Three-Person Leadership Teams in Group Therapy for Sexual Recovery

In this article we would like to discuss the reasons for and the results of developing a three-person co-facilitation team to lead our sexual recovery treatment group. Seattle Institute for Sex Therapy, Education and Research has been offering a group treatment component in our sexual recovery program for four years and has been treating adults with sexual trauma and exploitation histories since our founding in 1975. In the early 1980′s we began extensive staff discussions regarding the effects of such histories on sexual functioning and possible therapeutic interventions appropriate to this population. The publication of our self-help pamphlet, “Recovery from Rape: Healing your sexuality,” was one major outcome of these conversations. The senior author and other staff were experienced in the use of small group psychoeducation in the treatment of primary anorgasmia in women and convinced of its effectiveness for appropriate clients. Unfortunately no such group had been designed for the treatment of symptoms of childhood and adolescent sexual trauma/exploitation. Using a clinical model presented by Becker and Skinner and designed for rape survivors, the senior author organized and led four ten-session groups focused on sexual recovery. When we began, this model represented the only published information on treatment for sexual recovery.

We were aware at the time that a large percentage of our clients were survivors of childhood and adolescent sexual exploitation and/or trauma; only a small fraction of our clients had trauma limited to adulthood. Undaunted by the implications of such a clinical population, we entered this brave new world motivated primarily by the need to provide more effective and less costly services and by the challenge of developing a program design. The first two of the groups were co-led by interns. By the completion of the second group, our intrepid senior author was sufficiently convinced that burnout was just around the corner to cancel a third group until she could find another professional with experience treating this clinical population.

Fortunately local interest in the treatment work we were doing was increasing, particularly among therapists who treated adult survivors of chaotic childhoods, and the second author had joined our staff to do a part time internship. She had extensive previous experience in process-oriented group therapy with adult children from dysfunctional families. We again undertook a time-limited psychoeducational group. The additional clinical support accomplished the stress-reduction effect sought by the senior author and, perhaps more important, provoked a collaborative dialog on questions of design. A timely interest expressed by the third author in interning in the group gave us the necessary resources to expand our group design to its current model. Her experience added a specialization in group work with adult survivors of incest and/or sexual trauma.

We reformulated the group to be an ongoing treatment program with quarterly openings; the content of the group shifted to an increased focus on group process while continuing to include the educational material and recommendations for homework. Active leadership in each quarter was rotated to two of the three therapists. The third therapist, however, was often in attendance at group meetings as a silent partner. When not in attendance, the observing therapist listened to tape recordings of the group sessions; these recordings were also available on an appointment basis to group members who missed a session. The silent therapist acted as a consultant to the active leaders. Since the group had added a process component and since it was, in effect, now an ongoing group, we were able to elicit information from our clients about their experience of the design.

Results

The first effect noted by the treatment team was the increase in emotional and therapeutic support felt by the therapists. When challenging transactions with a client occurred, the presence of a therapist observer often assisted staff in more confidently sorting out the issues involved. Sometimes such transactions occurred in group, which allowed direct scrutiny; often, however, they were out-of-group contacts, i.e. sub-grouping. Even in these instances having three knowledgeable heads instead of two assisted the treatment team in exploring issues more quickly, comfortably, and (we believe) comprehensively. The complementarity of our skills was a welcome resource in challenging and difficult situations. Our increased resilience in dealing with stressful group process was immediately obvious to us. With a three-person leadership team we seemed to reduce the likelihood of counterproductive triangulations with the clients as well as personal burn-out.

