By Maureen A. Ryan, DNP, NP-C, CHWC
With her own Path to Intimacy, Connection, Sexual Satisfaction, & Love (PICSSL) model, the author aims to increase healthcare providers’ knowledge and confidence in caring for patients who are experiencing problems related to intimacy and sexuality. Various intimacy enhancers, body connection enhancers, and sexual satisfaction enhancers are described.
Key words: intimacy, sexuality, sexual dysfunction, sex therapy, mindfulness, PICSSL model
Studies have established that sexual satisfaction, along with mental and physical health, is essential to a woman’s well-being and overall quality of life.1 Unfortunately, studies have also shown that a large proportion of adults in the United States suffer from a sexual dysfunction.2 Given that many healthcare providers (HCPs) feel that they lack the ability to adequately address issues of sexuality beyond strictly physical health-related concerns, many patients with intimacy- and sex-related problems do not receive the help they need.3 HCPs who see these patients on a regular basis, and who have already gained their trust, have an opportunity to provide the guidance needed. To facilitate this process, the author has developed the Path to Intimacy, Connection, Sexual Satisfaction, & Love (PICSSL) model (Figure).
In order to best help their patients, HCPs must first assess their own attitudes about intimacy and sexuality, especially if these attitudes include resistance, discomfort, or a tendency to be judgmental. After all, a person’s sexuality—whether one is talking about an HCP or a patient—is affected by culture, religion, family history, and personal history, among other factors, all of which must be taken into account. Before helping patients, HCPs must be aware of their own beliefs and biases. Because PICSSL is a wellness model, and not a pathology model, its principles are relevant to HCPs too. HCPs will likely serve their patients best if they apply the tools of this model to their own relationships as well.
The PICSSL model
The PICSSL model guides both HCP and patient in heightening self-awareness and enhancing decision-making skills with regard to intimacy- and sex-related concerns. Each patient develops a vision of the relationship she desires and then identifies motivating factors that will propel her toward realizing her vision. Such motivators may include a desire for emotional intimacy, for love, or to meet a partner’s needs. Barriers to realizing the patient’s vision are reframed without negativity, and interventions—the action plan—are devised to overcome the barriers. In order to identify and address problems related to intimacy and sexual problems, the HCP draws from three compartments in the PICSSL toolbox: intimacy enhancers, body connection enhancers, and sexual satisfaction enhancers.
Intimacy enhancers facilitate an emotional connection between partners. Intimacy enhancers include self-care practices, a group of qualities represented by the mnemonic “A PIE,” and a group of suggestions called the “7 C’s.” In addition, the author describes seven different types of intimacy.
Many people engage in maladaptive behaviors (e.g., overeating, substance abuse) to numb unpleasant feelings.4 By listening attentively and empathetically to a patient who is troubled, the HCP can enable her to unearth buried pain, and possibly reduce her need to anesthetize herself. Then the HCP can guide her toward developing better self-care practices—that is, adaptive behaviors and selection of healthful options. The patient can track her progress via journaling and report back to her HCP.
To start, the HCP, adopting a holistic approach, assesses the patient’s diet, sleep habits, exercise regimen, stress levels, and level of self-compassion. Safe sex practices and prevention of sexually transmitted infections are discussed. Healthful coping strategies for stress reduction (e.g., exercise, meditation, yoga) are encouraged. Although the patient may believe that taking time to care for her own needs is selfish, the HCP can help the patient reframe this concept. The patient learns to see self care as necessary to recharge herself and have something of herself to give to a partner.
Appreciation, Presence, Intention, and Empathy are the basic ingredients in the recipe for emotional intimacy. Absence of any or all of these ingredients can result in relational dysfunction. The clinical relationship provides an opportunity for the HCP to model behaviors that the patient can then display to her partner. For example, the HCP can express appreciation for a specific admirable quality or deed of the patient by saying I admire your devotion to your aging parents or I thank you for always arriving on time for your appointments. The patient not only learns how to express appreciation for a specific quality or behavior, but also experiences how it feels to receive appreciation.
- A – Appreciation. Appreciation stems from openheartedness, acceptance, and kindness. The role of appreciation with regard to enhancement of intimacy can be a topic of discussion, and readings can be recommended to reinforce it.5What do you feel when you hear words of appreciation? Is it difficult for you to express appreciation? If yes, what stops you from doing so? Expression of appreciation can greatly enhance a relationship. People want to feel valued. The patient is asked to focus on what she appreciates about her partner in the moment—maybe the feel of his or her skin or the warmth of his or her body.
