Head, Heart and Balls

Sex Therapy: A Practical Guide by Keith Hawton, OUP, London, 1985


When couples first seek help for sexual problems they usually feel very vulnerable because they are exposing to a stranger some of the most private aspects of their relationship, and they are having to admit to failure.

The trust and respect that should develop between a couple and their therapist early in therapy is an important influence on how a couple engage in the treatment programme.

Some couples are very dependent on the therapist at the beginning of treatment. This is not necessarily harmful to the therapeutic process. The therapist should encourage the couple to gradually accept responsibility for their problems and should emphasize that the eventual outcome will largely depend on their own efforts.

As treatment proceeds, the solution to problems should increasingly become the responsibility of the couple. During successful treatment, couples become less and less dependent on the therapist until the time arrives when they feel happy to leave the treatment programme.

However, some couples offer profound resistance to this shift, and continually try to provoke an authoritarian response from the therapist, thus emphasizing their dependency and helplessness. Unless this situation is confronted it can prove a major obstacle to successful treatment.

When a therapist becomes aware that the relationship with a couple has developed in this way, several strategies are available, including the following. First, the couple can be firmly reminded of the need for them to take responsibility for themselves and to be prepared to seek their own explanation for, and solutions to, failures.

Secondly, they may need to be reminded of the limited nature of the therapeutic contact (p. 192) as a means of emphasizing this point. Thirdly, for a couple who are sophisticated enough to be able to examine the nature of the situation and relationship, the therapist could avoid being drawn into this situation.

Maximizing Therapeutic Effects and Overcoming Difficulties 155

times when it seems appropriate to allow a couple to be relatively dependent. This may happen, for example, when a couple have had a very distressing experience and require maximum support and encouragement from the therapist.

Some couples form a very different relationship with the therapist, and offer considerable resistance to the therapist's suggestions. It is often one rather than both partners who behaves in this way. This kind of interaction may develop because of excessive anxiety about receiving help.

Another common reason is that one partner feels extremely insecure about his or her sexuality. Refusal to engage constructively in the therapy programme is a means of preventing this insecurity being confronted and explored. The therapist should explain to the couple what appears to be happening, before this pattern has become established.

There are several other important general characteristics of the therapeutic relationship in sex therapy which may contribute to the success or failure of treatment.

These all apply to some extent to any therapy based on psychological principles. We shall briefly consider some ways in which a therapist can enhance the quality of the therapeutic relationship with regard to each of these factors.

Empathic understanding

The therapist should not only try to understand a couple's problems in terms of, for example, causal factors, but should also communicate to the couple recognition of the distress they are experiencing through comments such as : 'I can see how distressing the problem is for you both,' and 'It must have taken a lot of courage to come and seek help'.

Such simple statements provide considerable relief for many couples and may make it easier for them to engage in therapy.

Warmth and caring

The therapeutic relationship should not be distant and cold. The warmth of the relationship can be enhanced if the therapist adopts a generally friendly manner, and comments on events in the life of a couple other than solely those in their sexual relationship. The therapist might enquire, for example, how a special outing went, or how a child is getting on preparing for an examination.

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