TABLE TALKThe Growing Role of PatientEngagement Relatio.docx

TABLE TALK
The Growing Role of Patient
Engagement: Relationship-based
Care in a Changing Health Care
System
A
s health care providers, we rarely partici-
pate in discussions, watch interviews, or
read articles about our changing health
care system that do not concern patient engage-
ment. The Center for Advancing Health defines
patient engagement as
Actions individuals must take to obtain the
greatest benefit from the health care services
available to them. . . . Engagement is not syn-
onymous with compliance. . . . [Engagement]
signifies that a person is involved in a process in
which he [or she] harmonizes robust information

and professional advice with his [or her] own
needs, preferences, and abilities in order to
prevent, manage, and cure disease.
1
Patient engagement strategies have been shown
to improve care delivery and translate into better
outcomes related to patient satisfaction and re-
covery. One author captured the importance of
patient engagement with this statement: “If pa-
tient engagement were a [medication], it would
be the blockbuster [medication] of the century
Patient engagement begins with relationship-based care.
(Nurse’s warm-up jacket
and cap not shown.)
http://dx.doi.org/10.1016/j.aorn.2014.02.007
� AORN, Inc, 2014 April 2014 Vol 99 No 4 � AORN Journal j
517
http://dx.doi.org/10.1016/j.aorn.2014.02.007
and malpractice not to use it.”
2
Yet widespread

consensus among health care providers about how
to engage patients is still being determined.
The nursing profession’s role in patient engage-
ment and advocacy is key to the care that we de-
liver and continues to evolve to meet the needs of
patients. For example, before the 1970s, there was
not a high demand for patient’s rights.
3
In 2006,
AORN published a position statement on creating
an environment of safety, which set the ground-
work for patient-centered care as an important
element in defining the perioperative culture.
4
A
number of ethical, philosophical, and professional
considerations related to the rights of patients
have led to the nurse’s role as patient advocate.
According to one author, the three components of
this role are

1. informing patients of their rights,
2. providing patients with information necessary
to making informed decisions, and
3. supporting patients in their decisions.5
Regarding the patient’s role in engagement, one
author, who is also a perioperative RN, shared his
experiences as a surgical patient. In his article,
McGowan suggested that almost every patient en-
ters the surgical suite with anxiety and looks to
the perioperative team for reassurances. He be-
lieves that inaccurate portrayals of surgery in the
media “contribute to patients’ perceptions of sur-
gery and not always in a positive way.”
6(p493)
Critical to the health care provider’s ability to
establish trust is communicating in a manner that
informs and empowers the patient. For example,
he stated that, as a patient, he felt hurried in saying

goodbye to his partner before the procedure began,
which suggests that he perceived a lack of sup-
port from those providing his care. According to
McGowan, nurses must provide reassurances to
patients in their care and “remember the leap of
faith that [undergoing care] requires of patients
and never [to] take the trust that they place in
us lightly.”
6(p497)
By bringing together this panel of contributors,
my hope is that we come to a better understanding
of how we elicit our patients’ perspective and
involve them in improving satisfaction and health
outcomes. We would be remiss if this commentary
did not include the patient’s perspective. To that end,
a patient is one of the contributors. As you read these
commentaries, the clear themes among each disci-
pline and the engagement of key stakeholders can
be taken as a sign of the broader inclusion necessary

to achieving our desired outcomes. The panel of
contributors responded to the following statement:
Patient engagement and patient satisfaction
are playing critical roles in a changing health
care system and the emerging compensation
models. This directly impacts both the inpatient
environment and the ambulatory care setting.
From your perspective, please comment on what
you believe is the link between patient engage-
ment and improved outcomes for periopera-
tive patients.
CHARLOTTE L. GUGLIELMI
MA, BSN, RN, CNOR
PERIOPERATIVE NURSE SPECIALIST
BETH ISRAEL DEACONESS MEDICAL CENTER
BOSTON, MA
Nurse’s perspective
Our goal as health care providers is to meet the
physical, social, and emotional needs of patients

and their family members. This cannot be accom-
plished without fully engaging patients in their own
care or without fully engaging their families.
7
According to a white paper on patient and family
engagement from the Nursing Alliance for Quality
Care, “active engagement of patients, families,
and others is essential to improving quality and
reducing medical errors and harm to patients.”
8
As perioperative nurses, it is sometimes difficult
to see our role in this process because of the limited
518 j AORN Journal
April 2014 Vol 99 No 4 TABLE TALK
time for interaction and the drive for increasing
efficiencies. Perioperative leaders should promote
a culture that carefully balances efficiency, patient
safety, and patient participation by establishing

processes to support this philosophy. Strategies that
are developed to create this balance should estab-
lish a model for engaging patients and should en-
sure that perioperative nurses receive education on
communication techniques or methods that they
will use when interacting with those in their care.
At AnMed Health, Anderson, South Carolina,
perioperative leaders have adopted strategies that
offer a framework for successful engagement. Two
techniques that we use to guide personnel in their
interactions with patients and families are teach-
back (http://www.teachbacktraining.org) and Ask
Me 3
TM
(http://www.npsf.org/for-healthcare-profe
ssionals/programs/ask-me-3).
Teach-back is a research-based health literacy
intervention that improves patient-provider com-

munication and health outcomes.
9
By using inter-
active communication, the nurse prompts the
patient to explain, in his or her own words, the
information that the nurse has provided. This
method allows the patient to process health infor-
mation in a context that is meaningful to him or
her, and it demonstrates the patient’s understanding
to the health care provider. “Asking that patients
recall and restate what they have been told is one
of the 11 top patient safety practices based on the
strength of scientific evidence.”
10
Teach-back is a
particularly powerful tool to use when providing
postoperative discharge instructions. By using this
technique, nurses can be reasonably sure that the
patient and his or her family members understand
the postoperative care that will be needed at home.

This can help reduce the risk of complications re-
lated to miscommunication or misunderstanding
of instructions.
Ask Me 3 is a teaching methodology that is based
on health literacy principles and often is used in
combination with the teach-back approach. Part-
nership for Clear Health Communication developed
this technique with the intent of helping all patients
comprehend their particular health condition and
what they should do about it. There are three
questions
11
that patients are encouraged to ask
any health care provider:
n What is my main problem?
n What do I need to do?
n Why is it important for me to do this?
The use of these techniques adds structure to

patients’ interactions with their health care pro-
viders, thereby increasing patients’ engagement in
their own health. AnMed Health introduced these
methods in 2010, first in the surgical services and
pediatric departments, as part of an overall health
literacy and patient education initiative. Before
implementation, perioperative nurses received in-
depth training from the facility’s training and
organizational development department on both
techniques. Although these methods may seem
simplistic, both have proven effective in our facility
for allowing patients the opportunity to be part of
the conversation rather than passive receivers of
their medical information. The nurses in surgical
services directly teach patients to ask questions and
recall information. Nurses also use other commu-
nication methods, such as handouts and pamphlets,
to reinforce the delivery of information regarding

care. These methods of patient engagement start
when the patient arrives for surgical assessment
several days before surgery and continue through
postoperative discharge.
Although strategies provide a foundation for
patient engagement, it is nurses who establish re-
lationships with patients to make them partners in
their care. Nurses, in their role as committed patient
advocates, are uniquely positioned to embrace the
concept of active patient engagement. Therefore, it
is vitally important that perioperative leaders not
only provide the education and support necessary
for nurses to gain competency in patient engage-
ment practices but also actively participate in those
processes themselves. At AnMed Health, it is an
expectation that nurse managers and directors visit
with patients on a daily basis. Patient rounding by
AORN Journal j 519

TABLE TALK www.aornjournal.org
http://www.teachbacktraining.org
http://www.npsf.org/for-healthcare-professionals/programs/ask-
me-3
http://www.npsf.org/for-healthcare-professionals/programs/ask-
me-3
http://www.aornjournal.org
leaders sets an example for personnel but also
provides one more step in cementing the patient-
provider relationship that is so important to pa-
tient outcomes.
Helping personnel embrace “hardwire processes”
that are related to patient engagement is not sim-
ple, but perioperative leaders should be persistent
and supportive because these efforts are known
to be effective in improving postoperative patient
health.
12
Here are some key tips for nurses who are
getting started on this journey or who are renewing
their focus of patient engagement.

n Set aside a predetermined time each day to
round on patients. You can do this by putting
an appointment on your calendar. Allow enough
time to make the visits meaningful.
n Determine ahead of time the major points you
want to convey to the patient so that you can
work these into the conversation. Use teach-
back and Ask Me 3 whenever possible.
n Take a surgery schedule with you so that you
know the patient’s name, the scheduled surgical
procedure, and the name of the surgeon.
n If you are a director, ask a manager to ac-
company you for a few days. If you are a
manager, ask staff nurses to join you from
time to time.
n Manage up your team! Make sure you relay
to the patient what a wonderful team will be
providing his or her care.

MARTHA STRATTON
MSN, RN, MHSA, CNOR, NEA-BC
DIRECTOR OF NURSING, SURGICAL SERVICES
ANMED HEALTH
ANDERSON, SC
Surgeon’s perspective
The Institute of Medicine report To Err is Human:
Building a Safer Health System
13
documented sig-
nificant breaches in safe patient care. Many of the
breaches involved poor communication, a lack of
professionalism, and an inability to work as a team.
These deficiencies are major impediments to es-
tablishing good physician-patient relationships and
must be addressed by the profession. Doing so is
especially critical as the health care industry fo-
cuses on both increased patient engagement and
measured outcomes.
As surgeons, we have always been cognizant of

results (ie, outcomes). We have now been served
notice that we shall be rated and paid by the out-
comes we achieve. In many ways, however, we are
very reliant on others to achieve the best results
possible in any given patient encounter, perhaps
on none more so than the patient. Thus, educat-
ing and empowering the patient through effective
communication is now more important than ever.
By engaging with the patient in his or her own
care and providing education, health care providers
can show their dedication to safe patient care and
provide the patient with the feeling of not only
being cared for but cared about.
The surgeon must recognize his or her role as a
critical member of the preoperative, intraoperative,
and postoperative teams. A major component of
this role is serving as an educator to both the patient
and team members to explain the purpose, plan,

and expected outcome of the surgical procedure.
Each member of the team (eg, surgeon, anesthesia
professional, perioperative RN) must work together
to ready and empower the patient for the surgical
encounter. Silos are no longer effective or appro-
priate. As part of their engagement, patients and
their family members must be made aware that they
also have a responsibility to act as their own or as a
relative’s advocate and become part of the surgical
team. Thus, their goals and expectations must be
verbalized and understood by other members of the
team. I believe that having well-informed patients
and family members will lead to greater satisfac-
tion and will improve outcomes dramatically.
Yet, the world of health care becomes more
frenzied by the day, which has led to perioperative
520 j AORN Journal