- P – Presence. This quality can be displayed by the HCP and elicit a feeling in the patient. To display presence, the HCP, before meeting with the patient at a given visit, needs to release personal and work-related distractions and be able to fully receive the patient when she arrives. When the HCP is truly present in the moment and pays attention to the patient, the HCP is saying I see you, I hear you, I value you. You have my undivided attention. The patient can then model this behavior with her partner. Presence can be healing.
- I – Intention. A conscious intention is a vision, plan, or goal that opens up a person to what is possible. It is the North Star that guides a person to her intended destination. The HCP can ask the patient what she wants in terms of her intimate and sexual relationships. Many people know what they do not want but have not thought about what they do want. The patient may prefer to write down her intentions and then visualize these intentions as if she is already experiencing what she desires.
- E – Empathy. Empathy is the ability to understand and share the feelings of another person, a quality that the HCP is well positioned to display in the clinical setting. To display empathy, the HCP needs to listen to what the patient is saying and understand the feelings behind the words. Empathy creates a sense of safety and trust where intimacy can flourish.
The 7 C’s
The 7 C’s remind couples of their Commitment to maintain their relationship and hold it as a priority. Empathy, active listening, touch, and attending to verbal and nonverbal cues can both facilitate and enhance intimate Communication. Scheduling dates and sex nights on the Calendar may not seem spontaneous or romantic, but it provides an opportunity to spark the imagination, which fuels desire and allows anticipation to build.6 A deeply felt emotional, mental, and physical Connection with a partner builds trust and nurtures emotional intimacy, a prerequisite to satisfying sex for many women. Courage, a willingness to tell one’s “story” with one’s whole heart,4 may leave a person feeling vulnerable; however, allowing oneself to be authentically seen nurtures the seeds of intimacy, where love and belonging can grow. Extending Compassion toward oneself and one’s partner enhances feelings of acceptance and unconditional love. Confidence, a belief in one’s own value, along with that of one’s partner and the relationship, is essential to preserve and maintain the intimate partnership.
Seven types of intimacy
Sexologist Marilyn Volker uses the acronym “ASPIRES” to identify seven different types of intimacy.7 A couple can feel close to each other if just a few types of intimacy are present, but most people crave multiple types of intimacy with a partner.7 When interwoven, each type of intimacy strengthens the relationship.
Affection is a feeling of tenderness and fondness toward another person. Social intimacy refers to the process wherein a couple enhances closeness with each other by socializing with others. Physical intimacy refers to the sharing of leisure activities. Intellectual intimacy entails sharing a cerebral connection through conversation about areas such as politics, religion, science, culture, and literature. Romantic intimacy is more difficult to define because it varies with the individual; it may be expressed by giving one’s partner chocolates and flowers, drinking a glass of wine together, or gazing at a sunset together. Emotional intimacy involves opening oneself up and sharing one’s innermost feelings with a partner. Many women feel emotional intimacy when their partner turns toward them, establishing eye contact or what is known as the anchoring gaze.8Sexual intimacy involves physical touch, and encompasses foreplay, intercourse, and orgasm. Some couples may not be sexually intimate for one reason or another, but they have a solid relationship because other aspects of intimacy are strong.
Body connection enhancers
Body connection enhancers heighten pleasure, excitement, and eroticism. The HCP can give the patient written materials about these practices and products and refer the patient to educational resources such as A Woman’s Touch: Sexuality Resource Center9 and the Sinclair Institute.10 The HCP and the patient can then discuss the patient’s progress in terms of implementing these interventions, thereby promoting the feedback/support loop between HCP and patient as well as promoting adoption of healthy behaviors.
Personal hygiene is important not only for one’s self-esteem but also as an essential ingredient in partner attraction. The HCP may need to tactfully remind the patient about personal hygiene practices.
Breathwork and other relaxation techniques
Some people are too preoccupied, negative, and anxious to be able to experience intimacy and enjoy sex. To promote positivity and relaxation—and better sex—the HCP can teach the patient the practice of mindfulness, wherein one focuses on being completely aware and non-judgmental in the present moment. Mindfulness has been found to be an effective treatment for a variety of sexual dysfunctions.11 Mindfulness allows one to be more present and attentive to sensual sensations. This practice entails conscious breathing, which is considered the antidote to the stress response in that it returns the breath to a deeper, more relaxed pattern and stimulates the vagus nerve, which controls the parasympathetic nervous system and triggers the relaxation response.12
Other approaches include conscious muscle relaxation, use of visual imagery, and meditation. When body and mind are relaxed, the five senses are better able to be stimulated. Focusing on sensual experiences may in turn facilitate mental and physical relaxation while arousing feelings of sexual intimacy and affection.