A related effect was an increase in our awareness of treatment options since we worked as a problem-solving team. Given that the three of us were pioneering spirits, increasing creativity operated as a powerful reward. This reward arrived at a time when the material rewards from this work were meager. We were spending one to two hours of consultation time for every group session, a necessary reality in research and development but a real difficulty to three people who supported themselves as clinicians. Among several thorny issues, some of the most important were these:

  1. The ambivalence experienced by our incoming clients about even wanting to work on sexual recovery. Most clients entered treatment unclear about whom they were doing sexual recovery work for; often treatment was motivated primarily by a fear of losing a partner.
  2. The damage done to trust and bonding by childhood experiences made the establishment of rapport a major therapeutic undertaking.
  3. Questions about what priority should be given to processing the trauma history in group, i.e. breaking silence, versus using a problem-solving focus on here-and-now issues.
  4. Our conviction that control of decisions regarding her own body needed to be given to the client often clashed with concerns that we not allow escape avoidance patterns to sabotage sexual recovery.

One of the more obvious manifestations of these four issues was in the issue of homework assignments. Incoming clients would experience difficulty completing work between sessions and could become entangled in emotional reaction concerning this “failure.” We became increasingly alert to the meanings attached to the assignments, their completion or lack thereof, and the possible therapeutic opportunity such events offered.

Current Reactions to Leadership Design

In group process time we often solicited information about clients’ reactions to group structure, including leadership. Often as we approached the end of a quarter and a change in leaders, clients would have concerns about the “loss” of a leader with whom they had felt bonded. Clients varied as to whom they bonded with and what they perceived that staff person offered them. Handling this transition in group, we believe, offered clients an opportunity to work on issues of abandonment in conscious ways. Modeling of the natural comings and goings of life provided a structure to explore new ways to honor and process endings. The therapy team’s respect for each other’s differences in temperament, needs and resources gave opportunities to model the right to be me within a cooperative relationship.

Conclusions

As we approach the beginning of our second year using this design, we are enthusiastic about the results. To be sure the clinical challenges remain; what is encouraging is our sense of depth of resource. We are still grappling with the economic issues posed but are convinced that it would be false economy to go back to the two-leader design. At present the observing leader now attends the first and last of each quarter’s sessions, listens to the tapes of the other groups and attends weekly consultation meetings. We have been able in this way to continue to provide long term continuity while raising the cost only slightly. We are eager to share more details of our experience with other clinicians who may find it helpful in their work. A detailed article on the clinical issues and treatment techniques for sexual recovery has been prepared by the senior author and is available at cost from this agency.

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Lack of Sexual Desire

Lack of desire is the most frequently experienced problem presented by clients requesting sex therapy at Seattle Institute. The problem manifests as a disinterest in or avoidance of sex and, in many cases, is reflected as a discrepancy in two peoples’ desired frequency of sexual contact.

Lack of sexual desire is a problem that presents both partners in a relationship with a confusing dilemma. Couples often question the level of commitment and caring for one another when one or both lack sexual interest. A cycle often develops resulting in their undergoing increasing levels of stress in daily interactions which negatively impact problem-solving skills and communication patterns. While most (certainly some) couples may be reevaluating their commitment with a corresponding change in sexual desire, there is a broader range of factors that impact sexual interest.

Initial therapeutic assessment takes into account physiological problems that may be contributing to a decrease in sexual functioning. Medical evaluations often focus on assessing hormone levels, thyroid function, use of medications such as anti-hypertensive medications, vaginal infections, or any other illnesses or conditions that may affect sexuality. In addition, the use of alcohol and drugs must be evaluated since research has shown that excessive use of chemicals can drastically decrease sexual interest either while using or during recovery.

Once all physiological components have been ruled out, assessments focus on the interactions of the couple, their communication patterns, sexual expectations, stress levels, and the amount of time set aside for emotional and sexual contact. The lack of sexual desire is a frustrating problem for many couples irrespective of the causes. Entrenched patterns of responding often result in the inability to change dysfunctional interactions even though partners may spend many years attempting to understand and resolve their distress.

Treatment begins with structured and individualized touching exercises that the couple does at home between therapy sessions. They learn to be together physically and emotionally without the pressure and demand to feel or be sexual. Verbal and nonverbal communication is enhanced as attitudes, behaviors, and relationship dynamics are explored and modified. Each person learns that they are in control of their sexuality and can choose if and when to turn on or turn off their feelings.

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