FOUR ASPECTS OF THE QUALITY OF LIFE, THE BALANCE MODEL AND SEXUAL DISORDERS

Sexual life is an important part of daily life and it influences the quality of life and well-being. There are four aspects of life, the equilibrium of which is required to create and maintain mental, emotional, social and spiritual health. Any difficulties in making and keeping this balance or obstacles to it may cause various diseases, complains, problems or dysfunctions in sexual life. This paper will show the importance of good, regular sexual life and how it will influence the improvement in the quality of life on one hand and will help protect against or reduce the severity of many sexual disorders on the other hand. It will demonstrate how the balance model from the positive psychotherapy approach can work together with techniques of body psychotherapy in the treatment of different sexual disorders


Human sexual life
From birth to death we human beings are sexual persons, whether or not we are engaged in a sexual relationship.The word "sex" is probably the word most commonly thrown around in our daily life but one that somehow always tends to raise more than a few eyebrows.But despite the pervasive discussion on this subject, much of what we hear is inaccurate and can be confusing.A basic understanding of sex and sexuality can help us sort out myth from fact and allow us increased enjoyment of our lives.The myths and misunderstandings surrounding sex were not created deliberately by us but grew up because of people's discomfort in accepting the word "sexuality."How has this come about?My opinion is that from our earliest childhood we learned that even using the word "sexuality" is allowed only for adults, and if children use the word "sexuality" in front of adults, they will be made to feel shamed and embarrassed and will blush.Let me give an example.When a child asks her parents if they have sexual intercourse,", the answer to this question will normally be: "Yes, of course we do."But if the child continues to ask further questions such as: "did you have sexual Intercourse last night?",then the parents will either ignore the question or offend the child with an answer such as: "that's none of your business!".
This example shows very precisely that sex and sexuality are enveloped In a protective shield of privacy (Levine, 1992).Some authors (Levine, 1992;Kubie, 1971;Person, 1988) emphasize the distinction between privacy and secrecy in which the word "privacy" is more useful in relational communication rather than secrecy, which is protected by the personal concept of sharing and Enver Cesco ISSN 2710-1460 WAPP belongs to intra-personal communication.
If sexual development does not progress normally, it becomes dysfunctional, which evokes many disorders.Sexuality, however, is neither a disease nor a commodity.It Is an ever-present, ever-evolving, multi-faceted resource of every human being (Levin,1992).
Sexual life is one of the very important activities for the maintenance of human health and wellbeing.Regular sexual activities are not the same in all people who are trying to keep balance in daily life.A high level of involvement with other activities is often given as the reason for avoiding sexual activity.Many of us have no clear understanding of how often we actually have or should have sexual intercourse.As daily activities are becoming ever more stressful and we are consumed by the routine of mechanical behavior, modern people increasingly complain of "forgetting" or "postponing" sexual activity.
In my psychotherapeutic practice clients often complain that they do not have enough time for regular sexual activity, and they often blame stress for this.As I often face such situations with clients, I have searched for methods to assist them to re balance their disturbed balance of the quality of life, including regular sexual activity.
To understand sexuality, it is important to know the causes of sexual phenomena, which we can classify into five categories: Individual psychology, biology, interpersonal relationships, sexual equilibrium and culture (Levine, 1992).All of these five categories are crucial to maintaining and/or developing healthy or impaired sexual life in every person's unique set of sexual thoughts, feelings and behaviors.
Human sexuality includes the physical body, the neuro-biological mechanism of the human organism (Houts at el., 2011), psycho-emotional activities (Laan, Both, 2011) and the socioidentification of gender identity.The ways we experience and express our sexuality include our body images of how and what we feel about our bodies, desires, thoughts, fantasies, sexual pleasure, sexual preferences, and sexual dysfunction, the values, attitudes, beliefs, and ideals about life, love, sexual relationships, and sexual behaviors.