Exercise and yoga
Encouraging the patient to participate in a regular exercise regimen will support her sex life.
Exercise improves mood and increases energy, strength, and endurance, all of which enhance sexual functioning. A positive relationship exists between body image and sexual functioning and sexual satisfaction.13
The practice of yoga draws attention into the present moment and enhances body awareness. Yoga calms the busy mind and induces a state of relaxation; these effects are linked to an improved sexual response.14
Many couples have sexual experiences that are boring and unsatisfying because they have failed to communicate their sexual desires and fantasies to each other. Body mapping is a tool to enhance communication between sex partners, enabling them to have a more personalized and erotic experience. Couples who use this tool start with a drawing of the front and back of two nude bodies representing themselves and their partner. They number the order in which they wish that their body parts be touched, and use colors such as green for go and red for no. Creativity and attitudes of openness, curiosity, and acceptance are encouraged. The only rule is that neither partner can criticize or demean the other partner.
The next step is for the couple to touch each other on the top of the hands, forearms and arms, shoulders, upper back, back of the neck, head, and forehead to facilitate a sense of safety and security. Next, the couple can start—slowly and thoughtfully—touching each other’s body parts in the order indicated on the body map. The couple can then move on—slowly and thoughtfully—to touch erogenous areas such as the insides of the hands and arms, the front and sides of the neck, the ears, the mouth, and the top of the chest; these touches are likely to trigger a longing to be touched on the breasts, thighs, belly, hips, buttocks, and genitals. Arousing a woman’s desire naturally, rather than racing for her breasts and genitals, is more likely to lead to pleasure and satisfaction for both partners.
Self pleasuring and sexual aids
Many women, alone or with a partner, use sexual aids to enhance their sexual experience. Vibrators can relieve anorgasmia in women whose genital sensation or arousal is diminished, and they can increase the ease and the intensity of orgasm in anyone.15,16 First-time users of vibrators may find massager products less intimidating than traditional sex toys.15
Pelvic floor health and lubrication
A strong pelvic floor is needed to maintain urinary continence, support pelvic structures, and enhance sexual function. Kegel exercises are used to promote strength of the pelvic floor musculature, which can enhance orgasm intensity.17 Most women experience symptomatic vulvovaginal atrophy after menopause.18 Relieving vaginal dryness may enhance a woman’s interest in sex, subjective arousal, and capacity to reach orgasm. Restoring a natural pH and lubrication to the vulva and vagina through use of vaginal lubricants, moisturizers, and, in some cases, exogenous estrogen can minimize dryness.18
Sexual satisfaction enhancers
With a positive attitude, willingness, and openness to new possibilities, a woman can reawaken her libido and increase her sexual satisfaction.
Sexual empathy entails understanding one’s partner’s sexual desires and fantasies, and providing opportunities to explore these wishes.19 The HCP can suggest that the patient and her partner engage in listening exercises—to put themselves in each other’s shoes and to learn what excites the other person.
Creating an environment
The HCP can encourage the patient to imagine and create an environment that will enhance feelings of relaxation and sexual desire—quite a joyful project. The patient is asked to sketch out on paper an ideal—no holds barred—to set the stage for her to explore her deepest desires and fulfill them. Creating an environment conducive to sexual exploration involves details such as sleep/wake patterns, lighting, music, scent, and timing.
Touch releases oxytocin, an anti-stress hormone that promotes bonding.20 Touch is the essence of foreplay, so the HCP can initiate a conversation with the patient about the types of foreplay with which she is familiar and that she enjoys. Then they may discuss foreplay practices that the patient may not have experienced but that she might be interested in pursuing. Openness, playfulness, and curiosity can lead to new avenues of pleasure. The HCP can ascertain whether any forms of foreplay elicit discomfort. If so, measures can be taken to work around or alleviate the discomfort. Many guides to kissing and sexual positions and techniques are available; even YouTube is a good resource.
