Final Project Part Two1The Name of the Program .docx

Final Project: Part Two
1
The Name of the Program or Project
Student Name
Walden University
The Name of the Program or Project
Introduction
Part 1
Place part 1 here. It will not be graded but the connections
between part 1 and part 2 are needed.
Part 2: Methodology and Evaluation Plan

A brief introduction to part 2 and what will be addressed.
Methodology
Program Description
State the importance of the program and what your program will
(a paragraph or two). .
Research Design
This research design will be quantitative OR qualitatitve
…..state the type of quantitative design that will be used
(survey, experimental) or the qualitative design (open ended
questions, case study, etc.). State the reason for the design
chosen and briefly how it will be used. Use sources here to
define the type of design and how it will be used (a full
paragraph).
Human Subjects
The participant population will consist of ….are they children,
adults? How old are they? What is the requirement? (i.e. must
be homeless women with children). (a full paragraph).
Study Validity and Reliability
State what validity is and which one you are using (use
resources) and how validity will be used in your program (a full
paragraph). Use resources in this section to define validity and
reliability and the type you will use.
Do the same for reliability (a full paragraph).
Assumptions and Limitations
First identify the assumptions of the research and program. You
can make assumptions about the length of time that participants
will be treated, assume what will be applied to the participants
(therapies or training or any service that you are providing).
You can make assumptions about how these services are
provided and the purpose of them. There are also assumptions
you can make about the research design you are using (at least a
full paragraph).
Limitations are anything that limits the research for the
program. There can be limitations for the length of time, the
place, getting participants to return or remain in the study.
There are also limitations to the type of research design (at least

a full paragraph).
Again, use resources here to define some of the assumptions or
limitations.
Timeline (sample below)
Activity
Time Frame
Instrument/Survey Development
Weeks, months, etc.
Pilot Testing
State the length
Subject Recruitment
State the length
Application of therapy or service
State the length
Other possible services
State the length
Add in anything else that take time (i.e. parental education)
State the length
Add anything that takes time
State the length
Data Entry and Cleaning
State the length
Data Analysis
State the length
Report Generation
State the length
Analysis
Give a brief paragraph on how the analysis will be handled
(most of this will be covered in the evaluation section).
Non-personnel Resources
Discuss ANY and all non-personnel resources. This can be
buildings or rooms (even if no cost), pens/pencils/paper,
printers, computers, clipboards, folders or files, desks and
chairs, other office equipment, uniforms, food items, things to
cook food in, and the list goes on. (this can be short or very
long, depending on the program).

Personnel resources
State WHO will work for the program with a brief explanation
of each person and what they will do (at least a paragraph, but
some are longer when there are several workers for the
program).
Mangement Plan
State that you are the principle investigator and your role in
managing the project. What is the role of the other people in the
program in order for the project to managed effectively? (i.e.
the three different therapists, family, cognitive-behavioral and
emotion-focused, will be responsible for each of their therapies
being provided to the children and parents and/or guardians,
while the two human service professionals focusing on
substance abuse and addiction treatment will be responsible for
focusing and providing treatment and prevention). In larger
programs this section will be long. Most programs have a long
list to include the project director, assistants, therapists
(different types), clinicians, statistician to help with the data,
volunteers or interns, and so forth (the more personnel the
longer this is and the larger the program the longer this section
will be). *Sources might be used here.
Evaluation Plan
Description of Specific Criteria
Be very specific here on what criteria the participants must have
in order to participate. It may be a small paragraph if the
program is solely focused on one type of individual (i.e.
participants in a home that require a transportation). However,
most programs will be more detailed as the participants have
several needs and the program will focus on theses (as per your
objectives) (a full paragraph).
Explanation of Data That Will be Collected
All data (quantitative or qualitative) needs to be explained here
on how it will be collected. This is where you further the
information from the ‘Research Design’ section. You’ll need to
state how you will gain the data (i.e. Children's past and present
mental, psychological and emotional health will be collected to

assess how well the family, emotion-focused and cognitive-
behavioral therapy works to increase their well-being). There
may also be information needed at pre and post the program.
Information can come from several sources – therapists,
quantitative data on how many participate, academics, test
scores, qualitative data on how participants feel or how
therapists rate progress (a paragraph or two). (Sources should
be used here as per the research design and material collected).
Explanation of the Data Collection Plans
This will further the last section in where you will be very
specific on the ‘steps’ on how the data will be collected. For
example “To collect the above data, the children will go through
mental, psychological and emotional testing at the beginning of
the project, while academics will be collected from the
children's schools and discussions will take place with
teachers…..” This section will be long (a few paragraphs
usually) as details are needed to explain ‘how’ the information
will be collected, when, how often, what will be collected, etc.
(this section is usually longer as this is an ‘explanation’ of all
the data collected).
Evaluation of Instruments
State what instruments you used. For example “Interviews and
surveys were chosen as the evaluation instruments as we are
going to be implementing this program throughout a long period
of time, 36-months….” If you have a specific survey or
interview format then give this information. If there is
qualitative data then state how the questions will be formatted
and why. Again, give as much information as you can here. (this
section can be a paragraph to a page, depending on how many
instruments you are using). *Resources should be used here if
you are using an instrument that already exists.
Periodic Reports
State any periodic reports that you will gain in addition to
the larger evaluations you are focused on. This can be periodic
reports on program structure, how the program is running, the
effectiveness of personnel, etc. (a short paragraph)

Conclusion
A conclusion should summarize the entire part 2. State the most
important pieces of the part, as this is what will remain as most
important to your grantor (a full paragraph or two here).
References
List all references as per APA.
1. What is marketing? What is marketing strategy? Explain.
2. Explain why it is important for a company to have a defined
mission? Why is the development of a personal mission or
purpose important for an individual?
3. Why is it important to understand the external environment in
order to think strategicaly.

4. Discuss why superior efficiency is important and the many
ways that different parts of the organization can help achieve it.
5. Using the industry life-cycle model, explain how the threats
and opportunities for existing firms in an industry change over
time.
6. Describe how business-level strategies give a company a
competitive advantage over actual and potential rivals.
7. Identify and describe the four building blocks of
competitive advantage. Provide an example of each using a real
company situation.
8. Give one example of a firm that has achieved a distinctive
competency in efficiency and describe that
competency. Now, an example of a firm with a distinctive
competency in quality, innovation, and responsiveness to
customers.
9. Explain how tangible and intangible resources and
capabilities can lead to distinctive competencies. Give specific
examples.
10. Select at least three of the cognitive biases that individual
decision makers experience. Then describe the bias and a real or
hypothetical situation for each of them, explaining how the bias
is evident in the situation.
Sexuality and Shame

Carole Shadbolt
Abstract
This article discusses the development of
childhood and adult sexuality from a rela-
tional and cultural perspective. The roots of
shame are identified and the affect of shame
is described. The strong links between sexu-
ality and shame are explored. The author
suggests that sexual shame is a Type III im-
passe, and its resolution within the context
of therapeutic relatedness is addressed. The
article's central point is the unique, indi-
vidual, and shifting character of each per-
son's sexuality.
There is nothing tame about shame, which
wounds in direct proportion to the good
feeling and sense of relational safety it at-
tacks, impedes, stifles.
Nathanson(1999, p. vii)
There is a curious and abiding relationship be-
tween sexuality and shame. Both are multiface-
ted, fundamental aspects of our personal and
public lives. Sexuality, excitement, and shame
meet at the boundary of our private and public
selves. As such, they appear as central issues to
be thought about and addressed in psychothera-
py. Equally as curious is the relatively small
amount of writing and discussion within the
field of psychotherapy, especially humanistic
circles, about sexuality and shame.

Despite Freud's writings on the centrality of
sexuality as the key to human disturbance, cli-
nicians seem to hedge around the topic of sexu-
ality. As Pajaczkowska and Ward (2008) put it,
"Ironically, psychoanalysts today do not talk
about sex very much—preferring instead to focus
on issues of attachment, dependence, fears of
abandonment, aggression and envy" (p. 24).
They also quote Freud:
I can only repeat over and over again—for
I never find it otherwise—that sexuality is
the key to the problem of the psychoneu-
roses and of the neuroses in general. No
one who disdains the key will ever be able
to unlock the door. (p. 24)
Bollas (2000) comments on sexuality as be-
ing enigmatic and not easy to understand much
less to write about: "Questions that surround
sexuality—not the least being 'What is it?'—
are simply parts of the original complex im-
posed upon the child: What is happening to the
self? How is one to understand this develop-
ment?" (p. 15). Within the transactional analy-
sis community, of late, discussions and articles
on the importance of sexuality have been in-
creasing. Articles have appeared with sexuality
as their theme and a conference on sexuality was
held in Brighton in the United Kingdom in 2007.
The difficulty of dealing with sexuality in
clinical work was brought to mind when I
heard Irving Yalom lecture to a huge audience