personnel experiencing increased workloads and
greater stress. A sad fallout as a result of these
conditions is increased unprofessional behavior
on the part of members of the perioperative team.
When team members behave unprofessionally or
give the impression that they do not care about the
patient, it does not go unnoticed by patients and
serves only to sour their perception of the surgical
team, or at least some of its members. This weak-
ens their sense of engagement and increases the
possibility of a poor outcome.
14
Addressing the link
between stress levels and professional behaviors is
critical for physicians and nurses if we are to suc-
cessfully engage with our patients.
I believe that patients simply want to be part
of their own solution. A happy and relaxed patient

and surgical team are more successful than are an
unhappy and a stressed patient and surgical team in
achieving the desired positive outcome. Patients
want to understand what is happening to them and
to be informed about their care in a language that
they can understand. This means that they want to
be cared for in a safe environment by competent
professionals whose goal is a quality, cost-effective
outcome. In the end, we must not forget that pa-
tients do not care how much we know until they
know how much we care.
GERALD B. HEALY
MD, FACS
PAST PRESIDENT, AMERICAN COLLEGE OF
SURGEONS
PROFESSOR
HARVARD MEDICAL SCHOOL
BOSTON, MA
Anesthesiologist’s perspective
There can be very little argument that there is

indeed a link between patient engagement and
outcomes in the perioperative setting. This link
prevails across all settings of care, from hospitals
to ambulatory surgery centers to office surgery
suites. As a physician who has practiced almost
exclusively in the ambulatory surgery center set-
ting, I have no doubt that the patient plays a pivotal
role throughout the perioperative continuum in
the outpatient environment. Perhaps because of
the nature of the types of procedures we perform
(ie, those that are largely elective) and the relatively
short duration of the care provided (ie, usually less
than 24 hours), the extent to which personnel can
engage the patient and provide personalized, patient-
centered care is amplified in the ambulatory surgery
center setting.
Consequently, it is critical for the physician to
carefully assess the degree of patient, as well as

family member, engagement when considering the
most suitable location for the surgery to be per-
formed, regardless of the particular surgery and
anesthetic planned. A patient who is either unable
or unwilling to actively participate in his or her
own perioperative care, regardless of the reason,
is at an increased risk for poor outcomes. Further-
more, such a patient may be an unsuitable candi-
date for outpatient surgery.
As an example, a patient who is not motivated
to thoroughly administer his or her prescribed in-
testinal prep before a colonoscopy can adversely
affect the likelihood of an optimal procedure and is
at significant risk for cancellation entirely, there-
by defeating the opportunity for critical diagnosis
and treatment. Similarly, because patients are sent
home relatively quickly after outpatient procedures,
adherence to discharge instructions and attention to

possible signs and symptoms of surgical compli-
cations are crucial to a safe and timely recovery.
Although the relationship that perioperative
team members have with the patient is intuitive-
ly important, relationship-based care can place a
considerable burden both on the provider and on
the recipient of heath care in the outpatient setting.
For health care providers, it can be very difficult for
personnel to proactively ascertain the commitment
and ability of a patient to monitor and participate in
his or her own care, thereby making it difficult for
AORN Journal j 521
health care providers to help facilitate patient
compliance with the requisite postoperative self-
care regimens. For the recipient of health care (ie,

the patient), it can be very difficult to process and
attend to all the information communicated during
what is often a physically challenging and emo-
tionally charged time. Despite these difficulties, the
extent to which patient engagement can be lever-
aged during any given episode of care will almost
certainly enhance the outcome.
As definitive as I believe the relationship be-
tween patient engagement and outcomes is, the
relationship between patient engagement and pa-
tient satisfaction appears to be a bit less well es-
tablished or understood. The two are inexorably
intertwined, but the precise nature of the interaction
is considerably less clear. Are engagement and
satisfaction a cause or result of outcomes, or are
there other factors at play? I believe that, by clar-
ifying the factors that affect clinical outcomes, both
patient engagement and satisfaction will begin to

be better understood.
Although the very topical concept of patient
satisfaction recently has become the focus of an
inordinate amount of attention by the media and by
payers, I believe that much more research is needed
to determine the precise role that patient satisfac-
tion, or the patient experience, plays in health care
delivery and outcomes. At this time, however, the
precise nature of the patient-provider relationship
remains not only complicated but also largely un-
charted. Clearly, this is a fertile area of exploration
because patients, especially those undergoing sur-
gical or other invasive procedures, will most defi-
nitely play an increasingly important role in the
responsibility for their own perioperative care.
Only through further exploration and evidence-
based research will the precise nature of the link
between patient engagement and outcomes be

more clearly elucidated. As a result of this fo-
cus of endeavor, I anticipate that the concept of
relationship-based care will become more clearly
established as an important determinant of patient
satisfaction.
One important concept that surely will emerge
as an important area of continuing endeavor is to
arrive at clear, consistent, and universally accepted
definitions of terms such as engagement, satisfac-
tion, and outcome. Only after these definitions
have been refined and promulgated can we begin
the subsequent task of accurately quantifying, or
measuring, all the variables therein. Patient en-
gagement and patient satisfaction, therefore, are
an evolving and positive focus of health care, es-
pecially as we strive to improve the quality of
the perioperative services that we provide to our
patients. Surely, any efforts directed toward im-

provement on behalf of our patients are mission
critical for us as health care providers in the inpa-
tient and in the rapidly growing outpatient settings.
DAVID SHAPIRO
MD, CASC, CHCQM, CHC, CPHRM, LHRM
ANESTHESIOLOGIST
TALLAHASSEE, FL
Chief nursing officer’s perspective
I could not be happier with the growing focus on
patient satisfaction as a measure of quality. Mea-
suring patients’ perceptions of their care helps us,
their care providers, to understand their emotional
and spiritual health during all phases of periopera-
tive care. By referring to spiritual health in this
context, I am not discussing patients’ religious state
of mind but rather the health of the human spirit
that is inside all of us. Human beings are complex
creations who need to feel safe while also being
safe to thrive. Maslow’s hierarchy of needs de-

monstrated that, after an individual’s physical needs
are met, the individual ascends to more complex
needs to achieve self-actualization.
15
Understand-
ing the needs of our patients to thrive both physi-
cally and spiritually is critical to helping them
face whatever risks they encounter from disease
or injury.
522 j AORN Journal
As a nurse I have always viewed my practices as
providing a combination roles, that of scientist and
care provider. The scientist role allows me to focus
on assessing the physical needs, signs, and symp-
toms of those patients in my care so that I can
develop and implement suitable interventions. The
care provider role allows me to focus on enhancing

the spiritual health of my patients. I believe that we
are unable to be expert caregivers if we do not care
for all the needs of our patients, both physical and
spiritual.
16
Unfortunately, over the years, as the
cost of providing care has grown, our health care
systems have continually shifted the focus of care
delivery to developing processes and systems that
deliver physical care in as efficient a manner as
possible. In the surgical environment, we all have
experienced the ongoing push for efficiency and the
multiple meetings to discuss reducing turnover time
and cost per procedure. It was not until the Institute
of Medicine published its report, To Err is Human:
Building a Safer Health System,
13
which estimated
that 100,000 lives are lost each year because of

medical errors, that society demanded a response
to patient outcomes in the form of safer care de-
livery models that respect health care efficiency but
not at the expense of safety.
16
I believe the response to the Institute of Medicine
report aligns with Maslow’s theory. Nurses and
other members of the health care team have looked
to improve structures and processes to meet the
physical needs of the patient first. For example,
in the OR, perioperative personnel embrace safety
initiatives such as the time out and the Surgical Care
Improvement Project.
17
We have looked to reduce
variations to decrease human error from inexperi-
ence with a certain supply or piece of equipment.
Additionally, both the “captain of the ship” doctrine
and bullying behavior that were tolerated for so

many years have been replaced with huddles and
debriefings about the plan of care, so that all team
members can be equal partners in providing care.
Despite these efforts, we still face challenges
with outcomes. I believe that the realization must
be that problems related to mediocre outcomes
cannot be solved if we do not involve the patients in
their care. As McGowan stated in his article, a pa-
tient who is made to feel valued and part of the care
process is a patient who has a better chance to ex-
perience an optimal outcome.
6
Engaging patients
strengthens the health of their spirit. A healthy spirit
is critical to patients’ successdyet, up to this point,
everything the health care industry has been focused
on has been to address patients’ physical needs and
not their spiritual needs. It is only now that we are
responding to that oversight by enhancing physical

care with relationship-based care.
Let’s face it, receiving health care can be one
of the most dehumanizing experiences in a person’s
life. We strip patients of their clothes, their valu-
ables, and their family and friendsdand we may
even paralyze them with anesthesiadso that a
group of strangers whom they have never, or only
briefly, met can perform a surgical or other invasive
procedure on their body. I have had surgery only
as a child, but still I have wondered many times
as I put the safety strap on my patients about the
leap of faith that is required of those who undergo
surgery. The stress of a surgical procedure must
be enormous, and that stress can hinder a patient’s
ability to thrive throughout the perioperative course.
To me, this is why it is so important to engage our
patients and make them feel valued during the
perioperative process.

I believe that patients enter a hospital believing
that we know how to provide physical care, but
what they hope for, and are concerned about, is
whether we will value them as human beings.
When an individual feels valued, he or she feels
stronger; and the stronger the patient is, the better
the chances are for a great outcome. I frequently
see evidence of how important spiritual care is to
patients. In my 30 years as a nurse leader, almost
every letter I receive from patients discusses how
my nurse team members either did or did not make
them feel valued. Except for incidents of a clear-cut
error, patients rarely discuss the physical aspects of
care or their outcomes. It is clear to me that they
want to share their perception of the quality of the
AORN Journal j 523

spiritual care they received. For someone to stop
and take the time to write a message of thanks or
concern means that their spiritual care is something
they value very much; and, if this is important to
them, then it should be equally important to us as
their care providers.
WILLIAM J. DUFFY
RN, MJ, CNOR, FAAN
REGIONAL VICE PRESIDENT, CHIEF NURSE
OFFICER, PATIENT CARE SERVICES
LAKE SHORE REGION
PRESENCE HEALTH CARE
CHICAGO, IL
Patient’s perspective
My perspective as a surgical patient in an ambu-
latory setting is a bit unique because of my pro-
fessional background. For the past 42 years, I have
worked for a major surgical organization and have
witnessed the development of statements, guide-

lines, and protocols to meet the organization’s
mission to improve quality in surgery, trauma,
and cancer care and to have fewer complications,
better outcomes, and greater access for patientsd
all at lower costs. In my view, this laudable mis-
sion should include cooperative efforts from both
patients and perioperative team members. For
example, soon I will begin my term as the first
patient to serve on the Board of Directors of the
Council on Surgical and Perioperative Safety
(http://www.cspsteam.org), a coalition that previ-
ously comprised only representatives from profes-
sional societies.
I have been a surgical outpatient on three occa-
sions: for a torn meniscus repair, a cystoscopy, and
a colonoscopy. All three interventions had excellent
outcomes, and my recovery was within the normal,
prescribed time frames for each. Although I have

had additional surgical experiences as an inpatient
at a large Midwestern teaching hospital, all three
of the outpatient procedures were performed in
either a mid-size suburban hospital or in the sur-
geon’s office. In all three instances, I was impressed
with the level of preoperative and postoperative
care that personnel provided. During these experi-
ences, I was encouraged to ask questions about the
surgical procedure and was given written informa-
tion as well. I felt a part of the process and was
treated as a unique individual and not as an anon-
ymous patient or just another procedure.
I believe that patients must be their own advo-
cates or, if required, have someone with them to
serve in that role. No matter how routine a procedure
is for the perioperative team, it is perhaps the first
time for the patient. Not to be flippant, but I liken the
surgical experience to attending a Broadway play.

