Psycho-Sexual Psychotherapy

In some ways, sex has become a specialism within relationship counselling, so 
psycho-sexual therapists tend to do a specific piece of work around sexual 
dysfunction. Lack of desire isn’t necessarily a dysfunction and it crops up in 
relationships all the time, but clients with sexual problems may be seen as fitting
 into a slot, where a psycho-sexual therapist with special training deals with them.
 Actually I think there should be more training in counselling for all counsellors to 
work with sexuality. They all need more training on working with the sexual side, 
because it’s so basic. It always surprises me how counsellors sometimes find it
 difficult to broach the question of sex with their clients. It mirrors what happens
 in growing up. Like most people, counsellors can find it very hard to talk about 
sex and give permission to clients to talk about sex, because of their own difficulty.
 In a lot of cases, it becomes something we might need to get back to but don’t…
It’s the last bit that’s talked about. Again, thinking of when kids are growing up, 
it’s often the bit parents may dread having to talk about with their children.

Trivialization

This inhibition holds people back, and yet the only alternative model I can see goes 
to the other extreme – the American idealization of sex. There is a programme on 
TV called Sex in the City, with a self-obsessed thirty-year-old woman talking about 
sex in such a trivialized way, that it is going to the other extreme. I don’t know
 which is worse, over-talking about sex and trivializing it, or not talking about it and
 making it secretive. The balance must be somewhere in the middle.

Specific Sexual Difficulties


Some of the work I do is with couples who have a good relationship but who have 
a specific sexual difficulty, which is not putting pressures on the relationship. They 
have a specific sexual difficulty, such as erectile or ejaculatory difficulties in men 
or vaginismus in women, which is very common in Ireland. Disorders of desire
 would often put a relationship under pressure – different expectations, different 
sexual appetites. In a whole long period of the cycle of a relationship, there are 
bound to be appetite differences. These can be very interesting ones to work with 
because it involves working much more with a psycho-dynamic framework,
 whereas with specific sexual dysfunctions, one of the most effective ways to work 
is a behavioural treatment programme.


Forming a Hypothesis


I use my counselling skills and theory in the assessment, in the history taking and 
the information gathering. I will assess a couple to try and determine whether 
psycho-sexual therapy would be appropriate for them, to rule out other difficulties
 in the relationship or where a particular difficulty is more urgent or needs to be 
dealt with before the sexual side. I also check out any medical or physical causes
 which I might be able to work with in a limited way but wouldn’t necessarily be able to change the actual physical behaviour. Then I go on to take a more detailed 
history with the two people as individuals, going back over their lives, looking at 
their family upbringing, where they came in the family, the type of sexual messages
 they got in the family, how important religion was – all the things that would
 determine attitudes to sex – plus schooling, relationships, any signs of traumas like
 sexual abuse or other types of difficulties in their family of origin, and so on. Then
 I look at their current relationship, giving them a chance to talk about the positives
 and negatives, and whether it is a good enough relationship to work on the sexual
 side. It’s quite a structured interview involving a booklet of specific questions.
 Then that gives me a chance to put together a sort of hypothesis around the 
predisposing factors going back to family of origin, upbringing and messages, to 
the precipitating factors in this particular relationship and the maintaining factors -
 why it is on-going. Then, with that hypothesis, I have something to go back and
 offer the couple with an understanding of where their problems are coming from
 and whether I think the way I work would be appropriate.

