Traditional Learnings about Marriage Therapy and Couple Sexuality – 2021
Core Concepts – 2021
OVERVIEW OF INTEGRATIVE COGNITIVE-BEHAVIORAL COUPLE SEX THERAPY – 2021
Individual Psychological/Relational/Sexual History – 2021
Resource: Metz, M., Epstein, N. & McCarthy, B. (2018). Cognitive-Behavioral Therapy for Sexual Dysfunction.
Guidelines for Revitalizing and Maintaining Sexual Desire – 2021
Resources: McCarthy, B. & McCarthy, E. (2020) Rekindling Desire. (3rd edition).
The Crucial Couple Sexual Dialogue: Five Dimensions of Touch- 2021
The core psychosexual skill exercise is to increase awareness of each partner’s preferences for gears (dimensions) of touch. The majority of couples only use two gears- affection or intercourse. They fall into the trap of believing that sex=intercourse. This results in lower levels of both touch and intercourse.
In contrast, this psychosexual skill exercise focuses on five gears of touch (based on a ten-point scale of pleasure/arousal).
First gear: Affectionate touch—this usually involves clothes-on touching, such as holding hands, hugging, or kissing. Affectionate touch is not sexual, but it provides the foundation for intimate attachment. Subjective arousal is anchored at 1.
Second gear: Sensual touch—this involves non-genital pleasuring which can be clothed, semi-clothed, or nude. Sensual touch includes a head, back, or foot rub; cuddling on the couch while watching a DVD, a trust position where you feel safe and connected, cradling each other as you go to sleep or wake. Sensual touch is an integral part of couple sexuality. It has value in itself as well as a bridge to sexual desire at that time or later. Subjective arousal 1-3.
Third gear: Playful touch—this intermixes genital pleasuring with non-genital touch (usually semi-clothed or nude). Playful touch can include touching in the shower or bath, full body massage, seductive or erotic dancing, games such as strip poker or Twister. What makes playful touch inviting is the enhanced sense of pleasure and unpredictability. Playful touch is valuable in itself and/or can serve as a bridge to sexual desire. Subjective arousal 4-5.
Fourth gear: Erotic touch—this is the most challenging gear. Erotic, non-intercourse touch can include manual, oral, rubbing, or vibrator stimulation. Erotic scenarios and techniques are an integral part of couple sexuality providing a sense of vitality, creativity, and unpredictability. Erotic touch can be mutual or one-way. It can proceed to orgasm or transition to intercourse. Subjective arousal 6-10.
Fifth gear: Intercourse—there are two crucial concepts in integrating intercourse into the gears of connection approach. First, intercourse is a natural continuation of the pleasuring/eroticism process, not a pass-fail sex performance test. Second, transition to intercourse at high levels of erotic flow (7 or 8) and continue multiple stimulation during intercourse. Subjective arousal 7-10.
We suggest each partner fill out this chart separately. Then discuss feelings and preferences.
|Touch Type||Current percentage of all touch||Percentage of touch desired|
The purpose of this exercise is to facilitate dialogue with a focus on enhancing sexual desire and pleasure. Sexuality is more than intercourse. The essence of couple sexuality is sharing pleasure—oriented touch. You develop a common language to facilitate communication and embrace a variable, flexible approach to intimacy, touching, sexuality, and intercourse.
Resource: McCarthy, B. & McCarthy, E. (2019). Enhancing Couple Sexuality.
Desire Psychosexual Skill Exercises – 2021
First exercise: Comfort
A first step in healthy couple sexuality is developing a comfortable, non-demand approach to touch and sensuality. How can you enhance sexual comfort? Begin by setting aside at least two occasions for this exercise, one in your bedroom and a second time in the family or living room. Although most of the psychosexual skill exercises involve nudity, this exercise begins with clothes on.
Sensuality involves being receptive to and enjoying non-demand, non-genital touching. Sensuality means touching for its own sake, not as a goal toward arousal, intercourse, or orgasm. Being open to the joys of slow, tender, caring, rhythmic touch is the basis of sexual response and is essential for maintaining desire.