The cast and crew may have multiple performances
under their belts, but most members of the audience
are there for the first time and expect the best. Un-
like anticipating a delightful evening at the theater,
however, the patient may be fearful or anxious about
the procedure and outcome. These emotions usually
are linked to not knowing or understanding how the
perioperative phases of care will go. In my experi-
ence, patient education is instrumental to preoper-
ative planning and postoperative recovery. As stated
earlier, the written and verbal explanations were
very helpful and spoken in terms that were under-
standable to me as the patient. My questions were
encouraged and willingly answered, and I felt val-
ued as a human being.
In an outpatient setting, the nursing team does not
have much time with patients; therefore, effective
educational tools are far more focused and time

sensitive before …
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A literature review of forgiveness as a beneficial
intervention to increase relationship satisfaction
in couples therapy
Ross A. Aalgaard, Rebecca M. Bolen & William R. Nugent
To cite this article: Ross A. Aalgaard, Rebecca M. Bolen &
William R. Nugent (2016) A
literature review of forgiveness as a beneficial intervention to
increase relationship satisfaction
in couples therapy, Journal of Human Behavior in the Social
Environment, 26:1, 46-55, DOI:
10.1080/10911359.2015.1059166
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A literature review of forgiveness as a beneficial intervention to
increase relationship satisfaction in couples therapy
Ross A. Aalgaard, Rebecca M. Bolen, and William R. Nugent
College of Social Work, University of Tennessee, Knoxville,

Tennessee, USA
ABSTRACT
Forgiveness between couples is identified as a strong predictor
of relation-
ship satisfaction. Yet forgiveness is often overlooked as a
potential inter-
vention to help couples increase their relational satisfaction.
The purpose of
this literature review is to examine the use of forgiveness as a
therapeutic
intervention to increase relational satisfaction for opposite- and
same-sex
couple dyads. Forgiveness is also introduced as an effective
component of
marital interventions in the context of infidelity. Specific areas
that are
addressed within this article include forgiving personalities,
which benefits
stress and health, forgiveness affecting marital and family
functioning,
forgiveness and relationship satisfaction with mediating
mechanisms, and
limitations of forgiveness interventions. Recommendations for
practice are
offered.
KEYWORDS
Couples therapy;
forgiveness; marital conflict;
marriage; relationship
satisfaction
Exploring relationships that are compromised by interpersonal
conflicts and transgressions offers
opportunities to examine forgiveness as an effective therapeutic

component for enhancing relational
satisfaction. Paleari, Regalia, and Fincham (2009) described
three pathways in which people offer
forgiveness to others. Offense-specific forgiveness is a
particular forgiving act for a precise offense
within a defined interpersonal framework. Dyadic forgiveness is
the inclination to forgive one’s
partner for numerous offenses. Trait forgiveness relates to the
comprehensive disposition of a person
who has the tendency to forgive individuals for offenses across
multiple circumstances, including
interpersonal situations that involve a variety of relationships.
Despite the pathway that forgiveness
is derived, Maio, Thomas, Fincham, and Carnelley (2008) note
the process of forgiveness encom-
passes consciously moving away “from negative thoughts,
feelings, and behaviors toward the
transgressor to more positive thoughts, feelings, and behaviors”
(p. 307).
Considering the different contexts in which forgiveness occurs,
Gordon, Burton, and Porter
(2004) explored whether the concept of forgiveness among
women experiencing domestic violence
is truly forgiveness or a conscious rationalization to help them
move on. Their results showed that
“The less women interpreted their partner’s behavior as
malicious and intentional, the more likely
they were willing to forgive the behavior and consider
continuing the relationship” (p. 336). Since
forgiveness should never be used to excuse endangering or
harmful behaviour, clinicians may
identify times within couples’ therapy to explore clients’
interpretations of their partners’ behavior
and address enabling responses (e.g., forgiveness) to help
maintain their safety.

If forgiveness however can offer longevity, health, and healing
within relationships, then adding
this component to assist couples with enhancing their
relationship satisfaction and maintaining their
marriage is worthy for consideration. The purpose of this
literature review is to examine current
evidence related to the effectiveness of forgiveness as a
therapeutic intervention to increase relational
satisfaction for opposite- and same-sex couple dyads.
Additionally, forgiveness is introduced as a
CONTACT Ross A. Aalgaard [email protected] Minnesota State
University, Mankato, TN358 Trafton Science Center
North, Mankato, MN 56001-6055, USA.
© 2015 Taylor & Francis
JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL
ENVIRONMENT
2016, VOL. 26, NO. 1, 46–55
http://dx.doi.org/10.1080/10911359.2015.1059166
component of marital interventions in the context of infidelity,
which supports the concept of
forgiveness as a cornerstone of relationship success (Baucom,
Gordon, Snyder, Atkins, &
Christensen, 2006). This literature review does not address
forgiveness within relational contexts
that involve threatening behavior or domestic violence.
Method
A database search for peer-reviewed articles was conducted
using PsycARTICLES, PsycINFO, Social

Service Abstracts, Sociological Abstracts, ERIC, and Campbell
Collaboration. Keywords used for the
search included couple*, therapy OR counseling OR
intervention, forgiveness, and satisfaction. The
search was limited to articles from 2001 to 2013. A distinction
was made between forgiveness as a
religious concept and as a therapy intervention. Titles and
abstracts were reviewed for forgiveness
and relational/relationship/marital satisfaction. The three terms
for the types of satisfaction were
considered interchangeable in this search. Articles that did not
identify one of the three types of
satisfaction were excluded. The articles found were than
reviewed to ensure that relational satisfac-
tion was an outcome and forgiveness as an intervention was
discussed. After applying inclusion and
exclusion criteria four papers qualified for review.
Literature review
Forgiveness, relationship quality, stress, imagination, and
physical and mental health
Berry and Worthington (2001) studied 19 undergraduate men
and 20 undergraduate women ranging
in age from 18 to 42 years old (M = 22.9) who were attending a
mid-Atlantic urban state university.
The sexual orientation of the participants was not identified.
Students were initially recruited
through posted announcements on campus and information
shared in class to let potential partici-
pants self-select themselves for consideration. Without knowing
the nature of the study or the
inclusion criteria for involvement, potential participants were
asked to fill out a screening form that
included questions regarding demographics, information about

current or recent romantic relation-
ships, and a measurement to detect happiness. To qualify for the
study, potential participants had to
endorse that they had been in a relationship for at least 6
months and provide responses to questions
related to their romantic relationships. If someone’s relationship
had ended, he or she could still
qualify provided his or her relationship had lasted at least 6
months and ended no more than 3
months prior to the study. To assess the health impact,
participants also had to agree to have their
cortisol levels tested and blood samples drawn. Researchers
later decided to abandon the blood
samples and refocus the study on the detection of relationship
stress through salivary cortisol
because of time constraints.
A nurse collected baseline saliva cortisol samples by having
participants chew a cotton swab from
a salivette kit for one minute. The samples of saliva on the
swabs were then stored in a freezer.
Participants next engaged in an imagery activity that involved
imagining a typical scene that was
common to their relationship they had with their partners. They
were instructed to consider as many
details as possible and to reexperience the feelings that emerged
as strongly as possible for 5 minutes.
The time between baseline saliva samplings and postimagery
samples varied from 5 to 40 minutes
(Berry & Worthington, 2001).
Participants also completed several standardized tools to fulfill
the study. The Trait Anger Scale
(Spielberger, Jacobs, Russell, & Crane, 1983) was administered
to measure anger as a personality
disposition of participants. The Transgression Narrative Test of

Forgiveness (α = .82), (Berry,
Worthington, Parrott, O’Connor, & Wade, 2001) was used to
assess the ability to forgive transgres-
sions across situations and over time. The Trait Unforgiveness-
Forgiveness Scale (α = .89) (Berry &
Worthington, 2001) was given to assess the disposition to
forgive of participants. The Dyadic
Adjustment Scale (α = .98) (Spanier, 1976) was used to measure
relationship adjustment. The Love
ENVIRONMENT 47
Scale (α = .96) and Liking Scale (α = .98) (Rubin, 1970) were
utilized to measure the participants’
current attitudes about the relationship partner. The
Relationship Imagery Questionnaire (α = .83)
from the Vividness of Visual Imagery Questionnaire (Marks,
1973) captured how vividly respondents
imagined their relationship interactions.
The study by Berry and Worthington (2001) confirmed that trait
anger and dispositional
forgiveness personality predicted the quality of close
relationships and impacted a person’s mental
and physical health. Subjects who were asked to imagine past
transgressions by a partner that had
not been forgiven increased cortisol levels, which supports a
stress-related response. The hypothesis
that an intimate relationship of poor quality is associated with
physiological stress was supported,
because higher cortisol reactivity was associated with poorer
quality of relationship. The research
results further supported that individuals who had more

dispositional forgiveness had a higher
quality of romantic relationship.
Researchers have concluded that the personality traits of being
forgiving or unforgiving predicted
both physical and mental health (Berry & Worthington, 2001;
Thoresen, Harris, & Luskin, 2000;
Williams, 1989). Although forgiving personality and loving
relationship did not predict cortisol
reactivity, Berry and Worthington (2001) stated, “Statistically,
the results could suggest that a loving
relationship affects cortisol reactivity indirectly through
affecting a forgiving personality” (p. 452).
The explanation given for this was that personalities predate
relationships. The study provided
support linking one’s better health outcomes with better quality
of close relationships and with more
forgiving personality traits. The reverse was not supported,
because those with chronic relationship
stress did not have poorer health outcomes.
Berry and Worthington (2001) identified three limitations of
this study: the assumption that a
brief imagery task can produce the same stress response as an
ongoing relationship, the varied time
intervals for collecting the cortisol samples, and the small
participant sample size. Although the
researchers made adjustments for the varied time intervals when
determining the cortisol reactivity
results, a standardized approach would have made this a
stronger study. In addition, the use of a
convenience sample does not allow for generalization of
conclusions beyond the study.
Potential costs to forgiveness