The Balance model in sexual life
Many of us believe that contemporary modern life is producing successful and beneficial results because of significant forms of technological empowerment.To adapt to these new circumstances the human being must alienate the psychological part of his nature by behaving mechanically and focusing on achievements and results.These situations increase the physiological mechanisms that produce the stress hormones and this creates an imbalance in well-being in daily life.
Research shows that younger and middle-aged people, female and male, married and young single partners show differences in adult sexual activities (Eisenberg, at el, 2010).It is important to emphasize that each human being must develop his own quality of life.What does quality of sexual life mean?We will understand this better if we look through the balance model used in the Positive Psychotherapy approach (Peseschkian, 2016a,b,c).Look at the picture below.These are the four aspects that a human being uses continuously in his daily life.The first aspect is the physical body, including all psycho-physiological mechanisms through which the human being carries out not only physiological but also the emotional functions of the body, such as

Future and plans Work/ Achievements
Contact/ Relationship well-being.The physical aspect of the body will be empty and poor if its emotional aspect, which produces sensual satisfaction, is not activated.This may be activated if the body is in good condition, which means, our daily work and achievements are successful and effect material satisfaction.If our work is in good stress-management control, this means that our daily moods are in harmony with our bodies' sensations.When we are successful in our daily work, and have developed good coping skills for stress, our results will influence our motivation for sharing and making contacts with our partners.Thus satisfaction will be increased and this will influence others.Maintaining good contact with our partners influences the development of relationships and produces a better quality of life, which brings satisfaction and harmony into daily life.If we continue to foster harmony in these three aspects just mentioned, our future daily lives will develop and grow toward a better quality of life.This is the model from Positive psychotherapy that is used in our daily lives.If we port the same balance model into sexual life, then we will have the picture as it is shown in fig. 2. We use our body/sensations to arouse sexual impulses during intercourse which produces sexual satisfaction.In turn these intercourse relationships intensively mobilize psychophysical energy which further improves sexual satisfaction.
In a state of human well-being there is always harmonious relations with the partner so as to produce a better quality of life in the four model dimensions (Peseschkian,2016a).The model dimension is in harmony with the four aspects of personality development shown as in fig. 3. When we are using the same model dimension in sexual life, the four aspects will transform as Relationships become ever deeper and more harmonious, the concomitant sexual satisfaction will be increasingly more in balance and of higher quality.This is when partners feel that their two bodies merge into one and they experience sensations that develop Ecstatic Sexual Satisfaction, called "beyond orgasm" (Klisic, 2009).
All these four model dimensions create a higher quality of sexual life and make the balance model of well-being.This is shown in figure 4.how the positive psychotherapy model is carried across from daily life into sexual life.Many studies show that sexual activity may be an indicator of current and future quality of life, that indicates the importance of satisfaction as a strong predictor in reports of higher quality of life (Wilye, 2007).The problem is how to measure the quality of life.
Today the various therapeutic approaches provide us with many tools with which to do this.We can map a person's quality of life by using the positive psychotherapeutic model and its tool called Differential Analytic Inventory(DAI)*(N.Peseschkian, 2016a), which contains a list of secondary and primary capabilities.In psychotherapeutic sessions with clients, using the DAI method shows the picture of how people understand different meanings of capabilities in different situations and circumstances.For example, politeness, as a secondary capability, means intimacy for one person, "used to convey an emotional or psychological closeness" (Levine, 1992), but politeness also means "positive interpretation of inhibition of aggressive reactions toward society" (Peseschkian, 2016b).The word tenderness is very compatible with the context of intercourse relationships because it describes not only meaning but also behavioral content which allows an understanding of the quality of life of the partners.
The word "sex" includes all the psychological, physical processes in connection with sexual activities (Peseschkian, 2016b).Our activities are not maintained only in sexuality and their effects on it, but the quality of our relationships is determined by the balance we maintain in the four areas of daily life.Preconditions for qualitative sexual life, are based on personality structure, psycho-physical presentation, relationships and concepts of sexuality.
Love, as a primary capability, is an essential dimension of human life and consists of the capacity to love (Peseschkian, 2016a).Our capacity to love depends on how our relationships with our environment have developed from birth and our earliest experiences, which determine our emotional well-being.If we begin by using this model, it is possible to see different concepts of capabilities that people are using in their daily interactive relationships.In practice we see that the four aspects of the model dimension, which are shown in figure 5, are contributing to a better quality of life.An understanding of the different meanings of secondary and primary capabilities also shows how partners are coping with their conflict situations, which are one of the major factors that disturb the harmony and balance of the quality of life in human well-being.
The Impact of sexual balance may evoke the interaction of many factors and categories that show direct influence on sexual functioning.This will be demonstrated in the next picture.Psycho-emotional factors Include capabilities and experiential achievements such as ages of partners, sexual attitudes, previous sexual experiences, etc.