of some 900 psychotherapists in London in
2004. Ninety-nine years after Freud's words,
Yalom offered this: "If you are' not talking
about death with your patients at some point
during their psychotherapy, you are not doing
psychotherapy." His words had an immediate
impact on me, and I have remembered them
often as I work, maybe catching myself not
speaking to a client's fear of death, which by
implication raises thoughts and existential fears
of my own. I have come to think of sexuality in
the same manner: If I am not speaking at some
point about sexuality with my client, 1 am not
doing depth psychotherapy.
The avoidance or difficulty of speaking about
both sexuality and death is not deliberate or
intentional; it merely illuminates the traumatic
nature of both. In a child's developing and ar-
riving sexuality, there is a death of sorts: the
death, as Bollas (2000) puts it, of "mama and
baba" (p. 14) and of childhood. And with death
comes loss. Perhaps speaking to sexuality in
session or writing about it raises for us the
same anxieties and fears that are present when
talking of death.
It has been said before that most theoretical
writing turns out to be autobiographical and
Vol. 39, No. 2. April 2009 ¡63
CAROLE SHADBOLT

evolves from our efforts to make sense of per-
sonal experience. So it is with my fascination
and curiosity about sexuality and shame and how
to think about its resolution in psychotherapy.
Childhood Sexuality and Relational Shame,
or "Don't Do that Some More, You Naughty
Little Boy"
Attachment, relatedness, and the develop-
ment of our sexual ities seem to me to be in-
extricably linked. To the late Stephen Mitchell
(as cited in White & Schwartz, 2007, p. 1),
"Sexuality is the arena in which fundamental
relational issues and struggles are played out."
He continued, "It is the establishment and main-
tenance of relatedness that is fundamental and
the mutual exchange of intense pleasure and emo-
tional responsiveness is perhaps the most pow-
erful medium in which emotional connection is
sought, established, lost and gained" (p. 3).
Relatedness is central in understanding the
dynamics of an emerging sexuality and the po-
tential for shame in both mother and child. In
Sensuality and Sexuality Across the Divide of
Shame, Lichtenberg (2007) stresses the nature
of the massive transition children undergo
when their infantile sexuality develops from the
sensual experience of being touched to becom-
ing the one who desires to do the touching,
from the one who is desired, touched, loved,
and being impacted on to the one who desires
and wants to love back—and what is at stake as
a consequence. Elsewhere, Lichtenberg (2007)
has suggested that there is less risk in sensual

desires than in sexual desires, arguing that "the
interplay between desire and prohibition cre-
ates an experience of tension in sexuality that is
not present in sensuality" (p. 2).
The determination of which aspects of a
child's behavior, thoughts, or feelings become
sexual as distinct from sensual is a relational
decision or process, one that, to Lichtenberg
(2007), depends to a large extent on the cultur-
al and personal values ofthe child's caregivers.
And their approval or disapproval is mediated
through shaming ofthe unsanctioned expres-
sion ofthe child's body/mind.
An anecdote from my past comes to mind.
When I was a child growing up in working-
class London ofthe 1950s, a poor but neverthe-
less deeply conservative environment, I remem-
ber my beloved grandmother, a woman of few
words, announcing herself "disgusted" by the
sight of a mother breast-feeding her baby in
public. That was a truly shocking, radical sight
for those days and caused my grandmother
much disturbance. It brought to her| mind the
story often told in our house at an appropriate
moment—and this was such a moment—of a
woman, rather isolated, something of an out-
sider in our community, who was still breast-
feeding her 5-year-old child. He—for it was a
boy—would run back from school to his moth-
er's breast, which she willingly, apparently,
provided over the front gate! For what I now
wonder? Milk? I rather doubt it, but perhaps.

What is pertinent in this dialectical story is
the apparent absence of shame, in both;the moth-
er my grandmother saw and the long-ago moth-
er ofthe story. Perhaps the latter was "shame-
less," perhaps that was her "brazen"i defense/
protection against a disapproving society, in
this instance personified by my grandmother.
What is clear when one understands; the rela-
tional context of sexual development is that the
5-year-old boy in question could not! progress
from the experience of sensuality to that of
sexuality. i
For Lichtenberg (2007), as the toddler's emerg-
ing sexuality develops, as he or she begins
wanting to touch, caress, suck, and impact an-
other relationally (usually mother), the child
explores and touches as he or she always has,
as in breast-feeding (which is also breast fond-
ling and touching), except that now, what was
once a source of pleasure, life, and sensuality
has suddenly—inexplicably to the child, no
doubt—become sexual, and therefore forbid-
den, and his or her desires a source of shame.
The relational manner in which the child's
innocent, natural intentions are received and
responded to by the other (usually mother) are,
in part, determined by the mother's own morals
and value system. This relational manner, in
tum, determines the toddler's self-image in re-
lation to excitement, desire, and the sensuality-
sexuality dynamic. In addition, corresponding
joyous, erotic responses in the mother, who
perhaps cannot win here, lead to culturally "un-
acceptable, dangerously arousing, lustful sex-

164 Transaciional Analysis Journal
SEXUALITY AND SHAME
uality" (Lichtenberg, 2007, p. 3). If this rela-
tional dynamic, when curbed (as it eventually
must be), is communicated to the toddler as
something to be ashamed of, the child may in-
terpret that to mean that he or she is the source
of shame, that his or her body is shameñil. The
child may then conclude, in a body sense rather
than cognitively, that he or she is "a naughty
little boy or girl." A child's response to being
"a naughty little boy" might well be one of pro-
test in the form of embodied fury, temper, and
demand as well as shamelessness and entitle-
ment. A stronger response from his mother to
his now "bad boyness," added to her previous
mild removal of his hand from her breast,
would create tension between desire and prohi-
bition. Lichtenberg (2007) describes this as "a
bodily itch" (p. 4), a dynamic far removed trom
the safe comfort of sensuality.
• It is not difficult to understand the embodied
choice point between sensuality and an emerg-
ing sexual expression and what is at stake. In
this scenario there is more than the selfishness
ofthe toddler, entirely pleasure seeking in his
or her emerging sexual desire and sexual iden-
tity. What is at stake is the fear of loss in the
dawning awareness of difference. Bowlby ( 1986,
chap. 1) described this kind of loss as the
child's response to an unwilling separation, a

traumatic experience of difference and possible
rejection, of being thwarted, perhaps following
feelings of shame and humiliation. This separa-
tion process ñ"om both mother and an intra-
psychic infant self is perhaps experienced as a
mini-death, and it returns me to my preoccu-
pation with Yalom's statement, cited earlier,
about the centrality of death and the sexual
metaphors it brought to my mind. The child
who discovers that he or she now differs from
,the m/other as he or she develops sexual self-
consciousness is in, as Pajaczkowska and Ward
(2008, p. 3) describe it, a place of "abjection,"
where shame is very close. It is about differ-
ence and perceived difference. Abjection, first
described by Julia Kristeva (as cited in Pajacz-
kowska & Ward, 2008, p. 3), is a place of dis-
gust and marginal ization, a place without d igni-
ty, a place that is traumatic as a developmental
experience. "Shame is implicated in the first self-
conscious experience and the first experience of
self-consciousness since it is through the mir-
roring look of the mother, and the necessary
aversión of her gaze, that the nascent self is
brought into being" (Pajaczkowska & Ward,
2008, p. 3).
Adult Sexuality and Shame
Not every adulthood is solely determined by
childhood experiences, but adolescence and
sibling relationships undoubtedly make an in-
delible impact for some. The psychological,
physical, and sexual roller coaster of adoles-

cence and its potential for shame cannot be
underestimated or overstated. In the teen years,
through shame and shaming, the private and
public is again revealed, but during this time of
life it appears exaggerated. Differences be-
tween oneself and parents, now viewed as im-
perfections, become all too painfully obvious.
Shame appears in that we are often ashamed of
our parents as well as ourselves. The out-of-
control experience of unstoppable bodily chan-
ges brings excruciating shame if attention is
drawn in public to such changes. The certainty
and omnipotence of childhood is lost in identity
confusion, which can sometimes feel of epic
proportions until some order or wholeness and
clarity of identity is acquired.
Similarly, the influence of siblings and peers
has a dramatic impact on the development of
our sexuality. This factor is often overlooked,
no doubt because, as J. Mitchell (2003) puts it,
"of our preoccupation with vertical relation-
ships" (p. xv). In our developing sexualities
with siblings, there is the opportunity for mir-
roring, safe experimentation, role modeling,
observation and information gathering, and the
vital rough-and-tumble of childhood play. How-
ever, with even a moment's thought about sexu-
ality through the lens of sibling relationships,
the shame potential is obvious. Memories of
rivalry, murderous rages, shaming and shame-
ful comparisons about sexual attractiveness,
tauntings, and bullying all come to mind when
momentarily revisiting the lateral world of sib-
lings and sexuality. Unintentional shaming at
the very moment of a child's emerging sexu-

ality can be seen in the ubiquitous bath sce-
nario. Brothers and sisters may well share a
bath (as children may with their parents) until
Vol. 39, No. 2. April 2009 165
CAROLE SHADBOLT
the gender difference revealed in genital dif-
ferences becomes obvious. The message given
at that point is often that there is now some-
thing to be avoided, or perhaps to be ashamed of
While in many cases an adult life follows a
predictable path, in others, despite all the odds,
outcomes are different and autonomous, both
positive and negative. So, although the past is
also in the present, and our adult sexuality is
built, in part, on child and adolescent experi-
ences, adult'and childhood sexuality are differ-
ent in a myriad of ways. Adult sexuality and
shame are also culturally, socially, and politi-
cally shaped—directly experienced and con-
structed—through education, history, and religion.
In Westem culture, moral edicts about what
is sinful, the chastity of women, the sanctity of
marriage, the moral degeneracy and immaturity
of homosexuality, the superiority of male hetero-
sexuality, the deleterious effects of masturba-
tion, gender roles, sexist imagery, biological
determinism, and so forth are part of adult con-
sciousness and life experiences that directly im-
pact adult sexuality. And while the mother's