Behavioural Work


The work is largely behavioural, it’s changing and re-learning sexual behaviour in
 a different way. It’s giving the couple very specific tasks to do at home and the 
therapeutic process is in their doing those tasks and then coming back and giving 
the feed-back about what was good about it, what they learned about themselves,
 what they learned about each other. I often say it’s a bit like an exercise
 programme, in that if it works well, it motivates them to want to go away and get 
a bit further. It will start off with non-sexual behaviour because very often what 
people need is a chance to slow down, to learn to relax. Certainly one of the most 
obvious things around sexual difficulties is not having time – not putting aside a 
special time. So the programme might enforce that you need to spend an hour
 lying naked on the bed just touching each other – that is huge in itself, if they can
 actually do that. They might have difficulty being able to concentrate on it, but in 
fact once they master that, they realize that they have been missing out on a lot of 
things. It really is super working with couples who can fit that kind of programme.
 Of course, it doesn’t suit all couples, but with a specific dysfunction where the goal 
is very clear, for instance, if penetrative intercourse has never taken place, it’s a
 great way of working. It’s very measured, and if there are any blocks we can deal
 with them when they come up. Having the background information is useful so that when a block comes up we can go back and look at what it might be about. It 
may go back to family attitudes or the strong mother figure, for example, might be 
there, at the end of the bed almost. Sometimes you can circumvent it totally and
 you can just get straight to changing the behaviour. It’s very rewarding work 
because I am using both my skills of being able to change things behaviourally plus 
the psycho-dynamic element.

Your Own Sexuality

The couple will have joint tasks, and they will have separate tasks as well. For
 example, a woman who has very negative images about her own body needs to feel comfortable with her own body before she can share it with a partner, so she’ll be
 on a programme of learning about her own body that will be a step ahead of what 
she is doing in the joint sessions. Each programme will be tailor-made to suit the 
particular client’s needs. In fact all clients would be doing something for 
themselves as well as something in the joint shared tasks. Most teachings are that 
sex is something that takes place between two people, and therefore seems to be
 only a shared concern, but it’s not. You need to be aware of your own sexuality. 
Men particularly respond very well to this. While they may have had permission
 to masturbate – more maybe than females would – it would be very much seen as a 
physical function with a very specific goal; whereas if they take time to relax and 
to find out what’s pleasant and how they can really enjoy what they’re doing, they
 learn a huge amount too about their own bodies and that reduces anxiety and 
develops self-confidence.

Differences Between Women and Men

Quite a problem, though it may seem stereotypical, is that the man feels the couple
 don’t have sex enough and the woman feels they have it more than she wants.
 Behind that, what they’re really saying is that they’re not communicating, they are 
saying something about not having good enough shared time. For man it’s quite
 natural that his way of showing love is through having sex. He may not need all
 the build-up-to it, the meal out, the flowers. Of course, some men do, or the roles 
might be reversed, but more often than not it seems to me that, in the old saying: 
’men have sex to communicate and women need to communicate to have sex’. The 
woman likes to be talked through the whole thing and has to feel right, that the 
whole build-up has set the tone. Very often, it’s much more emotional thing for
 women, so that all those things have to be right – whereas men might have crashed 
the car, lost their job, had an argument with somebody and still feel like being 
sexual because that’s their way of communicating, the non-verbal communication. 
So really there is definitely a male and a female way of looking at things. Men
 seem to be much more aware of their own physical sexual responses, whereas for 
women it seems to be much more tied up with more complex issues. Even if you
 think of the plumbing, a man’s penis is visible; but for a woman, all her sexual parts
 are inside and hidden. A girl is not usually encouraged to look at her genital area,
 whereas a boy has to pull back his foreskin and make sure it’s clean, and all those
 things. That difference must have huge impact on how they actually see the sexual
 act and being sexual.

Male and Female Sides


The sexual relationship in a couple will generally mirror the general relationship
 and as a couple counsellor, I would normally work on the premise that if you work 
on the general relationship, then you hope that the sexual side will start to reflect 
the positive changes in the general relationship. If it dosen’t, then it needs to be 
addressed in a more behavioural way. Sometimes working on the behavioural side
 brings up blocks that you can then work with psycho-dynamically. I have sat with
 couples sometimes where I just haven’t been able to decide whether to work on sexual relationship or on the general relationship. I’ll sometimes check it out with 
them, and say we can go either way here. They’ll often choose the sexual side,
 because they see the clear goals and the shorter process, and it often works that
 way. The couple themselves might differ about which way to work, and the man
 might believe that everything would be good enough if their sex was better, 
whereas she’d be against having more sex till everything else is better. There is an 
interesting dilemma there, and I think gender issues come into it, because I do tend
 to identify with the woman and think that if he did spend less time at work and 
more time at home, relieving her of her traditional motherly chores, maybe she
 would feel more sexual. And yet, he’s saying, that if she was more of a lover, he’d 
enjoy being with her more and give her more time. Again there are different ways 
of looking at it, the male and the female perspectives. I always check out with a 
couple about how they feel about the fact that I am a female, because there are
 times when I’m bound to identify with women’s issues, and the couple are likely to 
assume that I will. All I can do is to acknowledge that I’m aware of the male side,
 and of my own maleness as well, and that I would hope to bring out the maleness 
in the female and the femaleness in the male. The male qualities and the female 
qualities have to come out in both of them.