Quality
Socio-Interpersonal factors include the functions and impact of socio-cultural heritages relating to sexuality.
Spiritual factors with belief systems and developmental concepts of sexuality include conceptual mechanisms for new perspectives for philosophy of sexuality.
To achieve sexual balance the endocrine system and its hormones need to be at a proper balance to maintain its functions, and this is affected by human activities.If the function of the endocrine system is disturbed, this results in various changes not only in the functions of bodily organs but also in human emotions.For this reason a person feels depressed, experiences mood swings, or suddenly suffers from fatigue and restlessness.This causes imbalance in the previously-mentioned four aspects which are directly influenced by hormones that greatly affect human emotions.Understanding our sexuality can help us to enjoy our lives more and the enjoyment of life produces a better quality of life.All of these make the harmonious balance of a healthy organism.All human beings are sexual from the day we are born until the day we die and a basic understanding of sex and sexuality shapes how we express ourselves as sexual beings.It is a matter of how we experience and express different aspects of the sexual being such as body image, sexual pleasure with its satisfactions and dysfunctions, sexual relationships, sexual behaviors, sexual health, sexuality as the reproductive function, and sexuality as unity in mankind.

Psychological aspects of sexuality
Another important aspect of good balance in sexual life is sexual motivation, the significance of which is emphasized by various authors.Conditions which are necessary to activate sexual arousal may focus on three major aspects; (1) intact system that enables sexual responsiveness; (2) stimuli with sexual meaning must be present that can activate the sexual system, and (3) the circumstances must be suitable to pursuing sexual activity.(EveraerdW., Laan E. 1995).
A large body of research concerning sexual health shows that the purpose of the sexual act is not only to give the partners satisfaction but also that the sexual act helps the partners to be healthy, happy, in good temper, successful, effective and less stressed in everyday life (Kinsey 1998).Abramov (1970), compared the sexual life of a hundred women, ages 40-60 who were recovering from acute myocardial infarction with a control group of a hundred women of the same ages who were recovering from other illnesses.Frigidity and sexual dissatisfaction were discovered in 65% of coronary patients an 25% of patients with other

Spiritual factors
Belief system and developmental concepts of sexuality illnesses.While Wahner and Burchel's research into sexual dysfunctions, using 131 men aged 31-86 who were recovering from heart attacks, shows us that two thirds of the patients had experienced significant sexual problems during the weeks or months immediately preceding their heart attacks.This study found that 64% of the patients were impotent, 28% had experienced a significant decrease in their sexual functioning and 8% of them had experienced pre-ejaculation (Wahner & Burchel, 1980).Dr. John Gray's landmark book shows that sexual relations are very important activities in a man's life."Every anger which grows in a man disappears as if it were removed by hand after good sex", and he adds, "There is no better therapy for man than a good sex."Sometimes during therapy or consulting it is necessary to get to the point where a man and woman experience good sex.Then when the couple arrives at this point and when they know how to get there every time, the sex is the same for the man as being able to attain and maintain love, passion and magic (Gray, 2012).
Frigidity is defined as a woman's sexual coldness and inability to have an orgasm.However, the positive interpretation of frigidity is her "ability to say no with the body."That means that there is a possibility that this capability may be enlarged upon to include the ability also to say no verbally and better formulation of her own needs.
Impotence is defined as incapacity for sexual activity or satisfaction.But its positive meaning is the ability to withdraw from the conflictual field of sexuality, relationship to one's own body, to the partner and her body, achievement, contact, future (Peseschkian, 2016a,).
A study of 16.000 adult Americans showed that sexual activity is a strong determinant of happiness (Ferrer-i-Carbonell and Frijters, 2004), married people have more sex then those who are single, widowed, divorced or separated…highly educated females tend to have fewer sexual partners".
Sexual satisfaction, as with sexual activity, is important for the quality of life (Wylie 2007), Better health was shown to lead to frequent good-quality sex in older adults (Goodson, 2010).