own unconscious, as it is transmitted to and in-
trojected by the infant, is an important factor in
this process, it is not the only one. The way in
which we hold prohibitions from both the past
and the present—embodied injunctions, impas-
ses, and interruptions—creates the difference
between sexual aliveness and sexual deadness
as described by Wilhelm Reich and others
(Smith, 1987, p. 6). Reich connected touch,
bodywork, sexuality, and politics to psycho-
therapy, describing in the process the embodi-
ment of emotional pattems and the rhythmic
energy flowlOf the body, which brings with it
vitality, emotional richness, and sexual alive-
ness. He understood the effects of oppression
and political scripting on individuals, including
their emotional, physical, and sexual lives. He
saw and named what was damaging to a per-
son's sexuaijty at the hands of another (e.g., a
teacher) whose own stified sexuality could
deaden a child's natural curiosity about his or
her body.
Whereas Freud believed in the existence of
a fundamental death instinct, which is some-
times referred to as "Thanatos," Reich believed
in the opposite: that human beings have a basic
capacity and instinct to love life freely, fully,
and without repression. He hoped foi" a society
that would refiect his views, even though they
were strikingly different from those of his con-
temporaries. He expressed hope for a time "when
you will only shake your heads at the time
when one punished little children for touching
their love organs; when human faces on the

street will express freedom, animation and joy
and no longer sadness and misery" (Reich as
cited in Emst & Goodison, 1981, p. !l 13).
Reich's ideas are close to those of
although the latter might place more
emmism,
emphasis
on the subjective experience of women's sexu-
ality, that is, women's relative lack oi"power, a
rejection ofthe centrality and necessity of vagi-
nal penetration, and the recognition! of wom-
en's pleasure in the clitoris. ;
My own experience reflects the views ex-
pressed by Reich (as cited in Emst & Goodi-
son, 1981) in that I leamed "the real facts of
life" as an adult, in my twenties, fromimy lesbi-
an feminist sisters. Like many young |women, I
learned from the women's movement that the
personal is political and that our sexual selves
and our experience of our bodies inl relation-
ship to other bodies (as well as our own) are as
diverse as the human face—not one in all the
world is exactly the same. Like our faces, our
sexuality is fiuid and has a myriad of expres-
sions and reactions. And it is seen differently
depending on who is doing the looking and
why. Our sexuaiities, like our faces, are unique,
multifaceted, shifting, deeply relational two-
way mirrors. !
That being so, I saw that my sexual identity
is not necessarily fixed or proscribed, ^h i l e for

historical reasons 1 may choose to identify my-
self as lesbian, to borrow from a deeply ques-
tioning Professor Joad of BBC radió "Brains.
Trust" fame in the 1940s and 1950s,
pends on what you mean by it. My
it all de-
eventual
enlightenment came years after my only visit,
in my teens, to a psychiatrist because of my
confusion and misery about my sexuality. Dur-
ing an exhaustive assessment, among other
humiliations (related to an absent mother and
lack of "proper" fathering), 1 passionately pro-
tested that ho, I most certainly did not mastur-
bate. The leamed professor of psychiatry and
166 Transactionat Analysis Journal
SEXUALITY AND SHAME
his ubiquitous trainee psychiatrist, barely able
to conceal their scepticism, conspiratorial ly
concluded that I had a lot to say for myself
Whether or not their hypotheses and my read-
ing of their judgments were correct, their man-
ner confirmed my worst fears about my "per-
version." I left red-faced, wronged, and "sick"
—in other words, deeply shamed—never to re-
tum. Later, in what felt like another life, as a
psychiatric social worker I worked with that
same psychiatrist. I f he remembered me, which
I doubt, he never let on, and I, who would nev-

er in all my life forget him, did not either. In
the intervening 20 years, the world had turned.
These days I might view autoeroticism, psy-
chiatry, and patriarchy differently, but femi-
nism has taught me that no one way of expres-
sing gender or sexuality has precedence over
another. Such expression is deeply rooted in
culture and social conditioning, and a woman's
sexuality can and should be in her own hands
as she becomes the subject instead ofthe object
in her own "herstory."
What is right, wrong, or fixed in the con-
struction of our sexualities and genders—that
is, moral, scientific, and biological absolutes
—is challenged and reshaped these days by a
number of factors, including a constructivist
view of identity, queer theory, and feminism.
There is a continuum between essentialist views
of sexuality, which assume that sexuality is
fixed and exists independent of culture and so-
ciety, and a constructivist, postmodern view
that assumes that "sexuality has no inherent
quality and merely represents a system of cul-
tural meanings which are themselves created
within matrices of social power relations"
(Drescher, Ercole, & Schoenberg, 2003, p. 1).
When reflecting on these vital matters with
regard to sexuality, it is easy to see that when
the uniqueness of our sexual identity collides
with the views of others or even our own views
and expectations of what is "normal" and of
how we should be in both our private and pub-
lic selves, shame will not be far behind. In the

area ofsexuality, all too often shame is the re-
sult when the inner meets the outer.
Shame and Affect
I f distress is the affect of suffering, shame
is the affect of indignity, transgression and
of alienation. Though terror speaks to life
and death and distress makes the world a
vale of tears, yet shame strikes deepest
into the heart of man. Shame is felt as an
inner torment, a sickness of the soul, the
humiliated one feels himself naked, de-
feated, alienated, lacking in dignity and
worth. (Tomkins as cited in Adamson &
Clark, 1999, p. 23) •
Although much more has been written of late
about shame, including its etiology and treat-
ment(e.g.,followinga 1993 Minneapolis trans-
actional analysis conference on "Shame," the
April 1994 Transactional Analysis Journal
guest edited by MaryeO'Reilly-Knapp focused
on the same theme), until comparatively recent-
ly the importance of shame has been over-
looked not only within transactional analysis
but also in the wider psychotherapy commu-
nity. As I consulted my books and papers for
this article, not surprisingly, I found few refer-
ences to shame.
Shame is a universal human experience. As
Morrison (1989) noted, hardly a therapy ses-
sion goes by without the appearance of some
expression of shame, humiliation, embarrass-
ment, disgrace, or mortification. In my own ex-

perience, the memory of the burning shame I
experienced as a teenager when I visited that
psychiatrist has never left me. It was as i f the
two psychiatrists could see right through me
with their judgmental gaze and know me to be
lying. What's more, I knew that they knew that
I knew that they knew.
The sheer all-encompassing physicality of
my experience fits well with Tomkins's ideas
of shame as an affect. His work is referred to in
the Transactional Analysis Journal by Nathan-
son (1994), an authority on the study of shame
and its effects. Tomkins's major contribution to
the psychological cannon was the theory of af-
fect and its etiology and complex nature, known
today as "affect theory." Nathanson's careful
article charts Tomkins's modem understand-
ings of affect, emotion, and shame. Nathanson
is somewhat critical of transactional analysis,
which he sees as seeking to alter emotional ex-
perience without having an adequate descrip-
tion of emotion itself.
Vol. 39. No. 2. April 2009 ¡67
CAROLE SHADBOLT
An understanding of affect as distinct from
feelings seems vitally relevant to understanding
sexuality and shame. Affect is experienced as
an all-encompassing body experience of pro-
found disturbance in which nervous energy is
released in a random manner. It has little to do

with cognitive processes and is not readily open
to behavioral social control (e.g., blushing).
Tomkins's view is reminiscent of the way
that psychoanalysis eventually recognized that
countertransference, far from detracting from
therapeutic work, was not only an intrinsic part
of such work but the congenital core of uncon-
scious communication. Similarly, affect is un-
derstood by Tomkins as natural, a communica-
tion of urgency and that something normal ra-
ther than pathological is going on. Whereas
previous theories had understood affect as in-
terfering with normal functioning, Tomkins
(1987, p. 143) sees it as innate. He describes a
number of innate affects, all of which emerge
as an amplification of a triggering stimulus,
ranging from mild to severe. They are most
clearly shown on the face, and shame is among
them.
Tomkins (1987, p. 143) describes shame as
an affect auxilliary—that is, a response to anoth-
er positive affect, in this case, excitement and
contentment. He describes shame as a specific
inhibitor of continuing interest and enjoyment.
The links between shame and sexuality are
not hard to appreciate. Tomkins (1987) links
shame and sexuality by using anthropology:
"Shame and sexuality is also a history of civili-
zations" (p. 156). Tomkins traces shame asso-
ciated with sexuality back to antiquity: from
Genesis in the Old Testament, where the source
of shame is camal knowledge; through the
Greek ethics of perfect platonic love versus

transitory, imperfect sexual desire; to the early
Stoic Roman privatization of sexuality as hetero-
sexual love, located within a monogamous mar-
riage viewed as the ideal; to the gradual renun-
ciation of individual self-will and physical de-
sire in favor of "ataraxia," an indifference to
and transcendence of desire itself (p. 157).
Tomkins goes on to describe the self-mastery,
ridicule, and control of sexuality and desire de-
manded during the Russian Revolution because
sexuality and desire were thought to weaken
Marxist ideology. Finally, he links sexuality to
Christianity, especially Puritanism,¡ in which
sexuality is hijacked into moral and religious
domains. There the fall from grace and inno-
cence and separation from the love bf God is
marked by an individual's sexual behavior, sin-
ning, and the threat of etemal damnation.
As Tomkins (1987) summarizes: I
Not only has sexuality tumed froni shame
and guilt, but a massive burden of terror
has been added to the sexual act. Sexuality
is no longer aesthetic or unaesthetic, plato-
nic or illusory, a threat to the reproduction
of the species and to the monogamous
family, nor a threat to the will ofthe indi-
vidual; it is now above all else a sign of
disobedience to the will of God, demand-
ing that the individual risk a vaijiety of
punishments, including an etemity in Hell.
Shame and terror are now tightly fused, (p.
158)