This exercise takes place in your bedroom with clothes on and focuses on nonverbal communication, with the woman as initiator. Traditionally, women have not had permission to initiate sensual or sexual activities. You can initiate in the morning, in the late afternoon on a rainy weekend, or early in the evening. We suggest not doing it right before bed when you are tired and do not have the energy or focus to engage in sensual exploration. Begin by taking a bath or shower and playfully washing each other. Towel dry your partner in a slow, caring fashion, and proceed to the bedroom. Put on clothing you feel comfortable with; it could be pajamas or an informal outfit.
How personalized is your bedroom? Does it have valued mementos? Is it decorated the way you like? Is there sufficient light? Is it a comfortable room to be in? Orchestrate the milieu to increase sensuality. You could burn a fragrant candle or put on music to romanticize the atmosphere. Be sure you are not too warm or cold.
Touch for yourself; do not try to second-guess your partner. Give yourself permission to experiment with a variety of ways to touch, hold, and caress. Use your fingertips, palms, both hands, or only one. Do not limit yourself. Use your legs; rub your body against his; let your lips or tongue explore his body. He can take off as much or as little clothing as you prefer. Some women find they are more comfortable if initially he keeps his eyes closed; others enjoy eye contact throughout. Try it both ways. Which do you find more sensual? Explore and enjoy his body from the hairs on his head to the soles of his feet. Be aware of at least two areas you enjoy touching. Do not be surprised if there are body parts you do not like; this is not Tom Cruise made up to look perfect on a movie screen, but your live partner with a scar on his kneecap, a roll of flab on his midriff, more hair than you like on his back. Switch roles and let him explore your body to redevelop sensuality and comfort.
The bedroom is one thing; being comfortable in the living room or family room can be quite another. Do the second part of the exercise in the next day or two. Since this exercise is done in the nude, ensure that you will have privacy and not be interrupted by neighbors or children. An intimate relationship erodes because of lack of quality couple time. Couples discuss and problem-solve about practical, external problems but take little time for personal, intimate feelings and communication.
Make this your special time. Would you rather talk in the kitchen, living room, or family room? Would you like a cup of tea or glass of wine? Would music in the background enhance or distract from communication? Sit comfortably, facing each other. Nonverbal components of communication—especially eye contact, body posture, facial response, and touch—carry a message as important as words. Is talking enhanced by holding hands, having your arm around your partner’s shoulder, playfully touching your partner’s hands, or caressing your partner’s face and neck?
How do you talk as a sexual couple? Is it comfortable to use proper words or to employ slang? Do you have a private sexual language? Can you share emotional feelings and intimacy as easily as you make sexual requests? Can you discuss what pleasuring and intercourse techniques increase sexual responsivity? To be an intimate couple, you need to be able to discuss both emotional and sexual feelings and preferences.
Share your fondest sexual memory. Take the risk of being vulnerable and discuss how you felt during and after that experience. The only time most couples are nude in the bedroom is while having sex. Being nude, touching, and talking comfortably in the living room, den, or kitchen can be a liberating experience. Enjoy the freedom and openness of non-demand pleasuring and talking while nude outside your bedroom.
Is it helpful to touch while clothed in the bedroom? How do you feel about touch while nude in the living room? Touching both inside and outside the bedroom is an excellent way to nurture sexual desire. Conclude this exercise by making requests and suggestions to make your sexual relationship, especially initiating sexual encounters, comfortable and inviting.
Second Exercise: Couple Sexual Attraction
Sexual attraction is not static. It is not a “magic” quality that you either have or you don’t. Sexual attraction is a dynamic process between two people that waxes and wanes. Attraction is affected by myriad factors. Physical attractiveness is but one factor; it is certainly not the only one or even the most important one. Turn-ons vary for each couple, contrary to the media myth that there is a perfect, youthful body type that turns everyone on or a sexual technique that works for everyone. You can increase sexual attraction for each other and for each other.
Start this exercise clothed in a comfortable, private setting conducive to communication. Set aside at least 45 minutes that could extend 2 hours if you wish. Present yourself in a manner that you feel is attractive; choose an outfit you particularly like, shave, fix your hair, brush your teeth, dab on your favorite perfume or after-shave. Do the kinds of things people do to get ready for a date but usually don’t do in a relationship they unfortunately have taken for granted.