Treatment protocol in the case study
Following the publication of Master and Jonson's (1970), research on Human Sexual Inadequacy, sex therapy developed by redrawing the map of sexual dysfunction.Today work with human sexuality is becoming more complex, not only in treatment plans but also in discovering the broader understanding of sexuality as essential for human beings.
New trends in sex therapy are oriented toward encompassing the multi-dimensionality of sexual experience and the diversity of needs among a variety of populations.Following in line with the newest research, sex therapy is focused on six dimensions.(1) multi-disciplinary; (2) systemic and theoretical integration; (3) a shift from sexual function to satisfaction and eroticism; (4) an increased attention to age and the consequent aligning of expectations to reality; (5) the impact and application of new technologies, and (6) a still lagging recognition of sexual needs of certain populations traditionally left out of the sex therapy arena (Meana & Jones, 2011).
This study is based on treatment of two clients who had sexual difficulties and were referred by doctors for psychotherapy.Having experience in training and education in both body psychotherapy and positive psychotherapy, I worked with the clients to make contacts and connections with their deeper feelings and to raise their awareness of current sexual difficulties.
In both cases the clients attended the sessions individually and sometimes with their partners.Following each session they were all given homework exercises to improve their progress.Methods used were the five stages of treatment from positive psychotherapy, beginning with Observation and ending with Broadening of the goals, and specific techniques from body psychotherapy with breathing exercises, Kegel exercises and relaxation techniques.The client with impotence required 12 sessions and the client with frigidity needed 14 sessions.
Treatment with these approaches offered them better understanding of their sexual life and helped to increase their capacities for releasing feelings conducive to love and satisfaction.The

Applied approaches in case study
This presentation of two typical cases of sexual disorders based on the criteria of DSM IV and ICD 10 will focus on a methodology of treatment using two psychodynamic and humanistic approaches, namely body psychotherapy and positive psychotherapy.From positive psychotherapy, we used the DAI to influence the sexual motivation for both to have the willingness and sexual drive to bring their bodies to their partner.The Balance model was used to see how the partners are coping with their sexual activities and satisfactions to reach their performance.The treatment process was followed in five steps described in the positive psychotherapy approach described by Peseschkian (2016b).The stories and proverbs (Peseschkian, 2016c.)were also used during the treatment process as tools to encourage increasing awareness about existing difficulties and problems.
The results received from DAI, show the importance of early development of primary capabilities, starting from the capability to love and developing and strengthening the relations between partners and performances in sexuality and tenderness, as these are the most important capacities.The secondary capabilities such as honesty, justice, confidence, orderliness, politeness and cleanliness are the capabilities that are needed to be respected in keeping the mutual balanced relationships between partners which are the important inputs for better performances in sexual life.

