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In A. Rambo, C. West, A. Schooley, & T. Boyd (Eds.). (2013 ). Family therapy review:
Contrasting contemporary models . New York: Taylor and Francis.
Relational Sex Therapy
Douglas Flemons and Shelley Green
Most clients come to us with the expectation, or at least the hope, that we will be able to
help them contain or cure a problem that they locate inside of themselves or someone else. We
respect our clients and work hard to develop an empathic understanding of their experiential
world; however, we never accept such a request at face value. Problems, from our perspective,
are best conceived not as things that reside inside of people i but, rather, as patterns of
relationship, unfolding through time. Such relat ionships are comprised of interweaving strands of
both intrapersonal experience (thoughts, sensations, emotions, behaviors, images, perceptions)
and interpersonal experience (verbal and nonverbal communications within a couple, a family,
an extend ed family , a group, and so on). ii
If problem s were thing s, they could be isolated and tossed away like so much garbage.
But because problems are relationship s that weave through the experience of those contending
with them , then no such isolation is possible. Relationships are always connection s, so any effort
to purposefully separate from a problem will only serve to create yet another connection to it.
We see this often in our sex therapy work when couples come in, struggling with the after -effects
of an affair. Their desire to put it behind them, to not talk or think about it, keeps it very much
alive. Similarly, clients trying to rid themselves of performance -related sexual problems discover
again and again that they can’t just w ill themselv es not to feel anxiety. If any effort to resolve a problem creates a kind of connection to it, then the art of therapy
is in helping to cre ate connections that are characteriz ed by a comfortable, loose grip —
connections that are able to fade in significance. One way we do this is to bring legitimacy to the
presence of a problem, honoring how it fits into the logic of the clients’ lives. When the problem
stops being an enemy to be destroyed, clients can relax their efforts to rid themselves of it,
thereby allowing it to diminish in significance and wander away on its own. We specialize in
seeing sex -related issues , but this work fits into a more encompassing relational approach to any
concern expressed by an individual, couple, or family (Flemons, 2002; Flemons & Green, 2007).
As the first session commences with Mary and Fred, and we have learned a bit about
their social, family, and professional contexts, we begin to explore their hopes and desires for an
intimate relationship. As we ask about thi s, we also attempt to learn about what they believe is
getting in the way of their intimacy . We learn about the meanings that each of them ascribe to
their intimate encounters as well as to the times when intimacy has not been possible. We also
learn about how they have attempted to resolve this situation, as we assume that the relationship
they have with the problem of “lack of intimacy” will be a particular focus of our therapeutic
involvement .
In the first session, Mary begins to tell us tha t Fred has a lways had an “inexhaustible ”
sex drive. In the beginning of their relationship, she found this incredibly sexy and in fact
bragged to her friends about his desire for her and their dynamic sexual relationship. However,
over time, and especially after the birth of their child, she began to feel oppressed by the
magnitude of his desire. She began accusing him of being a “sex addict,” interested more in
orgasms than in her. Fred o f course took offense at this. His anger, an expression of his hurt,
confirmed Mary’s growing sense that he was uninterested in and incapable of emotional closeness, which led to her pulling away from him more and more. In the last several years, she
has f ound herself rejecting almost all of Fred’s requests for sex. She explains this by saying that
if she “gives in ,” he will just want more and more, and “I will never be enough for him.” She
does worry now that Fred will seek sex outside their relationship; this has heightened her fears
for the marriage, but has done nothing to ease her anxiety that Fred will always want too much
sex from her if she opens the door to any sex at all. She says she loves Fred and deeply misses
the emotional intimacy they once sh ared, but it doesn’t feel it’s safe to initiate sex or to respond
positively to a sex addict .
As Fred listens to this story, he becomes increasingly upset. We ask him how this makes
sense to him and he quickly replies, “It doesn’t! I love Mary and I just need to be able to show
her that physically. I feel completely cut off from her, but I would never force myself on her. She
used to love sex with me; now she wants nothing to do with me. She never initiates, but she gets
mad at me when I try. If I stop tr ying, we will never have sex again, I guarantee it.”
This conversation helps us to understand the dynamics that are preserving Mary and
Fred’s impasse. Mary’s attempts to protec t herself from Fred’s strong sex drive have resulted in
no sex at all; Fred has alternated between angry recriminations, depressed withdrawal, and
vigorous efforts to rekindle their once -active sex life. In doing so, with increasing urgency, he
has unknowingly confirmed Mary’s belief that she will never be enough for him, further
entrenching her “no -sex” position . T heir efforts to control and rid themselves of the problems
they have each located in the other (“he needs to get his sex addiction under control”; “she needs
to thaw her frigidity”) have created painful connections to the problems and to each other.
At this point in the session, our primary goal is to shift the nature of these connections by
acknowledging and respect ing the efforts of both Fred and Mary, making sense of, and thus legitimizing, each of their behaviors wi thin the context of meaning they have created around
their relationship. We comment to Mary on the wisdom of her desire to preserve the integrity of
their intimacy by insuring that they are never reduced to having “empty” or “meaningless” sex;
we also note that while painful for both of them, her reluctance to have sex regularly with Fred
has allowed Fred to feel almost constant desire for her. Although at the moment, that desire is
coupled with anger, clearly the passion remains and can be a starting place for sexual and
emotional intimacy when that becomes safe. We acknowledge as well Fred’s willingness to
openly express his ongoing desire for Mary, and comment on the vulnerability he has shown by
continuing to risk rejection from her. We note that while t his has been painfully frustrating for
him, we believe the openness of his desire and vulnerability creates a beautiful place to begin
exploring what emotional intimacy would look like for them. We recognize that Mary has been
concerned that he has a sex a dd iction, but we are curious how his sexuality will be expressed and
satisfied when it isn’t intermixed with anger, fear, loneliness, and sadness.
Each of them begins to soften a bit as they hear their positions respected and honored.
We then ask Mary wha t it would be like for her to believe that Fred could be intimate without
necessarily being sexual. She says that would be “unbelievable” but that if she could actually see
that from him, she would feel less at risk exploring being sexual with him . We then ask Fred
what he believes this would be like for him. He says that it has been so long since he has felt any
emotional connection with Mary , he assumed she didn’t even want that any more. He had simply
continued to hope that she was at least “human” and s till had a sex drive. The idea that she
wanted an emotional connection with him was much better news than he expected to hear .
As the session ends, we ask Mary to consider what a sexual encounter with Fred might
look like if it were based on a stron g emo tional connection; we ask Fred to think about how he might make space for that emotional connection to grow, as it is clearly something that he values
as well.
This, of course, is a beginning, not an ending. We would anticipate seeing the couple for
as m any sessions as it took for them to begin noticing and negotiating their way through the
changes that are initiated by our inviting relaxed connections between them and between them
and the problems they have identified.
i See Bateson (1972) for his discussion of “dormitive principles,” and Albert North Whitehead
(1925/1953) for what he called the “fallacy of misplaced concreteness” — the “error of mistaking
the abstract for the concrete” (p. 51). ii We never attempt to educate our clients about these ideas, as this would mean telling them how
wrong they are. Our understanding is reflected in our therapeutic choices, in the ways we invite
clients int o alternative approaches to solving their problem.