McNulty (2008) investigated the effects of heterosexual
spouses’ tendencies to forgive their partners
in a longitudinal study of 72 couples over a 2-year period. The
newlywed couples who participated
had been married an average of 3.2 months. McNulty
hypothesized that forgiveness could have long-
term costs. The research found forgiveness having long-term
costs when moderated by the role of
negativity and the context in which the forgiveness occurred,
including the frequency of the spouse’s
offenses. He also hypothesized that greater forgiveness among
couples would be related to more
stable marital outcomes and satisfaction in marriages where
negative verbal behavior is reduced.
Couples were mailed a questionnaire packet with a letter asking
each partner to complete them
independently. The completed surveys were taken to a
laboratory meeting where couples partici-
pated in two 10-minute videotaped discussions designed to
assess the frequency of negative verbal
behavior. One was a private taping of each spouse identifying
what she or he considered the source
of tension in the marriage. The other recording was of the
couple together working out a resolution
or agreement about the previously acknowledged cause of
tension. Each videotaped discussion was
coded for observed behaviors by trained raters. Following the
initial evaluation, couples continued to
complete questionnaires every 6 months over 2 years to assess
marital satisfaction and problems
(McNulty, 2008).
Couples completed the following inventories regarding marital
satisfaction and marital problems
(McNulty, 2008). Assessment of marital satisfaction was

conducted using the Quality Marriage Index
(Norton, 1983). The internal consistency ranged from .93 to .96
for husbands and .94 to .95 for wives
over the four phases. Marital forgiveness was measured using
Transgression Narrative Test of
Forgiveness (α = .89 for husbands and α = .86 for wives) (Berry
et al., 2001). The spouses’ negative
48 R. A. AALGAARD ET AL.
verbal behaviors were measured using the Verbal Aggression
Subscale of Form N of the Conflict
Tactics Survey (CTS) (α =.84 for husbands and α = .84 for
wives) (Straus, 1979). Trained observers
used the Verbal Tactics Coding Scheme (Sillars, Coletti, Parry,
& Rogers, 1982), which is defined to
have adequate reliability, for the recorded videos.
McNulty (2008) found that spouses who reported being more
forgiving were happier in their
relationships, had less severe problems, and behaved less
negatively. Over time however, wives
became significantly less satisfied in their marriages. Results
showed that wives perceived relation-
ship problems as more severe while husbands viewed
relationship problems as having no significant
change. Within this study, gender influenced relationship
satisfaction.
McNulty’s (2008) study results further revealed that increased
forgiveness by spouses for partners
who engaged in reduced negative behavior was beneficial over
time but less forgiveness was harmful
to the relationship. For spouses married to partners who often

enacted negative behavior without
reduction, increased forgiveness became harmful to the
relationship, and the quality of the relation-
ship deteriorated over time. Conversely, decreased forgiveness
for those who frequently enacted
negative behavior was beneficial over time. Finally, relatively
healthy marriages experienced more
positive benefits than troubled relationships from the effects of
forgiveness.
McNulty (2008) suggested that an intervention that includes
forgiveness might help bring
relationship stability over time for benevolent partners.
However, these findings question whether
forgiveness interventions in high-conflict marriages will have
positive outcomes, especially in light of
the potential for forgiveness to cause a decline in marital
satisfaction over time.
Although researchers used a longitudinal design, the study was
limited by the use of a conve-
nience sample (McNulty, 2008). Still, these research results
provide some evidence for adding
forgiveness interventions as a component to couples therapy.
Future research should investigate
the effects of incorporating forgiveness interventions with same
same-sex couples.
Forgiveness in marital and family functioning
Gordon, Hughes, Tomcik, Dixon, and Litzinger (2009)
examined the role of forgiveness in marital
and family functioning by utilizing a cross-sectional study that
was conducted as part of a larger,
longitudinal study on relational family functioning. Emphasis
was placed on “devastating relational

conflicts” such as “infidelities, major lies, drastic unilateral
financial decisions, and other similar
humiliations and betrayals,” which often have long-term
negative effects on marital functioning (p.
1). Forgiveness was conceptualized as two constructs—negative
forgiveness and positive forgiveness.
Negative forgiveness was defined by grudges, withdrawal or
avoidance, and the desire for revenge or
punishment toward the betraying partner. Positive forgiveness
was delineated as the readiness to
forgive, increased empathy, greater dyadic trust, and release of
anger. Both negative and positive
forgiveness were examined for the impact they have on couples’
relationships and how they affect
elements of both dyadic and family functioning (Gordon et al.,
2009).
Gordon et al. (2009) hypothesized that couples’ self-report of
relationship satisfaction would
increase, with both more positive forgiveness and less negative
forgiveness occurring within the
relationship. Going beyond the couples’ intimate relationship,
the parenting alliance was predicted to
become stronger when more positive forgiveness occurred.
Finally, it was expected that marital
conflict would be related to more negative child functioning.
Therefore, reports by the parents of
more positive forgiveness and less negative forgiveness were
anticipated to coincide with the
children’s reports of less negative interactions and less familial
threats.
Participants were recruited from mailing lists of families in the
researchers’ community and were
contacted by phone to determine interest for involvement. To
qualify for inclusion one member of

each couple had to report a betrayal, as defined by the
participants, in the relationship and that the
couple had a child in the home from ages 11 to 16. Packets
including the measurement tools, consent
forms, and a cover letter asking for surveys to be completed
independently were mailed to a group of
111 married couples and their children. Separate envelopes were
made available for husbands, wives,
ENVIRONMENT 49
and children. Only fully completed materials that were returned
qualified for the study. The final
total sample included 91 couples and youth. Couples averaged
16 years of marriage and 2.6 children.
Nine families were blended families. Eighty-seven wives and 74
husbands reported a betrayal
(Gordon et al., 2009). The Forgiveness Inventory (Gordon &
Baucom, 2003) was used to measure
both positive and negative forgiveness. The alpha coefficient on
the negative forgiveness subscale was
.91 for women and .87 for men. The alpha coefficient for the
positive forgiveness subscale was .84 for
women and .87 for men (Gordon et al., 2009).
Gordon et al. (2009) found that both husbands and wives
reported that greater negative forgive-
ness predicted poorer perception of marital satisfaction. The
subjects’ perception of their relation-
ship remained the same when marital conflict and dyadic trust
variables were evaluated. Husbands
and wives that reported greater positive forgiveness predicted
their own perceptions of the higher

quality of the parenting alliance. Further, husbands’ greater
positive forgiveness predicted their
perception of greater dyadic trust, whereas the husbands and
wives’ greater negative forgiveness
predicted their reports of greater conflict behaviors and lesser
dyadic trust levels. When dyadic
conflict was controlled, both husbands’ and wives’ reports of
greater negative forgiveness predicted
their perceptions of poorer marital satisfaction, with dyadic
trust and conflict behaviors partially
mediating the relationships. These results support the
possibility that failing to resolve betrayals may
impact a couple’s relational functioning and, in turn, lower
relationship satisfaction.
Gender differences were found within this study. For wives,
greater negative forgiveness predicted
their perceptions of poorer marital satisfaction, greater trust,
and greater conflict behaviors. The
husbands’ patterns were slightly different, but only for greater
dyadic trust, which was also predicted
by greater positive forgiveness. In separate analyses, wives and
husbands’ greater negative forgiveness
predicted their children’s views of greater parental conflict but
only when forgiveness dimensions
were the only variables entered into the regression. When
wives’ forgiveness was entered together
with the husbands’ reports of marital conflict and parental
alliance, only the husbands’ reports of
greater conflict predicted the children’s perceptions of marital
conflict. When the husbands’ for-
giveness was entered together with the wives’ reports of marital
conflict and parental alliance, only
the wives’ reports of marital conflict and the parental alliance
were significant. Wives’ report of
greater conflict and a worse parental alliance were related to

children’s reports of greater marital
conflict (Gordon et al., 2009).
In cross-spousal reports, the husbands’ greater negative
forgiveness was mediated as a strong
predictor of their wives’ reports of poorer parenting alliances,
and the wives’ greater negative
forgiveness strongly predicted their husbands’ reports of poor
parenting alliances. Further, wives’
lesser negative forgiveness predicted the husbands’ greater
relational satisfaction, and husbands’
lesser negative forgiveness predicted the wives’ greater
relational satisfaction. For both wives and
husbands, their greater negative forgiveness predicted the
opposite partner’s reports of marital
conflict (Gordon et al., 2009).
One concern with these results is that wives’ positive and
negative forgiveness were strongly
correlated, as was the wives’ and husbands’ negative
forgiveness, suggesting that multicollinearity
might be a concern in certain analyses. Further examination
however found that multicollinearity
diagnostics did not suggest a problem (Gordon et al., 2009).
Further research needs to be conducted
to explore the role of positive forgiveness in women’s relational
functioning.
Because this study is cross-sectional (Gordon et al., 2009),
findings cannot be taken to suggest
direction of effect. A longitudinal study should be conducted to
see if these findings can be replicated
and to determine direction of effect and causality. Since no
comparison group of couples with low or
no betrayal was included, it is not clear whether these findings
are specific only to couples in which

one member committed a significant betrayal. This study was
also limited geographically, and the
data were collected from a convenience sample indicating that
findings cannot be generalized. Since
these results were based on self-report measures they need to be
interpreted cautiously. Notably,
however, previous research results does support the findings of
this study and adds support to the
importance of adding a forgiveness component as a therapeutic
intervention with couples.
50 R. A. AALGAARD ET AL.
In summary, forgiveness of major betrayals by a spouse was
significantly related to marital
satisfaction, the parenting alliance, and to children’s
perceptions of marital functioning (Gordon
et al., 2009). In addition, gender differences may exist in areas
such as conflict behaviors and
relationship trust. These gender differences need further
examination not only with heterosexuals,
but also with same-sex couples. If these findings continue to be
replicated, they will lend support for
using forgiveness as an intervention within family therapy as
well as with couples.
Forgiveness and relationship satisfaction
More recently, Braithwaite, Selby, and Fincham (2011) studied
the mediating mechanisms of the
pathway between trait forgiveness and relationship satisfaction.
They conceptualized forgiveness as
promoting not only a reduction in negative responses but also
“increased goodwill toward the