First case
A woman of twenty-three years old was recommended from neuropsychiatry for psychotherapeutic treatment for her sexual difficulties and high level of neurotic reactions that sometimes caused her to lose control, especially with her husband.She had a tendency to quarrel even with other members of her family.She had been married for eight months and had begun to hate her husband and to avoid sexual intercourse.She had not had sexual experience prior to the marriage.Throughout the entire eight months of marriage she had never achieved orgasm.During sexual contact she very often felt spasms, pain and dissatisfaction.She never told her husband about this problem.She thought it would disappear in time because she believed it might happen to anyone and that it did not need medical treatment.The medical diagnosis of her complains was described as female sexual disorders, with symptoms, frigidity, the delay in, infrequency of, or absence of orgasm, F 52.2.(ICD 10).
The beginning of our work was directed toward the improvement of self-contact with her body by her accepting her own body as a potential source of well-being and satisfaction.Breathing exercises were used to increase the awareness of her body's potential and to raise her energy level.Centering and other techniques were used with this client to unblock her anger.Defining her character structure as a pain blocker, we next worked to help her feel her body-center and to express her deeper feelings during the exercises.In time it was noticed that her infantile desires would not allow the opening of her capacities for pleasure.Her unconscious was repressing her sexual pleasures.During puberty she had looked like her mother and the meaning of sex and sexual relations had negative repercussions in her married life.This was shown very precisely in her model dimension when she showed her model as her mother.She was unconsciously resisting opening her capacity for sexual pleasure.When she was stimulated, at the moment when she should experience the sexual act with her husband, her resistance toward him would begin to emerge.Analyzing her resistance., we discovered that her husband's inferior position, being an inexperienced sexual partner, also contributed to her resistance and sexual dissatisfaction.
After the work of connecting, self-contact and contacts with her deeper feelings, the use of the fundamental methods of body psychotherapy, we moved to the theory of developing orgasm and used specific exercises for reaching orgasm.
We gave individual exercises to the wife and then to the husband.We worked with these exercises for five sessions.Special emphasis in this work was given to inhalation/exhalation and acceptance of repressed emotions.When we realized that the couple had mastered the individual exercises, we moved to exercises with the couple together.During the period while we were working on these exercises, the couple was informed that they were not allowed to have intercourse.They were to engage in sexual games and erotic massages in order to know each other's body better.Instructions were given on how to do the exercises and feel readiness for the sexual act.
At first we began using exercises focusing on sensations, observing and making the couple's talking much more romantic and exotic.Of course, we moved along as conditions allowed.After that each partner was asked to assist the other in specific exercises to improve reaching orgasm.When the wife was ready to feel lust by doing the exercises, they were advised to begin to have intercourse.After ending intercourse they were also advised to spend 10-15 minutes discussing their feelings during the whole process of sexual intercourse.These exercises were repeated for a few weeks until we found that the wife was in condition to feel orgasm easily.
In each session we used the Balance Model to see how the life energy was changing in the four areas and how her sexual function was progressing toward increasing her desire, arousal and orgasms.We used the DAI to influence the sexual motivation for both to have the willingness and sexual drive to bring their bodies to their partner.
The three stages of interaction, attachment, differentiation and detachment, were used as related to sexual arousal as requirements for orgasm.
After three months our client was able to feel orgasm regularly.In sexual relations she was much more relaxed, she could feel sexual excitement and satisfaction at a higher level, and she particularly noticed significant progress in experiencing orgasms.She was also very satisfied in human relationships and those with her family.Her love for her husband was increasing while her negative attitude to her husband was beginning to change.She expressed the recognition that the reasons for her dissatisfaction had not been with her husband but because of her negative attitude toward herself.