Discussing attraction can be awkward so we suggest a semi-structured communication exercise. Let the woman begin. Tell your partner at least five (and up to 15) things you find attractive about him, being as clear and specific as possible. You might find his slightly balding head attractive or like his new glasses, the way he jogs, his arms and hands, how he looks in a suit and tie, his laugh, the tenderness he displays when putting the children to bed, how he handles a household emergency, the look in his eyes before initiating sex, how responsible he is about paying bills, the sounds he makes when he has an orgasm, his newfound skill at cooking, the muscles of his legs, how caring he was when his aunt died, how enraptured he is with classical music yet can still enjoy country, the way he orally stimulates you, how generous he can be with his time when someone needs help, his penis when he is aroused, how he puts up a tent when you go camping. Be honest in disclosing what you find attractive—physically, sexually, and emotionally. He listens and acknowledges his positive qualities; he does not shrug them off or minimize them.
Now pick one, two, or at the most three things you want him to change that would increase his attractiveness for you. Do not just state the problem. Make a specific request for change. Say, “I’d like you to cut your hair one-and-a-half inches shorter and comb it at night,” rather than, “I don’t like your hair; do something about it.” Say, “When you initiate, kiss me and stroke my arms before you touch my breasts,” not, “you come on too strong.” Say, “Talk and play with each child individually,” rather than, “I get upset because you never pay attention to the kids.”
Let us suggest two guidelines about requests. First, request things your partner can actually change. For example, if he is 6 feet tall, you can’t say you are attracted to men over 6 feet 5 inches. You can suggest that he carry himself more positively by walking tall and forcefully. Second, frame this as a “request” not a “demand.” Your partner can agree, modify, or say no, and there will be no punishment or negative consequences. A healthy relationship is based on acceptance and a positive-influence process, not demands, ultimatums, or threats.
Switch roles and have the man share what he finds attractive about his partner. You may like the way she wakes you with a kiss, that people view her as super-organized, how she purrs when her back is scratched, that she can fix broken items, the shape of her breasts, what a good athlete she is, how wet she becomes when she is aroused, how she sings to the children before bedtime, how seductive she looks in a see-through nightgown, how she cheers you up after a bad day, how her nipple gets erect after you lick it, the way she pads around the house in bare feet, how attractive she looks when dressed for a night out, the care she takes planning family picnics, the effort she makes in picking clothes for the children, how she moves when she is sexually turned on, how assertive she is with neighbors. What is special about your partner that you value and find attractive?
In addressing the one to three requests for change, feel free to make them either sexual or nonsexual. What will increase your partner’s attractiveness for you? Remember, it is a request, not a demand. Say, “I want you to sit with me once a month and plan big purchases,” not, “Your don’t care anything about money except spending it.” Say, “I want you to try orally stimulating me when I’m standing,” not, “Stop being so hung up about oral sex.” Say, “I wish you would initiate by stroking my chest when you wake up on a weekend morning,” rather than, “You never initiate.” Remember, these are requests for things your partner can change, not things your partner can’t change. In terms of response to requests, she can accept, modify, or say no. A request connotes acceptance without a threat of negative consequences. A demand says I don’t accept you and if you don’t agree to these changes there will be negative consequences. This is especially important in terms of sexual scenarios and techniques. There is no place for “intimate coercion” in your couple sexuality.
After discussing the process of maintaining and enhancing attraction you can end the exercise or engage in touching, which could lead to intercourse.
Third Exercise: Trust and Intimacy
A major value of your intimate relationship is trusting that your partner is on your side, has your best interest in mind, and would not do anything intentionally to hurt you. Trust is a central ingredient in your intimate relationship. Communicate how you feel about the level of trust in your relationship, both in the past and at present. If it is not as high as you want, what can you do to increase trust? What “trust vulnerabilities” does your partner need to be aware of? What can each of you do to increase trust? Trust is not something that occurs automatically; it takes time to allow feelings of trust to develop and be expressed both verbally and physically.