transgressor” (p. 551). They also considered possible mediators
between trait forgiveness and
relationship satisfaction, specifically interpersonal conflict and
self-regulation. Important interperso-
nal conflict tactics examined were positive communication,
negative communication, and physical
assault. “Altering behavior to inhibit a dominant response,
usually in the service of longer term
goals” was the definition used for self-regulation (p. 552). They
believed that relationship satisfaction
was improved by relationship efforts to reduce problematic
conflict patterns.
Braithwaite et al. (2011) completed two studies. The first study
included 523 young adult
participants who reported they were currently in a committed
romantic relationship. This sample
was part of a larger study being conducted in a university
introductory family studies course. The
second study gathered data from 446 young people who were
followed for 2 months to evaluate the
relationships among forgiveness, conflict tactics, relationship
effort, and relationship satisfaction.
The potential role of commitment was also included.
The researchers utilized a number of measures to assess the
primary constructs of the studies
(Braithwaite et al., 2011). Within the first study, trait
forgiveness (i.e., the tendency to forgive) was
captured using a four-item scale of dispositional or trait
forgiveness with an alpha of .66 (Brown,
2003). In Study 2, the nine-item forgiveness tool had a
consistent alpha of .85 over an 8-week test-
retest period of time. The CTS-2 (Revised Conflict Tactics
Scales) (Straus, Hamby, Boney-McCoy, &
Sugarman, 1996) was used to capture how couples resolved

conflict and how much an individual
works at their relationship by regulating behavior to improve
the relationship quality. The CTS-2 had
an alpha score of .94 in Study 1 and an alpha score of .84 in
Study 2. Other constructs captured were
constructive communication patterns with the Communication
Patterns Questionnaire (Heavey,
Larson, Zumtobel, & Christensen, 1996), self-regulation with
the Behavioral Self-Regulation for
Effective Relationships Scale—Effort Scale (Wilson, Charker,
Lizzio, Halford, & Kimlin, 2005),
relationship satisfaction with the Couples Satisfaction Index
(Funk & Rogge, 2007), and the desire
to persist in spite of obstacles in a romantic relationship
(Finkel, Rusbult, Kumashiro, & Hannon,
2002). All alpha scores ranged between .80 and .94 (Braithwaite
et al., 2011).
The first study (Braithwaite et al., 2011) collected data from
participants through online surveys.
Forgiveness was not directly related to relationship satisfaction
but was related to increased beha-
vioral self-regulation and decreased negative interpersonal
behaviors, which were in turn related to
relationship satisfaction in the expected directions. Thus, these
mediating relationships were sup-
ported. Because the first study could not establish causality, the
variable of commitment to the
relationship was not included, and the relationships between
forgiveness and the other variables were
small a second study was conducted.
For Study 2 Braithwaite et al. (2011), followed the same
procedures that were conducted in the
first study with the exception of adding a second time period 2
months after the first. The

researchers designed and utilized a nine item, six-point scale
measure on forgiveness which had a
consistent alpha score of .85 and strengthened construct validity
and increased confidence in the
observed findings. This measure operationalized forgiveness by
assessing respondents’ avoidance,
benevolence, and retaliation, unlike the first study, which
compared vengeance and neuroticism,
ENVIRONMENT 51
dispositional forgiveness, perspective taking, and
agreeableness. Stanley and Markman’s (1992) four-
item scale to assess the desire to persist in romantic
relationships despite obstacles was used to
determine commitment. Braithwaite et al. (2011) extended the
findings of the first study by revealing
a longitudinal relationship between forgiveness with
correlations of self-regulation and negative
interpersonal tactics mediating relationship satisfaction and
forgiveness. The tendency to forgive
related to later relationship satisfaction. Limitations of the
second study included the use of a
convenience sample and not having a control group.
Discussion
…
ORIGINAL PAPER

Mindfulness-Based Sex Therapy Improves Genital-Subjective
Arousal Concordance in Women With Sexual Desire/Arousal
Difficulties
Lori A. Brotto1 • Meredith L. Chivers2 • Roanne D. Millman3 •
Arianne Albert4
Received: 3 February 2015/ Revised: 3 November 2015/
Accepted: 30 December 2015/ Published online: 26 February
2016
� Springer Science+Business Media New York 2016
Abstract Thereisemergingevidencefortheefficacyofmind-
fulness-basedinterventionsforimprovingwomen’ssexualfunc-
tioning. To date, this literature has been limited to self-reports
of
sexualresponseanddistress.Sexualarousalconcordance—the
degree of agreement between self-reported sexual arousal and
psychophysiologicalsexualresponse—hasbeenofinterestdue
tothespeculationthatitmaybeakeycomponenttohealthysex-
ualfunctioninginwomen.Weexaminedtheeffectsofmindful-
ness-basedsextherapyonsexualarousalconcordanceinasample
ofwomenwithsexualdesire/arousaldifficulties(n =79, M age
40.8 years) who participated in an in-laboratory assessment of

sexualarousalusingavaginalphotoplethysmographbeforeand
afterfoursessionsofgroupmindfulness-basedsextherapy.Genital-
subjective sexual arousalconcordance
significantlyincreasedfrom
pre-treatment levels, with changes in subjective sexual arousal
predicting contemporaneous genitalsexual arousal (but not the
reverse). These findings have implications for our understand-
ingofthemechanismsbywhichmindfulness-basedsextherapy
improvessexualfunctioninginwomen,andsuggestthatsuchtreat-
ment may lead to an integration of physical and subjective
arousal
processes.Moreover,ourfindingssuggestthatfutureresearch
mightconsider theadoption of sexual arousal concordance as a
relevant endpoint in treatment outcome research of women with
sexual desire/arousal concerns.
Keywords Sexual desire � Sexual arousal �
Vaginal photoplethysmography � Mindfulness � DSM-5 �
Sexual dysfunction
Introduction
Lack of motivation for sex affects up to 40% of women aged

16–44 (Mercer et al., 2003; Mitchell et al., 2013) and is the
most common reason prompting women to seek sex therapy.
Whenclinicallysignificantdistressaccompaniesthelossofsex-
ualdesire,estimatesrevealthatupto12%ofwomenareaffected
(Shifren,Monz,Russo,Segreti, & Johannes,2008).The 5th edi-
tion of the Diagnostic and Statistical Manual of Mental Disor-
ders (DSM-5)definesthissyndromeas‘‘FemaleSexualInterest/
ArousalDisorder’’(SIAD;AmericanPsychiatricAssociation,
2013) and a diagnosis is made when any threeof six criteria are
met for a minimum duration of 6 months and accompany clin-
icallysignificantdistress.Thecriteriainclude:(1)lackofdesire
for sex, (2) lack of sexual thoughts/fantasies, (3) lack of initia-
tionandreceptivityofsexualactivity,(4)lackofsexualpleasure,
(5)inabilityforsexualstimulitotriggerdesire,and(6)animpaired
physical sexual arousal response.
Todate,themostwidelystudiedtreatmentforlowsexualdesire
inwomenhasbeentestosterone.Alargenumberofrandomized
controlledstudieshavedemonstratedtheefficacyoftopicaltestos-

terone in surgically menopausal women (reviewed by Davis,
2013). Moreover, estimates suggest that 4.1 million prescrip-
tions for off-label testosterone are made annually in the U.S.
alone(Davis&Braunstein,2012).Nonetheless,testosteroneremains
unregulated,andalthoughitwasapprovedforuseinpatchform
in Europe (for surgically menopausal women with low sexual
desire), it is currently unavailable in North America. Various
other pharmaceutical agents have been the subject of clinical
& Lori A. Brotto
[email protected]
1
Department of Gynaecology, University of British Columbia,
2775LaurelStreet,6thFloor,Vancouver,BCV5Z1M9,Canada
2
Department of Psychology, Queen’s University, Kingston, ON,
Canada
3
Department of Psychology, Simon Fraser University, Burnaby,
BC, Canada
4
Women’s Health Research Institute, Vancouver, BC, Canada

123
Arch Sex Behav (2016) 45:1907–1921
DOI 10.1007/s10508-015-0689-8
http://crossmark.crossref.org/dialog/?doi=10.1007/s10508-015-
0689-8&domain=pdf
http://crossmark.crossref.org/dialog/?doi=10.1007/s10508-015-
0689-8&domain=pdf
trialsfortreatmentoflowsexualdesire,butasofOctober2015,
flibanserin is the only medication approved in the U.S. for this
condition.
Despiteconsiderableinterestintestingpharmacologicaloptions
forwomen’slowsexualdesire,psychologicaltreatmenthasbeen
themainstayoftherapyforwomenwithsexualdesiredifficulties.
Because cognitive distraction during sexual activity is prevalent
among women with sexual dysfunction, and negatively impacts
theirsexualsatisfactionanddesire(Nobre&Pinto-Gouveia,2006),
this provides justification for the application of cognitive chal-
lenging strategies (i.e., identifying, challenging, and replacing
irrationalthoughts)inherenttocognitivebehavioraltherapy(CBT).

Trudeletal.(2001)comparedtheeffectsofCBT(whichincluded
bothcognitivechallengingaswell as behavioral strategies) toa
wait-list control in 74 couples in which women met criteria for
HypoactiveSexualDesireDisorder(HSDD).After12weeks,74%
of women no longer met diagnostic criteria for HSDD, andthis
stabilized to 64% after 1-year follow-up. In addition to signifi-
cantlyimprovedsexualdesire,womenalsoreportedimproved
quality ofmaritallife andperception ofsexualarousal,butthe
groupcoupletherapyformatmaynotbefeasibleintypicalclini-
cal settings. Another treatmentoutcome study of10sessions of
CBT,2–3ofwhichincludedthepartner,foundonlya26%reduc-
tion in the proportion of women who had significant concerns
withlowsexualdesire(McCabe,2001).Takentogether,thesestud-
iessuggestthatCBTiseffectiveforaproportionofwomenwith
lowsexualdesire,butsuchanapproachmayalsohavelimitations.
Specifically,becauseofthe often-noteddistractibility,anxiety-
proneness,judgmentalintrusions,andinattentiondescribedby
womenwithlowsexualdesire(Meston,2006),andalsobecause

ofthevariedwaysinwhichdesireisexperienced(Meana,2010;
Sand&Fisher,2007),otherskill-basedapproachesmaybenec-
essaryforwomenwhodonotbenefitfromcognitivechallenging.
Toaddressthesegaps,third-generationCBTapproaches,suchas
mindfulness-basedcognitivetherapy,havebeengainingtraction
in many domains of physical and psychological health.
Mindfulnessmeditationhasa3500yearhistoryandfornearly
thepastfourdecadeshasmadeitswayintoWesternmedicine.
Defined as present-moment, non-judgmental awareness with
curiosity,openness,andacceptance(Bishopetal.,2004),mind-
fulness meditation has been a major addition to the psycholog-
icaltreatmentarsenalforthetreatmentofanxiety,depression,sub-
stance use,childhoodbehavior problems,andahost of medical
concerns, includingpain, irritable bowelsyndrome, fibromyal-
gia,and highbloodpressure (Grossman, Niemann, Schmidt,&
Walach,2004;Merkes,2010).Althoughtheprecisemechanisms
by which mindfulness is associated with symptom relief is not
fullyunderstood,itsbenefitsmaybeassociatedwithanincrease