Gender-specific and Genital Shame
Gender-specific shame and genital shame are
particularly poignant and painflil, it seems to
me. Nathanson (1987) writes of masculine
shame, wherein the culturally mediated idea of
the excessively excited, lustful male image
clashes with and makes shameful the effemi-
I
nate in a male who lacks "masculinity" (p. 39).
In contrastas the female whose self-jimage is
supposed to be as the object of lustful desire
and who, in reality, is ashamed of weakness,
prudishness, and ambivalence. This is, again,
an example of an intemal experience being un-
acceptable and exposed to public view, which
results in shame. ¡
Genital shame often finds its roots; in early
relationships. For example, a little boy who is
interested in his penis, rather than being cele-
brated, is viewed as a "cocky little sadist" who
needs to be "cut down to size." His penis be-
comes an object of disgust and embarrassment.
Similarly, the outer genitals of girls and women
are named "pudendum," which originates from
the Latin pudenda membra, â "part to be
ashamed of." Likewise, one ofthe most taboo
words in the English language is "cunt'," which
is still imbued with a sense of obscenity. Even
to write it in this article makes me feeli vaguely
¡68 Transactiona¡ Ana¡ysis Journal

SEXUALITY AND SHAME
anxious (or is it shame and excitement?) be-
cause it seems like a somewhat risky thing to
do. (You may care to check this out by noting
your own intemal reaction to reading it here.)
Shame about one's body—or, rather, what
we imagine the other is thinking about our body
—is widespread. For example, "The shy person
. . . is physically and constantly conscious of
his body, not as it is for him but as it is for the
Other" (Sartre as cited in Evans, 1994, p. 103).
As Sartre further wrote, "We often say that the
shy man is embarrassed by his own body. Ac-
tually this is incorrect; I cannot be embarrassed
by my own body as I exist in it. It is my body
as it is for the Other which embarrasses me" (p.
107).
The potential for shame is heightened during
the period of 18-24 months, when toddlers be-
come aware of themselves as objects of obser-
vation and become capable of self-awareness
and awareness of their own excitement. They
also become aware that the m/other does not re-
gard their genitals as something of importance,
pleasure, and vitality to them but instead views
their genitals as something to be ashamed of
I niention all these factors because they high-
light the depth and complexity of the mighty
cultural introjects, impasses, and embodied
scripting that accompany sexuality and shame,

all of which are likely to be present in some
form in psychotherapy when sexuality is the
focus ofthe clinical work.
Clinical Implications
Shame about being ashamed of all the issues
raised here appears repeatedly when working
clinically with sexuality and excitement. This in-
cludes shame about body image, genitals, pre-
mature ejaculation, making noise during sexual
activity, wanting too much, not being potent
enough, the inability to be aroused or reach
orgasm, wanting sex for pleasure rather than
procreation, not beihg wanted, and so on, rather
than the more vital and life-enhancing experi-
ences of excitement, pleasure, and satisfaction.
When excitement and a desire for enjoyment
and satisfaction bursts through, it often meta-
morphoses into crippling shame. In my experi-
ence, the all-dominating issue of sexual shame
—whether it be cultural, relational (and, by
implication, intrapsychic), embodied, or mani-
fested between therapist and client—involves
a Type III impasse, which occurs when two
self-states are in conflict with each other. In
this instance, the battle is between excitement
and shame, and it represents a massive "me
versus not me" conflict.
Shame and Excitement: A Type.lll Impasse
Usually, shame is understood to have its
roots in relationship and to be experienced inter-

personally. Nathanson ( 1987), for example, de-
scribes the shame experience as always involv-
ing a "shamer" (p. 251). However, when one
considers the example of intemalized homo-
phobia (Shadbolt, 2004) or the manner in which
women oppress themselves intemally, it is easy
to see how introjects and projections were in
existence sometime before they found reconfir-
mation in interpersonal experience. Thus, the
shamer is intemal as well as extemal.
A Type III impasse involves the intemaliza-
tion or introjection of an original interpersonal
experience that then becomes intrapsychic.
Mellor's (1980) developmental model of im-
passes suggests that the Type III impasse origi-
nates in very early experience. The experience
of shame that hides excitement fits with this
schema because both self-states occur without
words or cognition and appear to have their
genesis in primitive preverbal or protocol lev-
els of self-organization.
The impasse of shame versus excitement thus
operates outside of conscious awareness and is
a whole self-experience. This means that the
shame affect (as described earlier) so squelches
excitement that it is experienced as "me,"
whereas the experience of excitement is experi-
enced as "not me." The disavowed "not-me"
experience of excitement might also be described
as containing hope and an intense longing for
recognition and acceptance. When this aspect
ofthe self and its narcissistic need is wounded
—originally interpersonal ly—it is driven under-
ground out of fear that the person will experi-

ence reshaming rather than being supported or
welcomed.
In summary, there is a circularity to shame in
that it arises interpersonally, dwells intrapsy-
chically, and reappears interpersonally. As a
fo/. 39, No. 2, April 2009 ¡69
CAROLE SHADBOLT
Type III impasse, it is resolved interpersonal ly
first and intrapsychically later.
Thus, the treatment of issues related to sexu-
ality often involves the "treatment" of shame
and the recovery of excitement, vitality, and
aliveness as well as a resolution ofthe "me ver-
sus not-me" impasse. I put the word "treat-
ment" in quotes to emphasize the way it seems
to convey a sense of doing: of something need-
ing to be done by someone to someone else.
The idea of needing and getting "treatment for
shame" is a contradiction, because the treat-
ment of what is wrong is in danger of bringing
about the very thing that it is designed to
"treat." This is tricky terrain to traverse be-
cause, on the one hand, a rupture or reshaming,
whether it occurs because of the therapist's
own judgments about shame, his or her failure
to recognize it in the client, or the unconscious
enactment between them, can be seen as an es-
sential component to its resolution. At the same
time, if awkwardly and defensively handled by

a therapist who does not understand the etiolo-
gy of shame and its huge cultural and relational
roots, shame will probably go underground or
into the dark and grow. As a consequence, shame
is likely to be experienced and endured but not
acknowledged by either client or therapist. What
is problematic and pathological is not just the
experience of shame itself, unpleasant as it is,
but how it is "treated," that is, received and
handled by the other.
There are, of course, many transactional analy-
sis theories and techniques that can be used in
the treatment of shame: script analysis, decon-
tamination, ego state analysis, and game analy-
sis, to name a few. However, these excellent
and time-tested theories and techn iques al I have
the quality of someone (the therapist) doing
something to someone else (the client). They
thus have the potential for reshaming.
In my view, the transformation or resolution
of shame arises out of a particular quality of
therapeutic relationship, one that involves "be-
ing with" rather than "doing to." 1 refer to this
as a type of human-to-human attunement that
involves a particular use ofthe therapeutic space
between therapist and client. This kind of at-
tunement has a different quality from the attune-
ment described by Stark ( 1999), which involves
both empathy and authenticity. It is worth
briefly describing these two natural processes.
Empathy "involves the therapist suspending
part of herself in order to enter the client's ex-

perience as if it were her own" (Stark, 1999, p.
46). This has the potential to be reshaming be-
cause of the risk of exposing the client's
shamed self Similarly, authenticity-kiescribed
by Stark as "about the therapist remaining cen-
tered within her own experience, allowing the
patient's experience to enter into her, and tak-
ing on the patient's experience as her own" (p.
47)—might also be exjjerienced as intrusive by
the shamed client.
There are subtle yet relevant distinctions to
be made here. While empathy and authenticity
in this context might be conceptualized as
transferential ly attaching processes,land while
both are essential to create the trust between
therapist and client that is required for the suc-
cessful resolution of shame, humani-to-human
engagement is not characterized entirely as em-
pathy or authenticity. Rather, it involves the
therapist unself-consciously holding, respect-
ing, and keeping safe a therapeutic space in
which the client can dwell at the boundary or
crossroads of his or her public and private ex-
perience. This is the place where the ropt of
shame lies and where the dynamics ofthe Type
III impasse are to be found. |
Human-to-human attunement involves recog-
nizing separateness and differentness. ¡The thera-
pist may or may not entirely understand, be em-
pathie to, or express his or her authentic re-
sponse to the content ofthe client's shame. But
this is secondary to his or her recognizing and
accepting the client's truth about himself or
herself When this is provided, the client can

