Does Today’s Couples Therapy Promote Good Sex?

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Ginette and Phil had fallen into a pattern of barely managing, rather than resolving, inner pain and grief associated with unresolved sexual issues.  A dual strategy— one part avoidance and one part denial—wasn’t working. Eventually, anger erupted and overwhelmed the pair. That is when and why I met them for the first time.

At the initial session, Phil stated, “our communication skills are in the toilet. We can’t talk without arguing.” Although each complained about feeling unappreciated by the other, neither mentioned a word about sex. “We need to learn how to talk with one another,” Ginette offered. Phil nodded his head in agreement.

Ginette continued, “Sometimes we get furious and the intensity doesn’t match the issue at hand. I become irate when we talk about certain things and I can’t explain why.”

I asked Ginette to give an example of one of those conversations. She replied “This may be a silly example but it’s typical of a lot of the conversations we have. We order take-out a few times a week. Phil has two dishes he likes.  And he always wants to order them. I’m okay with chicken with broccoli or Thai basil chicken now and then, but I crave variety. He’ll compromise begrudgingly. Then, the next time, he insists on one of his two choices. He never takes the initiative to do it differently. He seems oblivious to how I feel. I’m invisible to him.” She looked at me with a flicker of some emotion that was hard for me to identify.  Then she said, “I don’t think it’s normal to get so angry at things like that. I think there’s something wrong with us,” her voice trailed off as she added, “Or maybe there’s something wrong with me.”

Next Phil said, “She’s not interested in what I feel unless my feelings match hers. She won’t even acknowledge that when we talk about food, we aren’t talking about whether I want to have new experiences with her, we’re talking about food. She twists everything.”

Ginette responded, “I’d love Phil to tell me how he feels. But he doesn’t know what he feels. What he knows are his habits, and he voices them. What I get to know is the rut that his thinking is in. He is a creature of unthinking habit, numb to his feelings.”

By the time our first session ended, the couple had interrupted, contradicted, debated, refuted, retracted, invalidated, and contested one another’s way of seeing things.  You might think that given the confusion in this couple’s dialogue, the first order of business in their therapy would be detailed analysis and working through of basic communication patterns. However, I sensed an ‘elephant in the room,’ something important that was not being identified or acknowledged. With this in mind, I encouraged the couple to continue to see me together in couples sessions, as well as each seeing me separately in individual sessions.

The ‘elephant in the room’ revealed its tusks and trunk almost immediately in the one-to-one meetings. Ginette and Phil, in their early-thirties, had not had sex together since the second week of their three-year relationship. Neither had they talked about the subject.

His back story: Phil had experienced sexual abuse in an on-going relationship with a babysitter between the ages of six and ten. After a period of compulsive and sometimes reckless sexual experimentation as a teen, sexual activity with others became linked to feeling out of control, vulnerable, and frightened. Between early college days and meeting Ginette at age 28 he retreated into a solitary, masturbation-only, sex life.

Her back story: Ginette had a history of feeling exploited and demeaned in sexual encounters with men prior to meeting Phil. She explained that Phil’s downplaying of the importance of sex was, at first, attractive to her because it “meant that he wanted to be with me for who I am. His caring for me, without the usual focus on our sex life, was welcome.”

One of the things that initially comforted him, and then cemented their relationship, was the fact that Ginette placed no sexual demands on Phil.  An undercurrent of anger now permeated their relationship. The lack of sex between them was, as if by tacit agreement, neither acknowledged nor discussed.

Once they began talking about sex with me, each partner confided feelings of inadequacy and fear. Each told me that without making progress in this area, they felt that their relationship was doomed.  

I asked each privately, “How do you feel about voicing these feelings and fears in a couples session?” Both agreed, when alone with me, that they would be willing to do that. I assured them that their decision to take this step—participating in a dialogue about their sexual feelings and history—could help.  I validated their courage in moving forward with this.

In addition to our therapeutic conversation, we employed sensate focus, an exercise  developed by Masters and Johnson, that is popular with sex therapists, and a central element in many sex therapy treatments. The multi-session exercise is flexible enough to be used to achieve many different objectives. The first session is often conducted in the therapist’s office and its purpose is to convey the structure and expectations of this work. Subsequent follow-up is  typically conducted in the partners’ home.

The sensate focus experiences typically start—with a couple that wishes to improve their sexual relationship in any of a variety of ways—by having partners take turns touching one another; that is to say, one partner at a time does the touching and the other receives touches. The partner being touched communicates what they like or prefer and what they do not like.

Sensate focus commonly moves along a continuum from non-sexual to actively sexual encounters. In the first sessions, touch of genitals or breasts is off limits and partners are usually clothed.

Layered into the touching are opportunities for partners to express, in addition to feelings, their associations to what they feel.

As it turned out, after the fourth sensate focus session Phil communicated to me and Ginette that he felt overwhelmed. He wanted to continue sensate focus at a future time but, for the moment, requested a referral to a trauma therapist to get help with the unresolved feelings and associations stemming from the childhood sexual abuse he had experienced. He wanted to feel motivated to succeed at sensate focus but felt despairing.

Phil began seeing a therapist who specialized in treating trauma with whom I communicated—having obtained Phil’s written permission—so that we could coordinate the couples and trauma work.

After approximately the fifth month of our couples work, Ginette reported that their arguments were becoming less frequent and less intense. She described a new willingness, on Phil’s part, to  try new foods.  I asked him what he thought had prompted this change and he replied, “I don’t really know. I think I got curious about doing things differently.”  

I made it my business to validate this development. I responded, “Allowing your curiosity to unfold is an achievement.  Being curious is very similar or, in some situations, the same as being open. What do you think about that?” He replied, “That’s a good thing.” He smiled. I wondered how often, if ever, anyone had complimented him on his being open before.

Along with confirming Phil’s ability to change—and I found opportunities to do the same with Ginette–I was trying to model, for both partners, ways they could be a source of validation for one another.

Couples sessions with this couple are on-going and, depending on how things develop, a continuation of sensate focus work is possible. The partners are able to share physical affection at times and each feels guardedly optimistic about working out a more satisfying sexual connection together.

[Note: this clinical vignette is based on combined treatments of real couples. Names and identifying details have been changed to protect confidentiality]

There is a myth in the culture that sex therapy is exclusively concerned with bringing about behavioral change through the application of specific techniques—sensate focus being one.  Most people do not associate sex therapy with sensitive exploration of the meanings of their clients’ behaviors. Yet many cutting edge sex therapists do target the meaning and underlying emotion that influences sexual behavior for exploration in their treatment of couples.

A second myth in the culture holds that couples therapists focus exclusively on interpersonal issues—such as helping partners to improve their ability to identify and express their feelings—and in the event that the issue of sex becomes central to the treatment they refer clients to a sex therapist.  That pattern does occur. Yet more and more, couples therapists are gaining expertise and experience in helping couples work on sexual difficulties. 

Further related readings:

Want to focus on a way to improve communication between you and your partner? 

Do you understand what emotional safety is and how to build it into your relationship?

Are you dealing with explosive anger in your relationship?


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