You can establish a “trust” or “safe” position where you feel cared about and secure. This involves being nude in the privacy of your bedroom. Personalize your bedroom. Have a special light that gives a warm glow, a favorite erotic book or love poem by the bed-stand, thick curtains so there is privacy, a full-length mirror to increase visual stimuli. Do you enjoy hanging out and talking in your bedroom? Caress your partner’s face and recall a time when you felt vulnerable and your partner was there for you.
You have experimented with non-demand positions to increase receptivity, sensuality, and responsiveness. Develop a safe or trust position that facilitates feelings of intimacy and attachment. You might lie side by side holding each other, your bodies touching from the tips of your toes to your forehead. Try a position where he is sitting up with his back supported and you are lying with your head on his lap while he strokes your hair. Another trust position is lying next to each other, holding hands and being silent. Some couples use a “spoon” position where you lie with your chest against his back, put your arms around him, and breathe in unison with his rhythm. In another position, he lies on his back and you nestle your head against his shoulder, your faces close so that you can maintain eye contact. A trust position some couples value is sitting facing each other, keeping eye contact, putting one hand on your partner’s heart. What adds to your sense of trust? Body contact, eye contact, being comfortable, feeling secure, being enveloped, talking, silence? Find at least one position where you feel intimate and trusting. Develop your unique trust position that establishes a solid base of physical security and connection.
In subsequent sexual experiences, when you become anxious, depressed, frustrated, or angry, utilize this trust position as a “port in the storm.” Rather than ending a sexual experience on an anxious or frustrated note, switch to your trust position as a way of anchoring yourself. You can choose whether to continue the exercise or end the experience from your trust position. This helps you remain connected and realize you can depend on each other. You trust you are an intimate team and your partner “has your back.”
Fourth Exercise: Create Your Sexual Scenario
When a relationship is new, there is strong anticipation of being sexual even if the quality of sex is not particularly good. Sex serves as an affirmation of your desirability and desire to be a couple. Romantic love and passionate sex energize a new relationship and make it “magical”. It is the thrill of sexual exploration as well as energy that goes into making your relationship exciting and erotic.
After the initial romantic love and passionate sex phase has dissipated, it takes most couples 3-6 months to develop a couple sexual style that is intimate, functional, and satisfying. Part of the process is crafting couple sexual scenarios, the focus of this exercise. As a reminder, you are not a machine, so it is normal in the best of couples to occasionally have mediocre or negative sexual experiences. A sign of a healthy couple is your ability to accept and not overreact to negative experiences and to turn toward each other as intimate and erotic friends.
What do you value most in a sexual experience? Each individual develops their sexual scenario. Let the women introduce her scenario first. At another time the man can develop his.
When is your best time to be sexual? When waking up? After the morning paper? At noon? Before or after a nap? Before dinner (sex as an appetizer) or after dinner (sex as dessert)? In the evening? Most couples have sex late at night; but few people say this is their favorite time.
How do you set your preferred sensual and sexual mood? Do you listen to music, go for a walk, talk, light candles, drink wine, take a bath, have 15 minutes of time alone and then come together, meet your partner at the door and lure him into the bedroom? As a preclude to being sexual some couples enjoy doing together things like shopping, working in the garden, going for a run, or sharing feelings. Many couples start touching and playing in the living room or den and do not move to the bedroom until both are turned on. Others prefer to start in the privacy of your bedroom. What is your favorite way to begin a sexual scenario? Remember, there is no right or wrong; it is your preference.
Once the scenario is under way, what is your favorite script? Do you like to take turns, or do you prefer mutual stimulation? Do you verbally express sexual feelings, or would you rather let your fingers do the talking? Do you prefer a slow build-up or do you begin intercourse as soon as you are aroused? Do you like multiple stimulation or one erotic focus at a time? Do you make use of all your senses—touch, taste, smell, hearing, sight—or does one element (observing your partner’s arousal, hearing soft moans, smelling sexy perfume, feeling sexual movement) turn you on? Develop the sexual scenario the way you want. Your partner is open to your guidance.