have the experience of being seen by the other
as "the other," that is, as a separate person. It is
close to the process of mutuality, in which the
therapist niay not self-disclose the details of his
or her own shame but will convey as another
human being (rather than as a transferential ob-
ject) that he or she sees and recognizes the cli-
ent's pain and responds to it as another human
being. When space is provided in which the
awareness of difference and the experience of
existing separately is accepted, integration and
recovery of the "not- me" aspect of the self
170 Transactional Analysis Journa¡
SEXUALITY AND SHAME
becomes possible, and clients can celebrate
their excitement, vitality, or whatever they wish
with regard to their sexuality. It is in this pro-
cess that the Type III impasse is transformed
and resolved.
Clinical Example
After a long struggle with issues related to
her disappointing sexual experiences, my cli-
ent, Kate, and 1 had come to a point where she
knew she felt deeply ashamed of being ob-
served during lovemaking. Kate did not trust
that any partner would not look at her while she
abandoned herself to her sexual feelings and
experience. Consequently, she remained de-
mure, quiet, and controlled, unsatisfied, and

thus unable to find her own pleasure or reach
orgasm. During lovemaking, she was constantly
checking her partner to see if he was watching
her. In fact, at one point Kate had experienced
just that. She discovered her partner staring
wide-eyed at her and smirking; he also made
critical and shaming comments about what she
looked and sounded like. This had awakened—
possibly reawakened—a deep and self-conscious
humiliation and shame in her.
As we sat together, saying very little, Kate's
face turned a burning red. Her head was down
and she slumped. Avoiding my eyes, she even-
tually whispered how shamed she had felt, and
how ashamed she now was about her sexual
identity and appetites and how disgusted she
was with herself. I waited. I was, of course,
aware that I too was watching her. I am sure
she was also aware of this only too well. I did
not consciously try to empathize with her exact
feeling of being watched or to be authentic in
allowing her experience to enter into me. Ra-
ther, 1 concentrated on being with her in that
space between her private and public experi-
ence, on understanding how she was publicly
and how she was privately. It was a quiet place
of hovering tension, of expectancy and possible
emergence. I imagined the space of the "me
and not me." Eventually, Kate looked up, met
my eyes, and told me clearly what she was
ashamed of showing and what she most ur-
gently wanted to show. She described how she
was sexually, what turned her on, what excited
her, how her body responded, how she wanted

the other to respond, and what she wanted to
see. She told me how disgusted she was of her-
self and her desires in the present and how she
loathed herself.
Her sexual identity was not in the least simi-
lar to my own, and I could not particularly un-
derstand her passions, but I could see her excite-
ment and burning desire to be and show her
"not-me" self and for this to be OK. Her face
was soft and her eyes looked quite different.
She scanned my face for any trace of censure
or ridicule. If she expected any, she did not
find it.
Conclusion
In the case study just described, I strove to
provide for Kate—and she seemed to take for
herself—the space to experience her different-
ness as it emerged between us relationally. As
the reader might gather, the moment of her
awareness was a careful balance between re-
experiencing shame and expressing excitement
and satisfaction. The moment of separation was
welcomed and "made OK" (though not con-
trived) by both of us: me giving, her taking.
The resolution of shame about an individu-
al's sexuality amounts to an awareness, accep-
tance, celebration, and delight in the person's
unique difference or, put another way, separa-
tion. For as much as our sexualities depend on
attachment and relationship for their develop-
ment, they equally depend on separation. Like
attachment, separation is fundamental to a healthy

model of sexuality.
Carole Shadbolt is a psychotherapist living
in Oxfordshire, United Kingdom. She works in
London, Edinburgh, and Oxfordshire. A rela-
tional psychotherapist by instinct, she has writ-
ten a number of articles on diversity and homo-
phobia. Her abiding focus and devotion is to
clinical practice. Carole can be reached at
Hawthorne, Horseshoe Lane, Chadlington,
Oxfordshire 0X7 3NB, United Kingdom: e-
mail: carolei^hawthornesc.freeserve.co.uk.
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172 Transactional Analysis Journal
Journal of Family Psychotherapy, 21:197–212, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 0897-5353 print/1540-4080 online
DOI: 10.1080/08975353.2010.505535
Male Sexuality and Couple Sexual Health:
A Case Illustration
MICHAEL E. METZ
Meta Associates, St. Paul, Minnesota, USA
BARRY W. MCCARTHY
Department of Psychology, American University, Washington,
DC, USA
Male sexual problems are common and offer exceptional oppor-
tunities for clinicians to not only relieve distress but enhance
individual and relationship satisfaction. However, limited clini-
cal focus on sex behaviors alone often overlook this
opportunity.
With more comprehensive approaches, clinicians are able to
both
facilitate improved sexual function and to promote positive,

realis-
tic principles for healthy and satisfying male and couple
sexuality.
Approaches such as the Good-Enough Sex model provide
clinicians
with crucial elements to resolve common male sexual problems
and
promote sexual health and couple satisfaction. This article sum-
marizes realistic features for men’s (and women’s) sexual
health
including promoting the positive value of sex, promoting realis-
tic expectations, supporting pleasure as well as physical
function,
promoting sexual flexibility by integrating 5 basic purposes for
being sexual and 3 arousal styles, appreciating the variable
qual-
ity of sex, building relationship cooperation as an “intimate
team,”
and integrating sex into one’s real life. Such features promoting
healthy, satisfying sexuality are illustrated with a case example.
KEYWORDS sex problems, sexual health, sex dysfunction,
couple
therapy, couple satisfaction, cognitive therapy, couple conflict
resolution, Good-Enough Sex model, male sexuality
Address correspondence to Michael E. Metz, Baker Court Office
Building, Suite 440,
821 Raymond Avenue, St. Paul, MN 55114, USA. E-mail:
[email protected]
197
198 M. E. Metz and B. W. McCarthy

THE PREVALENCE AND COMPLEXITY OF SEXUAL
PROBLEMS
Prevalence studies using multiple populations verify the
common occur-
rence of male (and female) sexual problems. For example,
Kinsey (Kinsey,
Pomeroy, & Martin 1948; Kinsey, Pomeroy, Martin, & Gebhard,
1953) using
a sizeable availability sample and other nonrepresentative
reports over the
past 50 years (e.g., Ende, Rockwell, & Glasgow, 1984; Metz &
Seifert, 1993;
Schein et al., 1988; Spector & Carey, 1990) indicate sexual
dysfunction (SD)
for men, women, and couples ranging from 10% to 95%
prevalence over the
life cycle. Masters and Johnson (1970) estimated that at any
moment in time,
approximately 50% of couples suffered SD—described as
personal and/or
relationship distress due to the inability to perform intercourse
with satis-
faction. These distresses include problems with low or absent
sexual desire,
arousal or excitement (erections or lubrication), orgasm (rapid,
delayed, or
absent orgasm), or painful intercourse. The classic study by
Frank, Anderson,
and Rubenstein (1978) reported sex dysfunction in 40% to 45%
of couples
while nearly 80% experienced other nonfunction difficulties
(e.g., conflict
over frequency, preferences, or styles). The best representative
study con-
ducted in the United States reported that approximately 45% of

couples at a
given time suffer a male (31%), female (43%), or couple
(combined 45%) SD
that commonly create relationship distress (Laumann, Paik, &
Rosen, 1999).
Public and professional awareness of SD has increased in recent
years
with the marketing of phosphodiesterase 5 (PDE-5) proerection
medications
(Viagra, Levitra, Cialis). At the same time, clinical experience
demonstrates
that SD and other problems with men’s sexual health are rarely
simple
problems with a simple cure in spite of people’s longing for
“quick fixes.”
Recent developments in sexual medicine to improve male SD
(better erec-
tion devices, medications for ejaculatory control) and increased
attention
to women’s SD offer distressed couples increased hope for
sexual func-
tion. However, in the last decade, there has developed an
imbalance in
the approach to treating SD with an inordinate emphasis on a
biomedi-
cal approach to physical function, especially to male sexuality.
The failure
of biomedical technologies to benefit many couples (Brock et
al., 2002)
as well as the suggestion of significant psychological placebo
benefit with
medications (Hatzichristou et al., 2005) highlight the
oversimplification of
human sexuality by focusing on sex performance and often
disregarding the

overall well-being and important meaning to couple sexual
intimacy and
satisfaction.
A sexual issue is commonly a profound human relationship
problem
that involves emotional suffering, distress, even agony.
Sometimes SD is the
secondary manifestation or symptom of other personal (e.g.,
depression,
anxiety disorder) and/or sexual and relationship problems (e.g.,
unresolved
couple conflict; Levine, Risen, & Althof, 2003; Metz & Epstein,
2002). In
addition to SD, other sexual problems—often concealed—are a
common
Male Sexuality and Couple Sexual Health 199
reason that individuals and couples seek therapy. Approximately
18% to 24%
of married men and 16% to 20% of married women have an
extramarital
affair (Allan et al., 2005). In addition, studies estimate that of
the 20% of
“netizens” (Internet users) who engage in some sort of online
sexual activity
as high as 17% of these have online compulsive or “addictive”
problems
(Cooper, McLoughlin, & Campbell, 2000; Cooper & Marcus,
2003) sometimes
described by the client as erectile dysfunction or low desire
(resulting from
compulsive sex) and potentially undermining relationship

cohesion.
THE PROBLEM TREATING MEN WITH SEXUAL
PROBLEMS
Sex problems are usually multicausal and multidimensional and
have mul-
tiple effects on the person, the partner, and the relationship.
Effective treat-
ment ought to integrate suitable medical, pharmacological,
psychological,
and relational aspects for adequate sex function and ensure
relational and
sexual satisfaction (e.g., Althof et al., 2005; Levine et al., 2003;
Metz & Pryor,
2000). Satisfaction with one’s sexual life is fundamentally
grounded on real-
istic physical, psychological, and relationship expectations.
Unrealistic con-
cepts precipitate frustration, a sense of failure, and distress
(Boul, 2007). The
prevailing societal emphasis on perfect sexual performance is
self-defeating
and needs to be replaced with realism such as the Optimal
Sexuality descrip-
tion (Kleinplatz & Menard, 2007) or the Good-Enough Sex
(GES) model
(Metz & McCarthy, 2007a), which identify the value of realistic
expectations
and the inherent variability of couple sex. Sex problems offer an
excep-
tional opportunity for the helping professional to relieve
distress, to promote
individual and relationship satisfaction, and to promote quality
of life.