inmetacognitiveawareness,ortheabilitytoexperiencethoughts
merely as mental events (Teasdale et al., 2002). Over the past
10 years, mindfulness has beenapplied to and found effective
for the treatment of sexual dysfunction in women (Brotto,
Basson,&Luria,2008a;Brottoetal.,2008c,2012a;Brotto,Seal,
& Rellini, 2012b).
Themechanismsbywhichmindfulnessledtotheseimprove-
ments in women with sexual dysfunction are not entirely clear
andmayrelatetoadecreaseinspectatoring—definedbyMasters
andJohnson(1970)astheprocessofwatchingoneselfduringsex-
ual activity from a third person perspective—a decrease in anx-
iety, encouraging an attitude of acceptance and non-judgment,
and/or an increasein perception ofphysical sexual response. In
supportofthelatter,onelaboratory-basedstudyinwhichfemale
studentswithoutsexualdifficultieswererandomizedtoeitheran
8-weekmindfulnessmeditationgrouportoanactivecontrolrated
theintensityoftheirphysiologicalresponsesafterviewingemo-
tionalphotos(Silverstein,Brown,Roth,&Britton,2011).Thepri-

maryanalysisfocusedon interoceptive awareness,thecapacityto
accuratelydetectphysicalsensations,afterthemindfulnessinter-
vention. Interoception has long been of interest to emotion
research-
ers,andisknowntocorrespondtoanafferentpathwayfromparts
ofthebodytothespinalcord,brainstem,andultimatelytothe
rightanteriorinsularcortex(Craig,2002).Studyparticipantswere
shown a series of 31 pictures containing sexual and non-sexual
imagesandwereaskedtoindicatetheirlevelofphysiologicalarousal
(calm,excited,andaroused).Reactiontime,orhowquicklyanindi-
vidualratedtheintensityofarousalintheirbody,wasusedasanindex
ofgreaterinteroceptiveawareness.Womeninthemeditationgroup
hadsignificantlyfasterreactiontimesthanwomeninthecontrol
group,andthequickerreactiontimesignificantlycorrelatedwith
increasesinmindfulness,attention,non-judgment,self-acceptance,
andwell-being,andwithdecreasesinself-judgmentandanxiety.Sil-
versteinetal.inferredthistomeanincreasedinteroceptiveawareness
followingmindfulnesstrainingthatmaycorrespondwithactivityin
the insula cortex.

Thereismarkedindividualvariabilityintheabilitytodetectinter-
nalphysicalsensations,withsomeindividualsbeinghighlyintero-
ceptivelyaware,andothersbeingrelativelynaı̈ ve tochangesin
bodilyreactions.Furthermore,there ismarkedvariationinsex-
ualconcordanceamongwomen.Intheirmeta-analysisofthesex-
ualpsychophysiologyliterature,Chiversetal.(2010)found,using
apooledsampleof n = 2345women,thatvariationinwomen’s
sexualconcordancewasnotaccountedforbyavarietyofmethod-
ological factors such as the number of stimulus trials in a given
experiment,theuseoffemale-centeredversusmale-centerederotic
stimuli,orstimuluslength;however,highersexualconcordance
was associated with using stimuli that varied in content, inten-
sity,ormodality(r = .49)andmethodofcalculatingcorrelations
(between-subjects[r = .29]versuswithin-subjects[r = .43]).
Chivers et al. also found that concordance among women was
relatedtomethodofassessinggenitalresponse,withgenitaltem-
perature (e.g., labial thermistors and thermographic imaging)
yieldinghigherestimatesofsexualconcordancethanvaginalpho-

toplethysmography (.55 vs. .26, respectively), although thermo-
graphic methods of assessing genital response also produce
wide
1908 Arch Sex Behav (2016) 45:1907–1921
123
inter-individual variation in sexual concordance, similar to
vagi-
nalphotoplethysmography(Kukkonen,Binik,Amsel,&Carrier,
2010). Regardless of measurement method, broad variation in
sexualconcordancesuggeststhepresenceofmoderators,ofwhich
sexualfunctioningmaybeone(Boyer,Pukall,&Chamberlain,
2013).
Low sexual concordance can manifest in one of two ways:
increasesingenitalsexualresponseintheabsenceofgenitalaware-
nessorsexualaffect,ortheconverse.Consistently,itistheformer
thatisthecaseforsexuallyfunctionalwomen;genitalresponseto
sexualstimuliisrapidlyandautomaticallyevokedbyprocessing
ofsexualstimuli(Chivers&Bailey,2005),butgenitalawareness

or sexual affect may not be simultaneously reported (Chivers
et al., 2010). This pattern is also common among women with
FemaleSexualArousalDisorder(FSAD)—whichtheformer
DSM-IV-TR characterized as self-reported impairments in
genital vasocongestion (American Psychiatric Association,
2000)—suchthattheyself-reportedlowersexualaffecttosexual
stimuli in the laboratory but showed a robust genital response,
similar to women without sexual arousal problems (Laan, van
Driel, & van Lunsen, 2008; Meston, Rellini, & McCall,2010).
In their meta-analysis, Chivers et al. reported the average cor-
relationforwomenwithvarioussexualdifficulties(n =235)as
.04(-.10to.17),whereasforwomenwithoutsexualdifficulties
(n =1144), the correlation was .26 (.21 to .37).
Sexualconcordancemayberelatedtosexualfunctioningamong
healthywomen,suchthatgreaterconcordanceisassociatedwith
morefrequentexperienceoforgasm(Adams,Haynes,&Brayer,
1985;Brody,2007;Brody,Laan,&vanLunsen,2003).Coupled
withdatashowinghighersexualconcordanceamongwomenwith-

outasopposedtowithasexualdysfunction,thesedatasuggestthat
sexualconcordancemaybeakeycomponenttohealthysexual
functioninginwomen.Currenttreatmentsforsexualdysfunction,
however,donotfocusonskillsthatmayenhancewomen’ssexual
concordancenorhavetreatmentefficacystudiesusedsexualcon-
cordance as a primary outcome.
In light of mounting evidence that mindfulness improves
women’sself-reportofsexualfunctionandawarenessofbodily
sensations, and that concordance between genital and self-re-
portedarousalmayberelevanttowomen’ssexualinteroceptive
awareness,thecurrentstudywasdesignedwiththese themesin
mind.Specifically,thegoalswereto:(1)examinetheeffectsofa
group mindfulness-based sex therapy (MBST) on concordance
between genitalandsubjectivesexualarousal; (2)examine the
effects of treatment on self-reported sexual arousal and, sepa-
rately, on genital arousal; and (3) test the relationship between
changesinconcordanceandimprovementsinclinicalsymptoms
(i.e., sexual desire and sex-related distress) with treatment. A

separatepublicationdocumentsthesignificantbeneficialeffect
of this MBST compared to a delayed treatment control group
ontheprimaryendpointofself-reportedsexualdesire(Cohen’s
dtreatment=0.97; dcontrol =0.12) (Brotto & Basson, 2014). Sex-
related distress also significantly improved with treatment, and
did not significantly differ from the control group (Cohen’s d
full sample=-0.56).
Inthisarticle,wefocusedonchangesinconcordancebetween
genitalsexualresponse(vaginalpulseamplitude;asmeasuredby
vaginalphotoplethysmography)(Sintchak&Geer,1975)andcon-
tinuouslyreportedsubjectivesexualarousal(Rellini,McCall,
Randall,&Meston,2005)followingtreatment.Giventhatthe
MBSTencouragedthedailypracticeoffocusingonandexperi-
encinggeneral and genital arousal responsesnon-judgmentally,
weexpectedtreatmenttobeassociatedwithsignificantincreases
ingenital-subjectiveconcordance.Sinceparticipantswereencour-
agedtopracticemindfulnessexercisesdailybetweengroupses-
sions,wepredicteddegreeofhomeworkcompliancewouldmod-

eratetheincreasedconcordanceaftertreatment.Asanexploratory
analysis, we also included age, diagnosis of FSAD, andarousal
scoresfromavalidatedmeasure(bothsubjectivearousalaswell
aslubrication)tomoderateimprovementsinconcordance.Fur-
thermore,wehypothesizedanincreaseinself-reportedsexual
arousalwithtreatment,consistentwithpreviousfindings.Wedid
notexpecttofindaneffectoftreatmentongenitalsexualresponse
perse,givenevidencethatvaginalpulseamplitudemaynotdif-
ferbetweenwomenwithandwithoutsexualdysfunction(Laan
etal.,2008).Finally,wepredictedchangesinconcordancetobe
associatedwithimprovementsinsexualdesireandwithdecreases
in sex-related distress.
Method
Participants
Participants werepart ofa largerstudy evaluatingoutcomesof
groupmindfulness-basedsextherapyonvariousindicesofsex-
ualdesire,sexualresponse,andaffect(Brotto&Basson,2014).
Womenseekingtreatmentforsexualdesireand/orarousalcon-

cerns from the British Columbia Centre for Sexual Medicine,
whetherthedifficultieswerelifelongoracquired,wereeligible
to participate. Inclusion criteria included: age between 19 and
65years,fluentinEnglish,andwillingtocompleteallfourgroup
sessions,regularhomework,aswellasassessmentmeasures(con-
sistingofbothself-reportquestionnairesandalaboratory-based
psychophysiological sexual arousal assessment) at three time
points. Women with difficulties in achieving orgasm were also
includedaslongasthosewerenotexperiencedasmoredistressing
thanthedesireand/orarousalconcerns.Weexcludedanywoman
with dyspareunia (chronic genital pain not resolved with a per-
sonal lubricant).
Theoriginalstudydescribingtreatmentefficacyincluded117
women who provided pre-treatment assessment data. The data
herefocuson79womenwhohadcompletedatafromtheirpsy-
chophysiologicalassessments(bothgenitalandsubjectivearousal)
atallthreetimepoints—immediatepre-treatment,post-treatment,
and6-monthfollow-up.Thesampleincluded41(51.9%)women

Arch Sex Behav (2016) 45:1907–1921 1909
123
who were assigned to the immediate treatment group and 38
(48.1%)womenwhoreceivedtreatmentafteraninitial3-month
wait-list period. Only pre- to post-treatment data for women in
thecontrolgroupwereincluded(i.e.,theirwait-listdatawerenot).
Also,inthisarticle,wedidnotincludedatafromthecontrolgroup
for their two pre-treatment assessments, so the present analyses
did not compare the effects of treatment versus wait-list control
onconcordance.Themeanage ofthesample was40.8years(SD
11.5, range 20–65). A total of 84.6% were in a committed rela-
tionship, 6.4% were casually dating, and 9.0% were single. The
mean relationship length was 13.2years (SD 10.7). Most partic-
ipantswereofEuro-Canadiandescent(81.0%)followedbyEast
Asian (7.6%) and South Asian (2.5%). This was a highly edu-
catedgroupin that 67.1% hadsome post-secondary education,
and 22.8% had an advanced graduate degree.