How do you transition from pleasuring and eroticism to intercourse? Some people prefer to begin intercourse at moderate levels of arousal, but many prefer not transitioning to intercourse until they are highly aroused. Do you want to initiate the transition, or do you want your partner to? Who guides intromission? Do you prefer multiple stimulation during intercourse rather than a sole focus on thrusting? What is your preferred intercourse rhythm and type of thrusting (short, rapid thrusting; slow up-and-down thrusting; circular thrusting; changing intercourse positions)? Do you prefer being orgasmic during intercourse, or do you feel greater pleasure being orgasmic during erotic sex?
How would you like to end the scenario? Afterplay is the most neglected element of the sexual experience. Your needs and desires are important here, too. Do you like to lie and hold, sleep in your partner’s arms, engage in playful tickling, have a warm kiss, take a walk, read poetry, nap and start again, talk and come down together?
When it is his turn to create sexual scenarios. She is free to design her own, which could be similar to or totally different from hers. Many men fall into the trap of trying to outdo their partner. Sex is neither a competition nor a performance. You are not clones of each other. Be yourself-develop an initiation, script, and afterplay scenario that is special and satisfying for you.
Resource: McCarthy, B. & McCarthy, E. (2012). Sexual Awareness (5th edition).
Exercises that Act as Bridges to Desire – 2021
First Exercise: Sexual Dates
You set dates to go to a movie, play bridge, go to dinner. What about sexual dates? Setting times for a sexual date need not be formal or awkward. It can be romantic and fun. A sexual date allows you to anticipate being sexual as you would anticipate a sporting event or a play.
As with other exercises, we suggest taking turns. Divide the week into two parts – for example, Saturday at 5 p.m. until Wednesday at 9 a.m. for the woman to initiate and Wednesday at 10 a.m. until Saturday at 4 p.m. for the man. This is the “ping-pong” system of initiation. After your partner initiates, it is your turn. If your partner did not initiate during this time, it becomes your prerogative to do so. The commitment is for each person to make at least one initiation per week.
When it is your “ping,” set the time, place and sexual scenario. Do it your way. Do not try to second-guess your partner or compare your way with theirs. Make the initiation as inviting as possible. Be creative in your invitations. Examples include cooking a special dinner with sex as dessert, cuddling for half an hour in front of the fireplace before starting genital stimulation, calling before you leave work to suggest a sexual date, surprising your spouse by joining him in the shower, putting on your favorite music, bringing lotion to bed and spending 15 minutes giving your partner a sexual massage. Men can and do initiate creative sexual dates, contrary to the myth that romantic, seductive initiation is the woman’s domain.
The woman becomes comfortable with her ability to initiate. If sexuality is to remain a vital part of your relationship, learn to be open to creating and crossing bridges to sexual desire. Initiations could include waking your partner in the morning ( or from a nap or in the middle of the night) by sucking on his penis and putting him inside you. You can share old pictures or letters to set the mood, rent your favorite R- and X-rated movie and fast-forward to the sexiest parts, ask your partner to put the children to bed and meet him in the bedroom where a scented candle is burning and you are wearing his favorite corduroy shirt, get a babysitter and plan a hotel weekend in the city to roam through art museums, eat Italian food, and have sex without worrying about interruptions.
We cannot stress enough that sex does not just spontaneously happen. It requires thought, planning, and setting aside couple time. Approximately 80% of sexual encounters are planned or semi-planned. Enjoy spontaneous sexual experiences when they do occur, but don’t fall into the trap of believing that spontaneous sex is more genuine than intentional sex. Sexual dates are important bridges to desire.
Second Exercise: Overcoming Discrepancies in Sexual Desire
If couples had to wait until both partners were equally desirous, frequency of sex would decrease by at least half. It is the norm, not the exception, for one partner to desire and initiate sex more than the other. What poisons sexual desire is anger about nonsexual issues (which need to be dealt with outside the bedroom) and resentment over feeling sexually pressured. Under no circumstances is it acceptable to physically force or verbally coerce your partner to engage in sex. “Intimate coercion” has no place in your relationship. Sex is best when it is voluntary and pleasure oriented. Pressure and coercion lead to alienation and anger, and the ensuring resentment poisons sexual desire.