However, when clinicians have only limited behavioral goals—
such as
to stop premature ejaculation; erectile dysfunction; or
detrimental male sex-
ual behavior such as misusing Internet pornography, soliciting
prostitution,
or engaging in affairs—quality of life promotion may be
undervalued, and
sometimes treatment may unintentionally set the stage for
relapse and disillu-
sionment. Limited approaches minimize sexual satisfaction by
only focusing
on performance when there is an SD or eliciting compliant and
marginal
promises to change when there is a sexual disorder such as
compulsive sex.
The man needs to be accountable not simply for his sexual
behavior but for
his sexual maturity, honestly addressing the reality of his sexual
being; pro-
moting positive, confident sexual health; and blending his
sexuality with his
partner’s in a manner that promotes intimacy, mutual pleasure,
and sexual
satisfaction.
The complexity of psychological and sexual satisfaction
expands
beyond the individual. Interpersonal therapies (e.g., Levine et
al., 2003;
Snyder, Castellani, & Whisman, 2006; Yeh, Lorenz, Wickrama,
Conger, &
Elder, 2006) that focus on couple understanding and
interventions are

valuable in formulating and clinically working with the
complexity of men’s
sexual health. Consider that a man’s sex problem, which on the
surface
seems an individual function problem (e.g., erectile
dysfunction, exces-
sive masturbation, rapid ejaculation), is inevitably a
relationship problem
whether because of cause or effect. Even a man who is seen in
individ-
ual therapy—because he has no partner, he refuses to involve
her, or he
has a partner who is unwilling to participate in couple work—
inevitably his
problem involves relationship dimensions. He has a “virtual
partner” in his
mind—his current real partner or an imagined partner, a partner
from the
past or one imagined in the future. Understanding and working
well with
the complexity of a man’s sexual issues warrants an
interpersonal, interac-
tional, relationship perspective. Although some individuals and
couples may
resist such systemic context promoted by the therapist, they will
deepen
their awareness and acquire insulation against future
disillusionment should
function-only efforts later relapse (McCarthy & McCarthy,
2003).
THE NEED FOR A NEW COUPLE APPROACH: THE GES
MODEL

The ultimate purpose of the multiple medical and psychological
treatments
now available to address sexual problems should be the well-
being of the
couple (Snyder et al., 2006). The GES model (Metz &
McCarthy, 2003, 2004,
2007a, 2007b; McCarthy & Metz, 2008) describes principles
that can guide
clinicians endeavoring to resolve male sex dysfunction and to
promote
healthy male and couple sexuality. This heuristic model is
grounded in the
more than 40 years of traditional sex therapy (Kaplan, 1974;
Leiblum, 2006;
Masters & Johnson, 1970), classic psychotherapeutic notions of
realistic stan-
dards (e.g., Winnicott, 1964) for the individual and couple, and
the marital
and sex therapy experience of seasoned clinicians and couples
(Kleinplatz
& Menard, 2007).
The GES approach is also consistent with the recent progress in
research
on positive psychology (e.g., Lent, 2004; Seligman, Rashid, &
Parks, 2006;
Seligman, Steen, Park, & Peterson, 2005; Turkington, 2006) as
the GES model
emphasizes how positive dimensions can improve one’s coping
with sexual
problems and promote aspects of happiness (e.g., Lyubomirsky,
Sheldon, &
Schkade, 2005). In the GES model, sexual meaning and self-
understanding
are crucial. For example, sex is not viewed as an isolated

fragment of one’s
life but rather seen integrated into the individual’s and couple’s
daily life—
and daily life is integrated into their sex life. Living daily life
provides the
opportunity to experience sexual interactions in a subtly yet
distinctively
personalized and enriched way. The GES model was developed
for long-
term committed couples who experience SD as a positive set of
principles
to guide sex therapists in their creative design of individualized
cognitive-
behavioral sex therapy and to facilitate couple reflection on the
meaning
and value of their sexual relationship. This approach is relevant
to serious
couples who want to enhance intimacy and sexuality as well as
for gay and
lesbian couples.
THE GES APPROACH: COGNITIVIE, BEHAVIORAL,
EMOTIONAL,
AND COUPLE CLINICAL FEATURES
Features that characterize the GES model include cognitive,
behavioral, emo-
tional, and relational factors that promote couple cohesion,
cooperation,
and intimacy (Epstein & Baucom, 2002). Examples of cognitive
dimen-

sions include a positive attitude toward sex and a deep
commitment to
mutual sexual health and taking personal responsibility for
pursuing devel-
opmental (“lifelong”) sexual growth. Emotional features include
accepting
and expressing one’s honest feelings about sex and body and
distinguish-
ing feelings from behaviors. Behaviorally, couples cultivate
cooperation to
ground their sexual pleasure on physical relaxation and learn
sensual self-
entrancement and role enactment arousal. Especially important
is that the
couple cooperate as an “intimate team,” prioritize mutual
emotional empa-
thy, forgive each other for prior disappointments, and view their
sexuality
as an essential relationship forum and opportunity for cohesion.
There are six crucial cognitive, behavioral, emotional, and
interpersonal
features that men (and women) adopt for sexual health that
merit emphasis.
These are open-ended qualities that offer the clinician
principles and clinical
“tools” to assist men and their partners to enhance their sexual
health, inte-
grate them into their personal lives, and serve as a directional
course or map
for sexual growth (e.g., McCarthy & Metz, 2008). Healthy men
and women
increase their understanding and integrate these concepts
throughout their
lives. In sex therapy, whether the clinician uses traditional sex
therapy inter-

ventions (e.g., “sensate focus”) or creatively designs individual
and couple
exercises, GES piloted interventions promote affirmation and
acceptance of
the man and woman and their relationship. During the process
of therapy,
the man and his partner confirm, or improve in, a number of
cognitive,
behavioral, emotional, and relational dimensions.
1. Positive value of sex: Essential to the GES approach is to
intentionally
value sex as inherently good. Men who develop sexual problems
usually
lack a positive value of their sexual body, lack mature sexual
confi-
dence, underestimate the power of their sex drive, and minimize
their
desires for emotional intimacy (Cooper & Marcus, 2003). Often
negative
cognitions (Boul, 2007; Fichten, Spector, & Libman, 1988) link
sex with
embarrassment, even shame, and compartmentalize sex from
real life.
Sex-positive therapy (Kleinplatz, 1996) facilitates acceptance of
men’s sex-
uality and honors sex as a means for a couple to use their bodies
for fun,
pleasure, affirmation, and closeness. Developing sexual self-
esteem—
the antithesis of shame—requires accepting and affirming his

sexuality,
respecting honest sexual feelings, regulating sexual behaviors,
and pro-
moting overall self-esteem (Cooper et al., 2000). Sometimes
promoting
sexual self-esteem requires his partner to become more
understanding,
accepting, and respectful of his sex drive and desires.
2. Sex is relational: As well as valuing sex, he and his partner
accept that
sex is inherently relational (Harvey, Wenzel, & Sprecher,
2004). He can
view his partner as his “sexual friend” and their relationship as
an intimate
team (Levine et al., 2003), and they cooperate to achieve
constructive con-
flict resolution and mutual satisfaction (Metz & Epstein, 2002;
O’Farrell,
Choquette, Cutter & Birchler, 1997; Weis, 1980). Rather than a
source
of bitterness and alienation, conflict presents daily
opportunities for the
couple to address issues cooperatively, understand and
appreciate differ-
ences, and deepen emotional intimacy (Eldridge, Sevier, Jones,
Atkins,
& Christensen, 2007; Jacobson & Christensen, 1996). Sexual
health and
satisfaction are more likely to occur when partners work
together—as
an intimate team—to achieve intimacy, comfort, pleasure, stress
reduc-
tion, self-esteem, and joy in and out of the bedroom (Johnson,
2008).
Partners recognize that relationship disagreements are a catalyst

