically ill, older couples, or individuals with disabilities are not sexually interested or active. Therapists may also have fears of their own about illness, disability, and death or they may be having trouble coping with one of these medical/ physical issues in their own families or relationships. The therapist must be open to their own vulnerability in order to help those in such a vulnerable position. If the therapist has difficulty accessing the client’s painful emotions or avoiding therapeutic discussion around sexuality, it is essential that they seek supervision or psychotherapy.