Couples with sexual concerns tend to gradually avoid physical and sexual contact over time. Avoidance of sex damages their connectedness and alienates them from each other, both psychologically and physically. Sensate focus, an exercise developed by Masters and Johnson to enhance emotional and physical intimacy, enables couples to reconnect slowly, safely, and in a mutually satisfying manner.21 Sensate focus involves structured and progressive touching between two partners, advancing from initially non-genital touch to more pleasure-oriented touch in subsequent stages.22 This approach is similar to that described in the section on body mapping. However, the focus is on sensual, rather than erotic, pleasure. In fact, overt sexual activity is prohibited during the early stages, which greatly reduces performance anxiety and heightens desire.
Novelty and fantasy
Couples who share exciting experiences, compared with couples with more mundane habits, report greater relationship satisfaction and more romantic feelings. New and exciting adventures release dopamine, causing feelings of exhilaration, hope, and romantic love.23 Adventurousness in one’s activities (e.g., travel, hiking, dining in new restaurants) can lead to adventurousness in the bedroom. Seeing a partner in a new light creates an air of mystery and fuels passion.6 The HCP can ask the patient to write down (for no one to see if she chooses) a list of the most exciting sexual activities she can imagine—giving full rein to her fantasies. The patient has an opportunity to pretend, to explore untested parts of herself. Engaging in sex play using fantasy, erotica, and vibrators can serve to heighten sexual arousal and enable her to live out her previously unrealized or even unconscious desires.
Making love mindfully
Making love with intention, attention, and attitude deepens intimacy and sexual pleasure. The direct, moment-to-moment awareness of what is happening as it is happening helps a woman notice subtle pleasurable sensations.23 Couples stuck in mediocrity can approach lovemaking as if it were the last time—or the first time. The HCP can recommend exercises such as slow touch and eye gazing. A practical point to mention to the patient: Many women do not experience orgasm with intercourse; in fact, most of them require clitoral stimulation to do so. To facilitate the process, the woman can touch her clitoris or position herself so that her partner can manually stimulate her.
Educational materials and bibliotherapy
Numerous books, films, and websites are available to educate the patient about sexual communication and techniques.9,10 Reading erotica and watching erotic films can fuel desire and arousal; such materials can evoke strong responses and can deepen a couple’s communication.
Through gentle questioning during the initial evaluation, the HCP ascertains whether a health-related intervention and/or psychiatric intervention is needed. Addressing organic dysfunction may involve referral to a specialist and maintaining communication with that specialist in the course of the intervention. Depending on the particular intimacy- or sex-related problem, the HCP can then proceed with an intervention plan or to refer the patient to a psychotherapist or sex therapist with appropriate training.
From the start, the HCP needs to establish a nonjudgmental, receptive tone. “Homework” assignments may be given as suggested in this article, and a schedule of follow-up sessions can support cultivation of healthy behaviors and attitudes. In some cases, a partner can be brought in for a consultation. Topics and techniques discussed in this article must be approached with empathy. Awareness of the predispositions, sensitivities, and cultural norms of the patient informs HCPs in their work. The medium is the message: Invaluable in helping couples step out of their usual sexual scripts and open themselves up to new possibilities and experiences are such styles as normalizing/destigmatizing, a sexually positive approach, and humor.
Problems with intimacy and sexuality can emerge at any stage of the lifespan as a result of a multiplicity of factors, including physical or emotional trauma, relationship problems, mental illness, injury, physical illness or disability, pregnancy, perimenopause, and advanced age. All of these conditions require sensitivity on the part of the HCP to changes that the patient has endured and the effects of these changes on her state of mind and relationships.
The HCP should push through his or her own vulnerability and find the courage to initiate these important conversations so patients need not suffer in silence. Many intimacy- and sex-related concerns can be managed with patient education and with empathetic listening. The HCP’s willingness to open this dialogue may lead couples to more joy-filled, meaningful, and purposeful lives.
The PICSSL model offers the HCP a toolbox of intimacy, body connection, and sexual satisfaction enhancers to help patients achieve greater intimacy and sexual health. Equipped with this knowledge, the HCP can facilitate love and connection in a society in which both are so intrinsic to health, happiness, vitality, and wholeness. The Box contains a list of resources for patients and for HCPs.
Maureen A. Ryan is a sexual wellness coach and Director of the Mind-Body Connection for Adult Health NP, PLLC, in Amherst, New York. The author states that she does do not have a financial interest in or other relationship with any commercial product named in this article.
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