for inti-
macy. When couples deal well with conflict, each partner feels
respected
and special in the other’s eyes. When these feelings of trust and
coop-
eration come into the bedroom, they generate a loving
environment that
fosters long-term, healthy sexual functioning. Sexual health and
satisfac-
tion are directly influenced by relationship cooperation, shared
empathy,
and mutual conflict resolution (Metz & Epstein, 2002).
3. Sexual pleasure is valued as much as sex function: Another
important
feature of GES is that the sexually healthy man progresses
beyond the
youthful preoccupation with sexual performance and increases
his enjoy-
ment of touch for affection and sensual pleasure (Kleinplatz,
1996). He
and his partner come to appreciate that an initial focus on touch
and
relaxation is the foundation for sensual response and pleasure
the foun-
dation for heightened eroticism (Aanstoos, 1991). This is a
challenge for
men and couples in our culture because performance
expectations and
anxious associations are intense—worrying about penis size,
ensuring his
partner has an orgasm, and performing like a porn star. The
clinician bal-
ances the “hype” and unrealistic performance expectations
promoted in
movies, television, and magazines with information about

sexual function
(performance) with realistic and accurate expectations and
appreciation
of sensual pleasures.
4. Sex drive is self-regulated: Learning to value sensual
pleasure is pro-
moted by his learning to regulate his natural sexual drive and
arousal.
Men’s (and women’s) bodies have “lust” (Buss, 1995), a
“biological
imperative” (Fisher, Aron, Mashek, Li, & Brown, 2002), or an
“urge to
merge” (Rolheiser, 1999). Healthy men and women accept and
respect
the power of these urges. Men whose sexual behavior creates
indi-
vidual and relationship distress invariably underestimate sex
drive and
the importance of sex drive regulation. The importance of
general
cognitive-behavioral-emotional regulation (e.g., anger, anxiety)
is evident
in a number of nonsexual studies (e.g., Kirby, Baucom, &
Peterman,
2007). For most men, lust is not just a youthful stage (Blum,
1998; Fisher
et al., 2002) but continues throughout life. Because male sex
drive is more
specific and “object focused” than female sex drive (Buss,
1995; Hamann,

Herman, Nolan, & Wallen, 2004), men have a special
responsibility to
regulate and manage their sex drive wisely, just as they manage
their
desire for food, sleep, and exercise. For sexual health, men
learn to bal-
ance sex drive through several regulatory learning tasks. For
most men,
this regulation is cultivated through strategies such as conscious
cognitive
management (Boul, 2007; McCarthy & Metz, 2008) and impulse
control
by limiting exposure to sex stimuli so as not to provoke or
incite the bio-
logical sex drive. When in an appropriate sexual situation, then,
he can
reverse the sexual regulation and freely engage in and enjoy
heightened
sex excitement.
An important regulatory task is to develop emotional
sophistication.
Emotions such as loneliness, anxiety, or shame can be
misunderstood as
sexual feelings with an urge to assuage them by sex (Adams &
Robinson,
2001; Cooper & Marcus, 2003; Leeds, 2001). Although tension
reduction is
a common and healthy use of sex, the unwitting sexualizing of
nonsexual
emotions may fuel problematic sex behaviors such as making
excessive
demands of the partner, affairs, or misuse of pornography.
Sexual health
involves becoming aware and comfortable with nonsexual
emotions and

healthy strategies to deal with them.
It is important to note that perhaps as many as 10% of men
expe-
rience low sex desire (Laumann, Gagnon, Michael, & Michaels,
1994).
The cause for some is a sexual secret such as a variant arousal
pat-
tern (e.g., fetish), preference for masturbatory sex rather than
partner
sex, a poorly processed history of child sex trauma, and conflict
regard-
ing sexual orientation. The more common cause of an acquired
sexual
desire problem is SD, especially erectile dysfunction. The man
has lost
his confidence with arousal and orgasm and avoids couple sex
out of
embarrassment. Unresolved relationship conflict is also a
common cause
of acquired inhibited sex desire.
For these men, promoting sex desire involves mutually
resolving
chronic relationship conflicts and developing self-confidence
and a sex-
positive attitude. For men with sexual repression, therapy
addresses
reducing emotional or physical fatigue, ensuring realistic
expectations of
his body and emotions, and directing his attention to healthy
sexual fan-
tasy and erotic images. Use of erotic fantasies is one of the
most sensitive

and controversial components of male and female sexuality. It
is normal
to have “abnormal” fantasies. Erotic fantasies can serve as a
bridge to sex-
ual desire as well as a bridge to arousal and orgasm during
couple sex.
Two examples of the destructive use of fantasy is when the
combination
of secrecy, eroticism, and shame result in a compulsively
controlling fan-
tasy and when fantasy serves as a “wall” that creates
disengagement from
partner sex.
When a man’s sex drive is well managed, lust does not create
prob-
lems and he can freely enjoy sex. When overregulated, it can
suppress
desire. Poorly regulated sex drive can cause a variety of
personal, sexual,
and relationship problems by leading him to pursue mechanical
sex and
compulsively act out (Adams & Robinson, 2001). Conversely,
repressing
sex drive and depriving him of pleasure and passion causes
personal
and relational problems. Self-regulation is not self-castigating
but rather
demonstrates self-respect. With good physical and emotional
health, sex-
ual drive continues his entire life and he integrates
physiological sexual
drive, psychological well-being, and interpersonal cohesion.

5. Healthy sex is flexible: One of the most fundamental features
of the GES
approach is learning flexible sexual arousal. Flexibility in the
bedroom
promotes the couple as an intimate team but can be blocked by
(a) differ-
ing, conflicted, or rigid purposes for being sexual; (b)
misunderstandings
about the different styles of sexual arousal; and (c) concerns
about sexual
overfamiliarity (“boredom”). Learning sexual flexibility
involves integrat-
ing three features: (a) accepting that there can be five general
purposes
for sex, (b) blending three basic arousal styles, and (c)
appreciating the
inherent variability of couple sexuality.
Purposes for being sexual. It is vital for partners to accept that
they
can be sexual for multiple and varying reasons and to
cooperatively
blend their sexual agenda. The five main purposes for sex are
pleasure,
stress reduction, self-esteem, intimacy, and reproduction. When
the focus
becomes invariably singular or rigid—for example, sex only for
romantic
intimacy or for conception among couples in infertility
treatment (Burns,
2006)—sex can become distressing and dysfunctional. The
relative impor-
tance of these five purposes varies for different people and at
different
times. For example, one partner may engage in sex primarily for

physical
pleasure or stress reduction, while the other may be focused on
self-
esteem and love. The potential for conflict exists as partners
feel this
difference in “agenda” and may interpret it as alienation.
Acceptance of
differences and partner cooperation promote cohesion and
satisfaction.
Styles of sexual arousal. Flexibility also involves appreciating
and
blending three sexual arousal styles. The three styles of arousal
(Metz
& McCarthy, 2003; Mezzich & Hernandez, 2006; Mosher, 1980)
are (a)
partner interaction arousal, which is focused on partner
interplay and
visual stimulation; (b) self-entrancement arousal, which is
focused on
relaxing the body and being receptive and responsive to touch;
and (c)
role enactment arousal, which is focused on role play, fantasy,
variety,
experimentation, and unpredictability. Many young men rely
primarily
on partner interaction arousal, while older and more
experienced men
can expand their arousal pattern to include the self-
entrancement and
role enactment arousal styles. Some men (and women) utilize all

three
arousal styles and others only two. Sexually healthy men can
comfortably
blend arousal styles. Different purposes for a sexual encounter
and dif-
ferent styles of arousal can complement each other and result in
flexible,
satisfying sexual experiences. The man and woman accept they
are not
clones of each other nor do they need to be on the “same page”
to have a
positive sexual encounter. An example of flexibility is the man
focuses on
the goal of orgasm as a tension reducer while the woman enjoys
being
the giving partner and the powerful feelings of being needed
and con-
trolling the sexual scenario.
Variability of sex quality. A vital aspect of the GES approach is
the
candid recognition that among sexually well-functioning and
satisfied
couples, the quality of sex varies. Studies support the
association of rela-
tionship satisfaction with regular sexual frequency and an
appreciation
of the variation in the quality of sex (e.g., Frank et al., 1978;
Laumann
et al., 1994). Although satisfied couples are “regular” in
frequency (e.g.,
one to two times per week), the sexual experience has “very
good” qual-
ity about 20% to 25% of the time, “good” quality about 40% to
60% of
the time, “fair” but unremarkable 15% to 20% of the time, and

dissat-
isfying or dysfunctional 1% to 15% of the time. These
expectations of
regular sexual contact with variable quality engender sexual
acceptance
and serve to inoculate the couple from sexual problems,
especially with
aging.
6. Regular sex is integrated into daily life: Integrating such
GES features can
culminate in the partners integrating sexuality into daily life
and daily
life into their sexuality (Metz & Lutz, 1990). Whether due to
biology or
socialization, sex for many younger men is compartmentalized
with the
focus on physical pleasure and orgasm. As a man matures, he
increas-
ingly integrates sex into his real life. Valuing his partner’s
emotions and
sexual health helps to create the couple’s unique sexual style
(McCarthy
& McCarthy, 2009).
Examples of life phases that can shape sexual experiences are
pregnancy, times of loneliness or disappointment, a sibling’s
wedding,
vacation, a friend’s death, career stress, a class reunion, times
of suc-
cess and achievement, unemployment, illness, raising children,
business
travel, military service, adjustment to the “empty nest,” aging,
and
retirement. Any and all of these events can influence the
functions, mean-