Intimacy


When people come to me for psycho-sexual therapy, it’s frequently because they
 are not having sexual intercourse. Often when we look behind that, it means they 
are not having intimate, close relationships. A close relationship doesn’t have to 
include sexual intercourse all the time, but it does have to be a choice. Being able 
to have sexual intercourse is part of the goal of therapy, but not necessarily the
 whole goal. I suppose it is one goal that is easy to work towards and certainly 
couples often choose to set goals around sexual intercourse. Sometimes I will
 challenge couples about this, but it’s very much working against the tide because 
sex on TV and films is all about sexual intercourse, and not about intimate touching
 or kissing. To quote Germaine Greer: ‘there’s thousands of ways of making love, 
but only one way to have a baby’. There are lots of ways of expressing our 
sexuality and enjoying our sexuality as a couple. Sexual intercourse is only a part
 of it all and is actually only necessary for fertilization. I often think that is a 
message that really needs to be hammered home to teenagers – that it’s not being
 sexual that’s wrong, it’s the actual sexual intercourse which may be harmful in 
terms of pregnancy and infections and so on, if there is anything harmful. But there 
are lots of ways of showing one’s sexuality, of feeling sexual, of enjoying a positive
 way of looking at sexuality.

Being Sexual Together

Very often wanting to have a baby will be the determining reason why a couple are
 actually prepared to do something about their ‘bad’ sexual relationship. In
 principle. I wouldn’t work with a couple only for the goal of a pregnancy. In fact,
 while they’re in therapy, I don’t want a pregnancy. They need to think about
 contraception because one of the spin-offs might be that they can get pregnant, but
 that’s not the core reason to be sexual together. With some couples where religion 
is still very important, there might be a strong belief that sex is only to procreate
 and then I need to check out my own values – it can be quite demanding from that 
point of view. From a practical point of view, if a woman becomes pregnant, it
 interferes with the programme. For sex therapy to work, it has to be a prime
 motive, and you need to have the time to learn it. I would also maintain that my
 role is to give people permission to be sexual, not just for procreation. However,
 if I did see a couple that only wanted sex for procreation, I wouldn’t want to think
 that I was so rigid that I couldn’t work with it. Certainly the learning to be sexual 
together without penetrative intercourse being the goal is a lovely pathway to work 
along. People may have got into a relationship early on where it was good enough 
for both of them and then had babies and developed their own lives – the sexual
 side can just go off balance totally, and it is increasingly hard to talk about if there
 are other difficulties in the relationship. It just snowballs, so that by the time they
 come to us, there may be no sexual communication at all, or it is just so bad that 
neither of them is feeling good as an individual, never mind as a couple.

Self Esteem


I sometimes think that you can by-pass working on the other sides of self-esteem
 if you can set up a good enough sexual self-esteem. It’s a very profound part of
 ourselves. Sometimes clients have been in relationships that haven’t worked
 because they haven’t been able to be sexual – for example, a vaginismic woman
 whose muscles clamp up and she hasn’t been able to have a sexual relationship, and
 she’s devastated and terrified to get into any relationship… or the man losing
 erections out of anxiety and never being able to have a sexual relationship. There
 is a vicious circle of decreasing confidence that pervades all aspects of their lives. 
So you can work with the sexual side and develop their self-confidence through 
their own sexual awareness. And they really flourish, they can blossom even
 though you may not be ‘fixing’ a specific sexual problem.