Althoughallparticipantsself-reporteddifficultieswithsexual
desireand/orarousalandmetcriteriafortheDSM-5diagnosisof
SIAD,33(41.8%)womenmetDSM-IV-TR(AmericanPsychi-
atric Association, 2000) diagnostic criteria for HSDD and 24
(30.4 %) women met criteria for FSAD. The remaining 22
(27.8 %) women met criteria for both HSDD and FSAD.
Measures
Assessment of Psychophysiological Sexual Arousal
Genital response was measured with a vaginal photoplethys-
mograph(Sintchak&Geer,1975)consistingofatampon-shaped
acrylic vaginal probe, inserted in private by the participant. The
probe (Behavioral Technology Inc., Salt Lake City, UT) contin-
uouslymeasuredvaginalpulseamplitude(VPA)duringtheneu-
tralanderoticfilmsegments.VPAwasrecordedusingapersonal
computer(HPPentiumMLaptop)thatcollected,converted(from
analog to digital, using a Model MP150WSW data acquisition
unit [BIOPAC Systems, Inc.]), and transformed psychophysi-
ological data, using the software program AcqKnowledge III,

Ver-
sion3.8.1(BIOPACSystems,Inc.,SantaBarbara,CA).Thesignal
wassampledat200Hzandbandpassfiltered(0.5–30Hz).Atrained
research assistant performed artifact smoothing of the signal
fol-
lowingvisualinspectionofthedataandbeforedatawereanalyzed.
VPAdataweresubsequentlydividedinto30-sepochs,producing
sixdatapointsfortheneutralfilmand13datapointsfortheerotic
film for each sexual arousal assessment.
Contemporaneous Assessment of Subjective Sexual Arousal
Subjectivesexualresponsewasmeasuredcontinuouslyduring
the neutral and erotic films with an arousometer that was con-
structedbyalocalengineermodeledaftertheonedescribedby
Rellini et al. (2005). This device consisted of a computer optic
mouse mounted on a plastic track with 10 intervals, and was
affixedtothearmrestofthereclinersothattheparticipantcould
easily move the mouse, while simultaneously reclining and
viewing stimuli. Women were instructed to move the mouse
up and down the track over the course of the film to indicate

theirlevelofsubjectivesexualarousal,from7to-2,with7 =
Highest Level of Sexual Arousal, 0 = No Sexual Arousal, and
-2= Sexually Turned Off.Wehavepreviouslyusedthisdevice
intreatmentoutcomestudiesonwomenwithsexualdysfunction
(Brottoetal.,2012b).LikeVPAdata,themeancontemporaneous
sexual arousal response was obtained every 30-s, producing six
datapointsduringtheneutralfilmand13datapointsduringthe
erotic film, corresponding with the 30-s epochs of VPA data.
Discrete Measure of Sexual Response and Affect
The Film Scale, a 33-item self-report questionnaire, was used
toassesssubjectivearousalandaffectivereactionstotheerotic
films.ThisscalewasadaptedfromHeimanandRowland(1983)
andassessedsixdomains:subjectivesexualarousal(1item),
perceptionofgenitalsexualarousal(4items),autonomicarousal
(5items),anxiety(1item),andpositiveandnegativeaffect(11items
each). The scale has been found to be a valid and sensitive mea-
sureofemotionalreactionstoeroticstimuli.Itemswereratedon
a 7-point Likert scale from Not at All (1) to Intensely (7). Pre-

treatmentreliability for the Film Scale duringthe neutral phase
wasverygood(Cronbach’salpha=0.82)andexcellentfollowing
the erotic phase (Cronbach’s alpha = 0.94).
Homework Compliance
Homeworkcompliancewasratedbythegroupfacilitatorsona
Likertscalefrom0(did not complete homework/did not attend
sessions)to2(notable efforts at completing homework/attend-
ing sessions).Aratingwasgivenforeachparticipantateachof
thefourgroupsessions,andthenameanscoreacrossthesessions
was derived.
Female Sexual Arousal Disorder symptoms
Subscales of‘‘Arousal’’and‘‘Lubrication’’on the Female Sex-
ualFunctionIndex(FSFI)(Rosenetal.,2000)wereusedinmod-
eration analyses. The FSFI is a 19-item self-report questionnaire
considered to be the gold standard measure of sexual function in
women.Therewere4itemsintheArousaldomainand4itemsin
theLubricationdomain;responseswerecodedona5-pointLikert
scale.Arespondentwhohadnotengagedinsexualactivityforthe

past4weekswasexcludedfromthoseitems.Cronbach’salphafor
these two domains was excellent (a=0.89 and a=0.93, respec-
tively) for the current sample.
Sexual Desire was measured with the 14-item Sexual Inter-
est/DesireInventory(SIDI)(Claytonetal.,2006).Possibletotal
scores range from 0 to 51, with higher scores indicating higher
levelsofsexualinterestanddesire.TheSIDIhasexcellentinter-
nal consistency (Cronbach’s a=0.90). Item-total correlations
1910 Arch Sex Behav (2016) 45:1907–1921
123
were high for‘‘Receptivity,’’‘‘Initiation,’’‘‘Desire-frequency,’’
‘‘Desire-satisfaction,’’‘‘Desire-distress,’’and‘‘Thoughts-
positive’’
(r[.70), good for‘‘Relationship-sexual,’’‘‘Affection,’’‘‘Arousal-
ease,’’and‘‘Arousal-continuation’’(r[.50),butpoorfortheorgasm
item(r =.10)(Claytonetal.2006).Cronbach’salphaforthecurrent
sample was a=0.76.
Sexual Distress was measured with the 12-item Female Sex-
ual Distress Scale (FSDS) (DeRogatis, Rosen, Leiblum, Burnett,

& Heiman,2002).Scorescan rangefrom0to48,where higher
scores represent higher levels of distress. The FSDS has been
shown to have good discriminant validity in differentiating
between sexually dysfunctional and sexually functional women,
with 88% correct classification rate, and found to have satis-
factory internal consistency (ranging from 0.86 to 0.90) (DeRo-
gatis etal.,2002).Reliabilityfor the current samplewas excel-
lent at a =0.92.
Procedure
Followingacomprehensiveassessmentbyanexperiencedsexual
medicineclinician,eligiblewomenwereinformedaboutthe
study.Ifinterested,theywereprovidedwithaone-pagebrochure
outlininginformationaboutthestudyandcontactinformationfor
thestudy’scoordinator.Next,theytookpartinatelephonescreen
thatfurtherexplainedthestudyprocedures,providedsomeinfor-
mation about the treatment content, and informed women about
upcomingschedulesfortheMBSTgroups.Theywerethenmailed
a consent form. The return of a signed consent form indicated

informed consent, at which time women were assigned to par-
ticipate in either the immediate treatment group or the delayed
treatment group. Whenever possible, we utilized random assign-
ment to group; however, in cases where participants’ schedules
werenotflexible,weassignedwomentothegroupthataccommo-
datedtheirschedules.Participantswerethenscheduledforabase-
line sexual arousal assessment to take place in a sexual psy-
chophysiologylaboratory.Womenwerealsomailedapackageof
questionnaires and asked to return them completed at the time
of
their sexual arousal assessment. These same questionnaires and
sexual arousal assessment were repeated 2–4 weeks after the
completion of their MBST group as well as 6 months later. The
duration between baseline and the two subsequent assessments
was relatively equal across all participants, with no more than
2-week variation, typically at the follow-up assessment.
The sexual arousal assessment took place in a sexual psy-
chophysiologylaboratory,locatedintheuniversityhospital,and
housed a comfortable reclining chair, a large screen TV, and an

intercom. A thin blanket was placed over the seating area of the
chair. Following written consent, participants were tested by a
female researcher. Women were first shown the vaginal photo-
plethysmographandencouragedtoaskanyquestionsabouthow
to insert it. The female researcher then left the room, while
participants inserted the probe and informed the researcher via
intercom of their readiness. In order to habituate to the testing
environment, participants were encouraged to relax on a com-
fortable reclining chair for a 10-min period after the probe was
inserted. Subjective sexual arousal and affect were assessed at
the end of the adaptation period using the Film Scale, which
servedasthediscreteassessmentofarousalandaffectbeforethe
erotic film sequence.
Before the film sequence began, women were reminded to
use the arousometer to capture their subjective sexual arousal
throughout the film sequence. The researcher instructed partic-
ipants to:‘‘Monitor your subjective feelings of sexual arousal to
the film by using this device. By ‘subjective feelings of sexual

arousal,’ we mean how mentally sexually aroused you are in
your mind while you’re watching the film.’’Further instructions
were given on the numerical demarcations on the device and
whattheupper(mostsexualarousalyouhaveexperiencedorcan
imagine) andlower (sexually turned off) anchorsreflect. Partic-
ipants practiced moving the arousometer in the presence of the
researcher and any questions on its operation were addressed
before the film sequence began.
The researcher then initiated the video sequence from the
adjoining room. The audio component was delivered via wire-
less headphones to the participant. Women watched a 3-min
neutral documentary about Hawaii followed by a 7-min erotic
film that depicted a heterosexual couple engaging in foreplay,
oral sex, and penile–vaginal intercourse. There were three dif-
ferent film sequences counterbalanced across women and ses-
sions so that participants viewed the same film only once over
thethreetestingsessions.Immediatelyafterthevideosequence,
participantscompletedtheFilmScaleasecondtime,whichasked

them to evaluate their subjective sexual arousal and affect to
theeroticfilm.Theyweretheninstructedtoremovetheprobeand
meet the researcher in a separate room. After a debriefing
period,
the researcher disinfected the probe in a solution of Cidex OPA
(ortho-phthalaldehyde 0.55%), a high level disinfectant
(Advanced
Sterilization Products, Irvine, CA, USA), promptly following
each session.
All procedures were approved by the Clinical Research
EthicsBoardattheUniversityofBritishColumbiaandtheVan-
couver Coastal Health Research Institute. All procedures were
carriedoutinaccordancewiththeprovisionsoftheWorldMed-
ical Association Declaration of Helsinki.
Mindfulness-Based Sex Therapy
TheMBST(Brotto,Basson,&Luria,2008b)was based onan
integration of psychoeducation, sex therapy, and mindfulness-
based skills, the latter of which have received extensive empir-
ical support in other populations (Grossman et al., 2004). Stem-