What can you do when one wants to have intercourse and the other does not? This exercise uses the “yes/no” technique to deal with desire discrepancy. Our culture socializes men to always say yes to sex, so the woman is stuck in the role of sexual gatekeeper. In fact, it is perfectly natural, normal, and healthy for men to say no to sex, and on occasion more than 80% have.
In this exercise, each partner has to say at least one “no.” The focus is on expanding your repertoire of what is acceptable when there is a desire discrepancy. The quality of the intimate experience is more important than frequency of intercourse. Sexual intimacy is reinforced by caring about each other’s feelings and sharing pleasure rather than perceiving sex as a goal-oriented power play.
This exercise requires a number of cycles rather than one structured experience. Each person will have several initiations. The initiator speaks from an awareness of what she wants – to feel desirable, attractive, and valued; unpredictability and playfulness; orgasm; time to be alone before erotic contact; multiple stimulation before and during intercourse; affectionate touch. Ask for and initiate activities you enjoy. The woman is aware that her partner will say no at least once and preferably more than once. This allows them to practice negotiating sensual and sexual alternatives. He will not just say no but will offer an alternative that both suits his fancy and addresses her needs. For example, if she wants a whole body massage as a way of meeting her needs for sensuous time before erotic contact and he is lukewarm toward the idea of a body massage, he offers to draw a bubble bath or suggest building a fire and talking and touching in front of the fireplace. If her initiations have been co-opted because he is action oriented, she can offer a number of feeling-oriented, non-intercourse ways to intimately connect.
This illustrates the major struggle in desire discrepancy. The woman had a right to request a range of sensual and erotic experiences without her partner contending that only intercourse is real sex. She can suggest manually pleasuring him to orgasm, that they engage in non-genital pleasuring, that he pleasure her and she’ll decide if she wants a mutual sexual experience, that they have oral sex, that they share an activity (going for a walk, playing golf, going shopping) before being sexual, that he stimulate himself while she holds him. He can say no to suggestions he is not comfortable with, but he needs to say yes to at least one of her alternatives. There are many emotional, sensual, playful, and erotic ways to connect that may or may not evolve into intercourse.
A common male trap is using sex to meet nonsexual needs. In extreme cases, men use sex like alcoholics use alcohol – to deal with emotions from anger to boredom, from excitement to emptiness, from celebration to depression. You can learn emotional coping strategies to deal with nonsexual problems. Sharing feelings is a better way to deal with sadness than having intercourse. Celebrating a merit bonus with couple friends can make more sense than using sex as a reward when your partner is not feeling sexual.
The most common issue is inhibited sexual desire. At the other extreme, some men use sex compulsively to avoid dealing with problems and emotions. Hyperactive sexual desire results in an alienated relationship. Sexual bridges are meant to encourage pleasure and intimacy. Couple sexuality is subverted when sexual initiations carry negative emotions and compulsive sex demands.
The man is urged to personalize his sexual invitations. He is less likely to be distracted by nonsexual factors such as fatigue, hunger, anger, alienation, and anxiety about children. This can be a sexual strength, but it can also be a source of misunderstanding and strife. She complains he wants sex, not her. Making your sexual invitations and requests personal and caring will avert this problem. Sex is good, but not when it’s at the expense of your partner or relationship.
Will the experience of saying no to intercourse and yes to sensual and erotic alternatives resolve all desire discrepancies? Of course not, but it will allow you to stay intimate friends and provide greater flexibility and degrees of freedom in expressing your needs for intimacy and sexuality.
Arousal and Erection Guidelines – 2021
Resource: Metz, M & McCarthy, B. (2004) Coping with Erectile Dysfunction.
Guidelines for Ejaculatory Inhibition – 2021
Resource: McCarthy, B. & McCarthy, E. (2012). Sexual Awareness (5th edition).
Dimensions of Good Enough Sex (GES) Model – 2021
Resource: Metz, M., Epstein, N., & McCarthy, B. (2018). Cognitive-Behavioral Therapy for Sexual Dysfunction.