Individual Work


Working with an individual is slightly limited in that you can’t guarantee an 
individual that they will have a good sexual relationship, but you can give them
 more understanding of themselves and understanding of the opposite sex. The 
information, showing them how the body works, how it goes through stages of
 arousal, how different women are from men, what they have in common, and all
 that knowledge, will improve their self-confidence too. I suppose that working
 with an individual is more like sex education. I would still set exercises for an 
individual – for instance if it was a woman where vaginismus was evident, she 
probably won’t be able to use tampons, she will never have explored with her own 
fingers, so we can work on a programme towards that. For a male who maybe 
ejaculates too quickly or can’t keep his erections, it usually isn’t a problem in
 masturbating but through masturbatory techniques, learning to slow down, learning 
to focus more, either to fantasize or to concentrate on what he’s doing, he can feel 
more reassured. Certainly, while obviously I can’t prove that it’s because the therapy was a success, individuals rarely come back with a couple problem. It is a 
good chance for them to learn something about themselves and to discover that 
therapy can be a positive experience.

Viagra


Men sometimes attend here on their own, convinced that it’s their problem, a
 physical problem that is only theirs. They are quite surprised when I say that I’d
 like to hear their wife’s side. This is something that is coming up now with Viagra.
 Men go to their doctors and they ask to be on Viagra. If they’re lucky and have a 
good GP, he will ask how the man’s wife feels about it. The men often think, what’s 
it got to do with her? And that’s where I really think that there needs to be a more 
integrated approach to sex and to sexual difficulties. Doctors need to see that there 
is a role for people who understand the relationship dynamic, as much as
 counsellors and therapists need to understand that there is also a medical or a
 physical side – it’s not either/or, this is all physical, or all psychological: it’s very 
often likely to be a bit of both.

The Fun-Loving Side

Clients feel desperately isolated because they can’t talk about it. A lot of couple
 counselling referrals are from family and friends, but people don’t find it so easy to 
talk about having a sexual problem. Often they haven’t spoken about it and they’re
 convinced that they are the only person with this problem. There is an awful lot of 
reassurance needed, starting off with the permission given to explore, to express 
their feelings, their fears around being sexual, which is very often such a relief. A
 lot of humour is used too – I notice that when I work with psycho-sexual clients,
 there’s a lot more humour, a lot more bantering and it has a light touch. I think that 
sex is bringing out the child – bringing out the fun-loving, spontaneous side of a 
person. Sometimes in a couple, one person holds the parenting side (“we
 shouldn’t”, or “it’s not right”, or “you mustn’t”) and this takes away from the 
spontaneity that might have been there when the couple were first living together,
 the more playful or child-like need. That’s where he becomes adamant that they
 need sex because that’s a way of being playful, whereas often for the female, the
 parent side is coming in to say “No” and has more rules around it. Maybe women
 have more rules about sex than men do – that it has to take place in the bedroom,
 at night-time – whereas men would tend to want to experience more. Maybe it
 reflects responsibilities in general between men and women. Very often when a 
couple say they don’t have much sex at home, and I ask about when they go away
 for weekends or on holidays – oh, no problem then! They are getting way from the
 house, getting away from the parental model.

The Spectrum of Sexuality


One of the areas we look at in the history taking will be their own feelings around 
same-sex relationships, whether they’ve ever thought about it themselves, whether
 they’ve ever had any same-sex relationships. I don’t work with teenagers but I
 imagine it would be a hugely difficult area for teenagers whether they’re ‘normal’ – a very important stage. Certainly from my experience and from hearing about
 other people working with gay couples, the difficulties are still the same. It’s a
 totally different problem if, within a heterosexual relationship, one partner is
 moving into being gay. I think that there is actually a huge grey area of bisexuality 
too, which is underestimated and that, on a spectrum of life, people will move in 
and out of the spectrum, towards same-sex relationships and then back to
 heterosexuality, more than is commonly thought. For example, at certain stages of 
life I think that women often worry that they might be lesbian because they find
 that they are very attracted to and feel close to other women. Again, it’s about 
permission to talk about it. There is no absolute or right or wrong way of being
 sexual, but it’s about being able to talk and have permission to look at it from lots
 of different angles.

Yvonne Jacobson is a psycho-sexual therapist, couple counsellor and supervisor with Marriage and Relationship Counselling Service, 24 Grafton Street, Dublin 2, Phone: 6799341