ings, and quality of sex. One time, sex is for anxiety release
through
orgasm, another time for escape and fun, another time for
emotional
healing, another time for romance and intimacy, or another time
sex is a
spiritual experience such as having gentle intercourse while
sharing sad-
ness about a parent’s death weeks earlier. Sharing life provides
the
opportunity to experience sexual interactions in a subtly yet
distinctively
personalized and enriched way.
A prerequisite for blending real life events and sex is a regular
rou-
tine of touch and sex. Rather than being routine, boring,
lethargic, or
perfunctory, sex on a regular basis in the context of a
committed rela-
tionship can be honest and genuine, adapting to the rhythm of
life. Sex
can be respectful, passionate, tender, playful, and experimental.
Couples
who permit life’s stresses, fatigue, careers, parenting, or
irritations to over-
ride regular sex are at risk of alienation. Ongoing, real-time sex
produces
benefits like comfort, diversion, relaxation, trust, pleasure,
cooperation,
and emotional intimacy. For many couples, deep respect for the

human
experience of sex includes transcendental, spiritual experiences
that cel-
ebrate the meaning of life and death.
A reliable indicator of quality sex is the occasional presence of
play-
fulness. Playfulness involves more than a trivial role in sexual
health (Metz
& Lutz, 1990; Tulman, Dornbush, Gilner, Kolodny, & Tullman,
1981). In
order for play to occur, other aspects of intimacy must be
functioning
well—trust, mutual acceptance, focus on pleasure, freedom to
be oneself,
feeling safe, and deeply valuing the relationship. The
idiosyncratic nature
of couple sexual playfulness (such as affirming teasing or
“nicknames”
for sexual body parts) adds uniqueness to sexual experiences
and “per-
sonalizes” the bedroom. Further, playfulness is a way to
acknowledge
the complexity and ambiguity of life, the multiple levels of
reality, the
spiritual dimension, and the value of interpersonal connection.
Sexual
playfulness enhances and strengthens intimacy and facilitates
partners
feeling “special.”
CASE ILLLUSTRATION: DANIEL AND KAY
Daniel and Kay exemplify some of the important elements of
the GES
approach, which provided the “context” or milieu for their sex

therapy.
Background
Daniel was a very demoralized 49-year-old man in a second
marriage
of 2 years’ duration with 50-year-old Kay (this was her third
marriage).
Daniel bragged about his youthful sexual escapades and the
easy sex
of the early years of his first marriage. Daniel fantasized about
those
experiences, and they took on an almost mythical meaning for
him. After
Daniel’s first wife was diagnosed with bipolar disorder and
psychiatrically
medicated, she told Daniel that their “wild” sex life was a
manifestation
of her disorder. She was “healthier” now and was unwilling to
engage
in the high emotionally and erotically charged sex of their early
years.
Daniel’s off-hand comment that he liked sex better when she
was “crazy”
contributed to an escalating downward cycle that both caused
and resulted
in decreased sexual frequency and increased emotional conflict.
Daniel felt
this was unfair and used masturbation to Internet porn as his
sexual outlet.
During their separation/divorce process, Daniel found it easier

to use escort
services, massage parlors, and masturbation rather than re-
engaging in
dating relationships. In the ensuing 3 years, he had four short-
term sexual
relationships, and five one-night stands but did not find this as
exciting as
previous sexual experiences.
Daniel and Kay met at work and started as friends (a good way
to
begin a new relationship). They respected each other’s
professionalism and
enjoyed meeting for coffee and going to lunch. It was Kay who
took the
emotional risk to introduce a romantic touch component to their
relation-
ship. She invited Daniel to her home for a special dinner with
wine and
dancing. Daniel liked the idea of being seduced and by the next
weekend
they were a sexual couple.
Kay was a sexually sophisticated woman who had experienced
men
with erection and ejaculatory inhibition problems, so she was
sure that with
love and support Daniel and she could enjoy a satisfying sexual
relation-
ship. However, 2 years into the marriage, Kay felt emotionally
and sexually
rejected and increasingly hopeless about the viability of the
marriage. Daniel
felt Kay had pulled a “bait and switch” and blamed her for the
low-frequency
dysfunctional sex. He felt justified returning to Internet porn as

his sex-
ual outlet. Sexual conflict, alienation, and avoidance were
draining loving
feelings from the relationship.
GES Features in Treatment
At Kay’s insistence they consulted a couple therapist with a
subspecialty in
sex therapy. After an initial couple session followed by
individual psycholog-
ical, relational, and sexual histories, the couple was given
feedback during
which the clinician recommended a 6-month “good faith” effort
to develop a
satisfying couple sexual style. This meant breaking the blame–
counterblame
cycle and approaching sex with the goal to develop as an
intimate team.
The most important challenge for Daniel was to accept Kay as
his intimate,
erotic friend rather than unrealistically compare marital sex as
an almost 50-
year-old man to youthful sex. The core issue was to accept the
GES model
rather than cling to the totally predictable erection and perfect
intercourse
performance model.
When Daniel masturbated to porn, he had predictable erections
and
orgasms relying on the novelty of the erotic visual stimuli
(heightened
partner interaction arousal style). When Kay tried to sexually
seduce him,

Daniel experienced anticipatory anxiety (fearing he wouldn’t
get an erection
without heightened erotic stimuli and viewing intercourse as a
pass–fail test),
as well as concern he would not be able to ejaculate and instead
lose his
erection. For Daniel, couple sex was frustrating and
embarrassing. Better to
avoid and be the “master of masturbation.”
The therapeutic plan was not only to relieve the distress of their
alien-
ation but to promote reasonable and reliable erections and
ejaculation and
a new, healthier sex life. Cognitively this involved providing
them with the
GES schema and coaching the couple in select features of the
approach that
were relevant to their situation. As a perspective for more
reliable (but not
perfect) sexual function, the couple intentionally embraced the
global sex-
ual focus on intimacy and satisfaction. While ensuring Daniel
that he would
learn how to have reliable erections and redevelop his sexual
confidence,
the clinical focus endorsed pursuing sensual, emotional, and
sexual pleasure
as valuable as sexual function. Kay and Daniel discussed with
the therapist
the value to be gained by learning flexible sexual arousal and
the variability

of sex quality. They would cooperatively integrate sexuality
into their daily
life and daily life into their sexual relationship.
Behaviorally, this involved putting a computer block on the
porn sites
(not to shame Daniel but as an aid to self-regulation); agreeing
to engage
in masturbation only when feeling sexual desire and when Kay
was not
available; using Cialis both as a placebo and to enhance
vascular efficacy;
and beginning by focusing on playful and erotic, nonintercourse
sex with
Kay. Both Kay and Daniel understood the rationale for the
therapeutic plan
but found the explicitness and degree of transparency awkward
to accept.
Daniel was afraid that without porn he would have no desire.
It was very helpful for Daniel and Kay to appreciate the
different pur-
poses for sex and how they vary from time to time and how
having multiple
bridges to sexual desire integrated into couple sexuality. It was
especially
useful for Daniel to learn about the three basic styles of arousal.
From youth,
he had relied on partner interaction arousal to perform, then the
“wildness”
of sex with his first wife, then the raucous images of porn. It
was a powerful
unburdening for him to learn through couple psychosexual skill
exercises
that his erections were “easier” and more reliable grounded in
“sensual self-

entrancement” arousal. Kay also felt relief that his arousal was
not so focused
on her body (she worried about her aging and weight gain).
Positive, realistic information and adopting new sexual
cognitions
was of great value, but most motivating was designing
psychosexual skill
homework to facilitate positive sexual experiences. During their
second
play-oriented sexual exercise, Kay was very aroused and
orgasmic. Daniel
found her excitement highly arousing. At the next therapy
session, the clin-
ician emphasized the psychosexual skill of the man
“piggybacking” his
arousal on the woman’s. At their next sexual exercise, Kay was
again
aroused, which was arousing for Daniel. He was
receptive/responsive to
Kay’s manual and oral stimulation to orgasm.
In subsequent therapy sessions and psychosexual skill exercises,
Daniel with Kay’s support learned to accept that couple sex is
more
variable/flexible and less predictable than masturbatory sex.
However, it is
more human, genuine, and bonding. Giving up porn was a loss
for Daniel,
but a “necessary loss” if sexuality was to play a 15% to 20%
role in energizing
their marital bond rather than draining it. Learning that his

erections could
be more reliable with relaxed pleasuring and “self-entrancement
arousal”
was a confidence builder. In addition, learning to rely on Kay’s
support,
cooperation, patience, and attention were crucial to their
growing as an
intimate team.
A big challenge for Daniel and Kay was to learn to transition to
inter-
course at high levels of arousal rather than Daniel pushing
intercourse as
soon as he became erect. For a period of time Kay agreed to
take the role of
intercourse initiator and to guide intromission so Daniel did not
fall into the
“self-conscious spectator” trap. In addition, they engaged in
multiple stim-
ulation during intercourse to enhance erotic flow. If arousal did
not flow
to intercourse or intercourse did not flow to orgasm, Daniel
learned, with-
out apologizing or panicking, to transition to an erotic,
nonintercourse or a
cuddly, sensual scenario.
Using the GES template as the framework for the changes they
made in
treatment also served them well in designing their relapse
prevention plan.
Accepting GES and valuing each other as intimate and erotic
friends would
inoculate Daniel and Kay against sexual problems in their 60s,
70s, and 80s.

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