Guidelines for Female Pleasure, Eroticism, and Orgasm – 2021
There is more written about orgasm than any other area of female sexuality. The good news is that awareness of your “sexual voice” which includes desire/pleasure/eroticism/satisfaction is in the best interest of the woman, the couple, and the culture. The bad news is that sexual performance demands, specifically viewing orgasm as a pass-fail test, increases self-consciousness and reduces sexual desire and satisfaction. Secondary non-orgasmic response is a common problem.
These guidelines empower the woman (and her partner) to value desire/pleasure/eroticism/satisfaction. Female sexuality is first class – variable, flexible, complex, and individualistic, but not inferior to male sexuality. Orgasm is integral to the pleasuring/eroticism process. This approach confronts the performance pressure of having the “right” or “perfect” orgasm as an individual pass-fail sex test.
Resource: McCarthy, B. & McCarthy, E. (2019). Finding Your Sexual Voice.
Guidelines for Enhancing Sexual Comfort and Reducing Painful Intercourse – 2021
Resource: McCarthy, B. & McCarthy, E. (2012). Sexual Awareness (5th edition)
Guidelines – Learning Ejaculatory Control – 2021
Resource: Metz, M. & McCarthy, B. (2003). Coping with Premature Ejaculation.
Extra-Marital Affairs (EMA) T-F Test 2021
Resource: Allen, E., Atkins, D., Baucom, D., Synder, D., Gordon, K., & Glass, S. (2005). Intrapersonal, interpersonal, and contextual factors in engaging in and responding to extramarital involvement. Clinical Psychology: Science and Practice, 12(2), 101-130.
Extra-Marital Affairs – 2021
Resources: Allen, E., Atkins, D., Baucom, D., Snyder, D., Gordon, K., & Glass, S. (2005). Intrapersonal, Interpersonal, and contextual factors in engaging in and responding to extramarital involvement. Clinical Psychology: Science and Practice, 12 (2), 101-130.
Overview of EMA Treatment Model – 2021
Although the treatment program needs to be applied flexibly with respect for individual, couple, cultural, and value differences, it reassures and motivates the couple to know there is a plan and structure.
Resource: Synder, D., Baucom, D. & Gordon, K. (2007) Getting Past the Affair.
Causes of EMA – 2021
Contrary to traditional beliefs about EMA, there is not one cause or one outcome. EMA is an example of multi-causal, multi-dimensional behavior which is influenced by individual, couple, cultural, and value issues.
Among the possible causes of EMA are:
Of course, there are many other possible causes
Dimensions of EMA – 2021
In making meaning of the EMA, the clinician needs to explore and help the couple understand the EMA from the perspective of the involved partner, injured partner, and their relationship.
EMA – Specific Questions – 2021
EMA – Genuine Forgiveness – 2021
Forgiveness is an integral component of EMA treatment, and can be therapeutic whether the couple stays together or not. A genuine apology is very different than the politically correct “I’m sorry and let’s not talk about this again” on one extreme or “I am a bad person, sex is destructive, and what I did is unforgiveable” on the other extreme.
The apology session is part of a process where the involved partner clearly recognizes and acknowledges the distress and pain caused by the EMA, takes responsibility for the impact on the injured partner, and apologizes for the emotional injury. The involved partner makes a genuine commitment to trust, intimacy, and sexuality. The apology session is a face to face process, usually accompanied by an apology letter. The injured partner’s acceptance of the apology does not mean forgetting about the EMA, but it does mean that the relationship is no longer controlled by the hurt/anger of the EMA. The injured partner is no longer driven by punishment or revenge. The apology frees both partners to move on with the therapeutic process and their lives.
The apology session has value whether you recommit to your marital bond or decide to terminate the relationship. If you choose to recommit to building trust, intimacy, and sexuality, the apology is a crucial component in making meaning of the EMA and freeing energy to create a stronger marriage, a new couple sexual style, and a trustworthy relapse prevention plan. If you terminate the marriage, the foundation has been set for a “good divorce” with each person free to create a new life and relationship.
Sexual Recovery from EMA – 2021
We focus on a largely ignored issue- sexual recovery from EMA. The traditional model was a hierarchical approach: 1. understand what caused the EMA, 2. focus on the role of the “infidel” and effects on the “victim”, 3. recovery from betrayal, 4. work to rebuild trust, 5. after a period of months or years explore couple intimacy, 6. resume sexuality. The new therapeutic model is a time-focused “both-and” approach of making meaning of the EMA for the involved partner, injured partner, and marriage as well as rebuilding trust, intimacy, and a new couple sexual style. This is a positive, integrative process.