ming from evidence that women with sexual desire/arousal dif-
ficulties are often distracted during sexual activity and/or judg-
mental(ofthemselvesortheirpartners),mindfulnessskillswere
primarily aimed at orienting the woman to the present experi-
ence,whilesimultaneouslynotingnegativethoughtsas‘‘mental
Arch Sex Behav (2016) 45:1907–1921 1911
123
events’’—something to be noticed but not focused on. Consis-
tentwithmindfulness-basedcognitivetherapyforpreventionof
depression relapse (Teasdale et al., 2000), MBST aims to help
womendevelopawarenessinallareasoftheirlife,includingreal
andanticipatedsexualsituations.Atleast4weekswerespentencour-
aging women to practice mindful self-awareness in non-sexual
sit-
uationsasameansofdevelopingtheskillofmoment-by-moment
awareness.In-session‘‘inquiries’’followingmindfulness practice
wereintendedtoallowparticipantstoviewtheirpracticeasadepar-

ture fromtheir typicalmodeof being,whichmayhave beenchar-
acterizedasfuture-oriented,multi-tasking,and/orruminativeabout
pastevents.Atlaterstagesofthegroup,womenwerethenencour-
agedtoapplytheirnewskillsinprogressivelymoresexualsitua-
tions—firstontheirown(followingexposuretoaneroticstimulus
suchasavibratororeroticfilm),andnexttogetherwithapartner
(ifapplicable,duringactualsexualactivity).Theaimofthehome
practice was to encourage participants to develop a regular
mind-
fulnesspracticeandacquireexperienceobservingthoughts,espe-
ciallynegativeones,asmentalevents,beforeintroducingpractice
togetherwithapartner,orapplyingmindfulnessduringat-home
sexualactivities.Althoughsensatefocusshareswithmindfulness
thegoalofpresent-momentawareness,theformerrequiresapartner
tobepresentanddoesnothavetheadvantageofportabilitythat
mindfulnesshas(i.e.,inhomeworkactivitieswomenwereenco-
uragedtouseinformalmindfulnesspracticethroughouttheirdays
tocomplementtheformalpractices).Concurrentwiththeprinciples
ofmindfulness,womenwereencouragedatthestartofSession1to

…
1.1
1.2
2.1
Negotiating Intimacy, Equality and Sexuality in
the Transition to Parenthood
by Charlotte Faircloth
University of Roehampton
Sociological Research Online, 20 (4), 3
<http://www.socresonline.org.uk/20/4/3.html>
DOI: 10.5153/sro.3705
Received: 9 Dec 2014 | Accepted: 12 Jun 2015 | Published: 30
Nov 2015
Abstract
Whilst both 'parenting' and 'intimacy' have been explored
extensively in recent social scientific research (for example,
Lee et al
2014,Gabb and Silva 2011 ), their intersections in the context of
family life remain curiously absent. This paper presents
findings from
on-going longitudinal research with parents in London, which
investigates how the care of children, and particularly the
feeding of
infants, affects the parental couple's 'intimate' relationship. In

particular, as part of this special section, it looks at couples'
accounts of
sex as they make the transition to parenthood, as a lens on the
themes of gender, intimacy and equality. Far from being an easy
relationship between them, as predicted by some scholars, this
research shows that they are in fact, 'uncomfortable bedfellows'.
Keywords: Parenting, Gender, Intimacy, Equality, Sex, Couples
Negotiating intimacy, equality and sexuality in the transition to
parenthood
Based on longitudinal work with new parents in London, this
paper draws on research which
investigates how the care of children, and particularly the
feeding of infants, affects the parental couple's intimate
relationship. To that end, it brings together two (traditionally
distinct) bodies of literature – one calling attention to
a shift in British parenting culture towards a more 'intensive'
and 'child-centred' form of care, the other, looking at
changes to intimate relationships in an age of 'reflexive
modernisation' and greater gender equality. Specifically,
this paper focuses in on couples' accounts of sex as they make
the transition to parenthood, as a lens on the
themes of gender, intimacy and equality.
Whilst intimacy itself can incorporate a range of different
practices, as a vehicle for intimacy, sexual
intercourse often serves as a barometer for couples in how they
assess the quality of their relationship (Weeks
1995). In line with other papers in this special section, then, the
research shows that far from being a
straightforward correlation between gender equality and greater
intimacy, (as predicted by Giddens et al 1992),
the two are, in fact, 'uncomfortable bedfellows', particularly
once couples become parents. The article briefly
reviews the two bodies of literature, explains the policy context

around parental leave and childcare in the UK,
discusses the study methodology, and then presents findings,
analysis and discussion by way of conclusion.
Theoretical background: Intimacy and parenting
As Gabb and Silva (2011) note, the 'conceptual challenge to
researchers working in the field of family
and relationship studies…is how to carry on building concepts
and finding new methods to capture the vitality of
personal relationships while keeping sight of the social
contexts, patterns and practices of contemporary intimate
life' (1.1, 2011). Famously, work by Giddens (1992), Bauman
(2005) Beck (1992) Beck and Beck-Gernsheim
(1995) and others has explored shifting patterns of intimacy in
the contemporary age of 'individualisation'.
Broadly speaking, this body of work argued that, in the age of
'reflexive modernisation', there had been a shift
away from traditional, patriarchal couple relationships, based on
an inherent inequality between men and
women, toward a more equitable, mutually fulfilling model,
accompanied by the rise of a more 'plastic' sexuality in
http://www.socresonline.org.uk/20/4/3.html 1 30/11/2015
http://www.socresonline.org.uk/20/4/3/faircloth.html
http://crossmark.crossref.org/dialog/?doi=10.5153%2Fsro.3705
&domain=pdf&date_stamp=2015-11-30
2.2
2.3
2.4
2.5

2.6
particular (Giddens 1992; this special section). Giddens argued
that in the late twentieth century, in the place of
traditional patterns of marriage, for example, individuals
became more aware of the need for a fulfilling
relationship, based on 'confluent love'; one that is active and
contingent. The 'pure relationship', which is not
bound by traditional notions of duty and obligation, has come to
depend, instead, on communication and
negotiation. The implication of this work is both that greater
equality leads to greater intimacy, and that this is a
desirable aspiration for contemporary relationships.
Since this work was published, however, scholars working in
the field of family and relationship studies
have critiqued the model, arguing for a more nuanced
perspective, grounded in the realities of everyday
experience. Specifically, Gabb and Silva identify three main
strands of thinking which have been particularly
influential in shaping and reorienting contemporary UK family
and relationship studies over the past 15 years,
since the publication of Beck and Giddens' work, including
Morgan's notion of 'doing family' as sets of
expectations and obligations connected to kin relations (1996);
Smart's conception of 'personal life' beyond that
of the family (2007); and Jamieson's notion of intimacy defined
as 'any form of close association in which people
acquire familiarity, that is shared detailed knowledge about
each other' (Jamieson 1998: 8).
The last of these is particularly relevant here, specifically as it
relates to changes in the division of labour
between couples once children arrive. For Jamieson, '[t]he
majority of people in Euro-North American societies

have lives which are sufficiently privileged to seek 'good
relationships' which are not dominated by necessity.
However [even then] most personal relationships include a mix
of love, care, sharing, understanding and
knowing, which involve a degree of relying on, needing or
depending on the other, if not desperate necessity'
(1998: 174).
The intention here is to bring this perspective on intimacy to
bear on the subject of parenting, my own
area of research to date (Faircloth 2013). The underlying
argument of that work was that there has been a
significant shift in 'parenting culture' in the UK over the last
twenty years. The word 'parent', for example, has
shifted from a noun denoting a relationship with a child
(something you are), to a verb (something you do).
Parenting is now an occupation in which adults (particularly
mothers) are expected to be emotionally absorbed
and become personally fulfilled; it is also a growing site of
interest to policy makers, thought to be both the cause
of, and solution to, a whole host of social problems (Lee et al
2014). 'Ideal' parenting is financially, physically and
emotionally intensive, and parents are encouraged to spend a
large amount of time, energy and money in raising
their children, often with the aid of 'experts' (Hays 1996).
Whilst this ideology of parenting is not carried out by all
parents, or affects all parents in the same way, it nevertheless
serves as an ideal standard to which all become
accountable (Arendell 2000). This 'intensive parenting' climate,
as several scholars have now argued, has
changed how parents experience their social role, to the point
that one's style of parenting has become more and
more central to adult 'identity-work' (for example, whether one
is a 'Tiger Mother', an 'Attachment Parent' or a
'Gina Fordist '). Drawing on Goffman (1959) this term is used in
place of a more static 'identity' to highlight the

active processes by which identity is constructed, and the
inherently social nature of this enterprise, as opposed
to being simply a means of self-expression (Faircloth 2013).
Accounts of the development of this 'intensive parenting'
culture, including my own, have emphasized
how it influences mothers in particular, noting how the demands
placed on women in their role as mothers have
intensified as women have continued to enter the labour market
(rather than decrease, as one might expect).
Partly as a means to counter this imbalance, which sees women
working the 'double shift' Hochschild (2003),
British society has witnessed the construction of the 'involved
father' – mirroring, to some extent the more familiar
'intensification' of motherhood (Dermott 2008, Miller 2011).
Men are increasingly encouraged to be 'engaged' in
childcare, with a particular emphasis on the importance of
creating a close emotional connection with children, in
place of the more traditional model of the patriarchal
breadwinner (Dermott 2008, Lee et. al 2014). Involved
fatherhood is also promoted as a means of building stronger
communities, with a particular concern about rates
of single motherhood in poorer communities (BBC 2007). Not
surprisingly, then, accounts from sociologists
reveal that fatherhood is becoming more and more central to
men's 'identity work' in their accounts of personal
life.
Yet whilst discursively fathers may be encouraged to be
'involved' in parenting and take more of an
equal load of childcare, in reality, it is women who continue to
shoulder most of the responsibility for this (Dermott
2008, Lee et. al 2014). It is women who typically take extended
periods of time away from paid work, and move
to part-time hours when they do return to the work place, if they
return at all. What is more, despite this emphasis

on the importance of splitting responsibilities, optimal infant
care as promoted by the state is an inherently
gendered, embodied one: women are strongly encouraged to
breastfeed their babies by health professionals and
[1]
http://www.socresonline.org.uk/20/4/3.html 2 30/11/2015
2.7
3.1
3.2
3.3
3.4
4.1
policy makers, particularly in the early months, a practice which
has a cascading impact on many other aspects
of infant care (such as soothing and sleeping).
To heed Jamieson's caution again, then, we need to consider
how relationships alter when children
arrive, and the increased 'necessity' and 'dependence' they create
between partners. How, for example, does
'plastic sexuality' work in the context of parenthood, for both
men and women? Does the equitable model of the
'new fatherhood' fit into this picture, or does the reality of life
as parents inevitably engender a more traditional
family set up? And finally, how does the state provision of care

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