Second case
A man in early middle-age was referred by a Neuro-psychiatrist (NP) after medical treatment for some depressive reactions.He was treated for depressive neuroses underlying sexual impotence.During his first psychotherapy session he explained that he had a fiancée whom he was expected to marry in two weeks.
At this time he did not believe in either psychiatrists or psychologists because he had been "wandering" from one to another for more than four years.Several times he had visited magicians, mullahs and priests and at the end he also once went to what he referred to as a parapsychologist who worked with black magic.Describing my work, I said to him: "I am not working with that nonsense, my work is in a genuine profession, which is called psychotherapy."The client had to choose between two options, whether to come and to believe or not.After much thinking he decided to accept psychotherapeutic treatment.
The sessions began by using the five stages of treatment from positive psychotherapy.During the first two stages, observation and inventory, we looked at his psychosexual development and at his life variables during the period of his engagement.At the beginning of the sessions he seemed fearful and shamefaced.Earlier he had been afraid of physical contact with girls.The influence of his father had had a significant importance in forming his character structure.Considering his retiring character, embarrassment and anxiety in social contacts, we treated him as a combination of fear blocker with a lot of anger.During the work we determined that the young man had an oral character characterize by an inability to be alone and a great need to be protected by someone.Before moving from the second stage to the third, the stage of treatment, and encouragement with exercises, we discussed the anatomy and physiological aspects of genital organs.After succeeding in the methods of getting into contact with himself in his deeper feelings, we used tantric breathing exercises to increase his feelings for orgasm.He was instructed to practice all these exercises with his partner at home and later on to discuss this in detail during the next session.During the sessions we practiced exercises for selfacceptance to strengthen his consciousness.Specific techniques working with body and feelings were also included in those exercises.The aim of this method was to follow deeper feelings on one side and to realize blocked feelings on the other side.All exercises were done carefully without pressing the mind and leaving the free expression of feelings to come out.We gave particular attention to achieving wider and deeper opening of the eyes, At the beginning of our work he was unconsciously avoiding maintaining eye contact, but later on he could stare and watch himself.
After three months of intensive work once a week, our client has made very good progress.His relationship with his fiancée had continuously improved even in their sexual games during the first weeks of treatment and in their intercourse later.After practicing exercises at home, his fiancée declared that each time that she masturbated his penis, it achieved a better erection then before.The erection was coming after each sexual warmup and also the feelings were stronger and he was not concerned with the potency of his penis.His love for his partner was growing much stronger and he felt happy and satisfied in his daily life.The happiness' and trust of the client was indescribable.Now he wanted to have coitus.Encouraging him to have sexual contact after 113 THE GLOBAL PSYCHOTHERAPIST Enver Cesco ISSN 2710-1460 WAPP successful exercises and expressing feelings of satisfaction, it was the time to go forward.Even though he was not sure enough that he would succeed in coitus, he received very strong encouragement from his partner.It was suggested that he use specific positions (succubae) during the sexual act.It was recommended that they use their meditation technique before the sexual warm-up and after that to start with sexual games and to end with intercourse.
After practicing the same techniques for a few weeks, his impotence had quite disappeared.He became very happy and his feelings for sexual intercourse were becoming stronger.In everyday life he was in a positive mood, less stressed and not unsure.Also he was more comfortable in social contacts and his relationships with his family members were better.
His partner, who had lost confidence in him, perceiving him as not being a real man, had lost hope that their marriage could be saved.Their quality of life became more productive, happy, satisfied and important.She also felt that she was no longer just an object for the expression of his body's lust but received psychosocial satisfaction by his accepting her as a human being.

Conclusions
Treatment of different sexual dysfunctions must use a multi-disciplinary approach (Meana & Jones, 2011).Combining the methods of positive psychotherapy, such as the five stages of treatment, with techniques from body psychotherapy in the treatment of different sexual dysfunctions may give great success in releasing blocked feelings and solving interpersonal and couple relationship problems by improving the client's or couple's quality of life.Using the balance model in daily life provides one instrument to examine and measure our quality of life and of sexual harmony in partnership relations.Replications of this study on a larger scale are needed to reach a definite conclusion that this approach of combining methods from body and positive psychotherapies will regularly yield great success in relieving sexual dysfunctions.Similar investigations in different cultural environments and using other psychotherapeutic approaches are also recommended.

Figure 2 .
Figure 2. Balance model according to the positive psychotherapy approach transforming sexual life (Cesko, 2011)

Figure 3 .
Figure 3. Model of dimensions according to the positive psychotherapy approach (Peseschkian, 1985)

Figure 4 .
Figure 4. Model of dimensions according to the positive psychotherapy approach transformed to sexual life (Cesko, 2011)

Figure 5 .
Figure 5. Model of dimension of the four modes of the capacity to love (Peseschkian, 2016b)

Figure 6 .
Figure 6.Model dimension of the four modes in the quality of life (Cesko, 2011)

Figure 6 .
Figure 6.Model of interaction (developed by author) Recent studies (Laurent & Simons, 2009) show that the model of internalization of Psychopathology is based on the interaction of four factors.First are Psychodynamic factors which include unsolved conflicts from the past that directly influenced Cognitive Behavioral factors such as negative responses, learning attitudes, model creation and behavioral reactions.The third are Socio-cultural factors which includes social expectations, ability to communicate, attraction, and gender stereotypes, and last are Physical-Biological factors that include phenotypes, hormones, neurotransmitters, and physical injuries (Laurent & Simons, 2009).
From body psychotherapy breathing techniques, Kegel exercise, autogenic meditation, sensual relaxation methods and homework exercises about different sexual positions(Klisic,