You cannot compare EMA sex and marital sex, it’s “apples and oranges”. EMA sex is more dramatic and exciting – the limerence phase multiplied by 3. The healthy comparison is the new couple sexual style with couple sex before the EMA. Your challenge is to build strong, resilient sexual desire and reinforce the desire/pleasure/eroticism/satisfaction mantra.
You cannot change the past nor can you have a “do-over”. You can learn from the past, but your power to change is in the present and the future. You can process past experiences and “honor” EMA learnings, but do not be controlled by the EMA. We do not advocate EMA as a way to change couple sexuality, but given the reality of the EMA a positive outcome is to create a new couple sexual style which reinforces the 15-20% role of sexuality to energize your bond and enhance feelings of desire and desirability. Rather than anguishing about the past and obsessing about the details of EMA sex, the injured and involved partners integrate intimacy, pleasuring, and eroticism as intimate and erotic allies. Although individuals and couples are different (sexually one size never fits all), the EMA is best understood as a wake-up call and a challenge to create a vital desire/pleasure/eroticism/satisfaction relationship. Many couples treat sex with benign neglect until the crisis of an EMA. In sexual recovery, a vital component is putting time and energy into maintaining desire, intimacy, pleasuring, eroticism, and a vital couple sexuality.
Traditional EMA Prevention Agreement – 2021
Couples would rather create a relapse prevention plan than have to deal with a second EMA. The traditional EMA prevention agreement involves three components. This is based on the assumption that EMA can occur with all people and all marriages.
First, recognize and process individual and couple vulnerability factors. Specifically, each spouse identifies what type of situation, mood, or person would make you vulnerable to an EMA. These vulnerabilities are shared with the spouse so that both are cued into potential high-risk people, situations, and moods. Interestingly, few people share the same vulnerabilities. Sharing and processing personal vulnerabilities is therapeutic itself as well as increasing each partner’s awareness.
Second, the couple make an emotional commitment to alert the spouse if you are in a high-risk situation rather than impulsively and secretly acting out the EMA opportunity. This agreement makes clear the importance of an emotional cost-benefit assessment of the potential EMA and its impact on the person, spouse, and marriage. This makes the EMA a conscious and planful process, robbing it of secrecy and illicit transgression. EMA is approached as you would other important individual and couple decisions.
The third component is the commitment to tell the spouse within 72 hours if there has been an emotional or physical EMA incident. As in politics, the cover-up is more damaging than the actual incident. With EMA, the injured spouse’s feelings about lying and betrayal grow over time. This results in giving the EMA more power than it deserves.
A major challenge for couples who successfully heal from an EMA is to create a genuine narrative about the EMA which empowers you to make meaning of the EMA, identify positive and negative personal and couple learnings, create a new trust bond, and a new couple sexual style with strong, resilient sexual desire. This is easier if the involved and injured partners deal with the EMA in a timely and efficacious manner.
The key to an EMA prevention agreement is to confront denial (“it could never happen to us”) and make a clear agreement, which recognizes personal and couple vulnerabilities while affirming the value of your trust bond, couple sexual style, and commitment to a satisfying, secure, sexual marriage.
Relapse Prevention for Non-Traditional Couples – 2021
Approximately 8-15% of couples adopt a non-traditional approach to fidelity and monogamy. These couples deserve high quality clinical services to help them clarify personal and couple understandings, boundaries, and goals. You create clear and wise emotional agreements about sexuality in your relationship.
The first issue is to clarify what you value about your relationship-what is the core of your emotional fidelity agreement. It might be family, home, social acceptance, finances, a respectful bond, a solid attachment. Especially important is to be clear whether both partners value satisfaction, security, and sexuality.
The second element is what type of sexual relationships are acceptable for each partner. The boundary between autonomy (privacy) and secrecy deserves careful exploration. A common guideline is the right to emotional and sexual autonomy and privacy, but not secrecy which is at the expense of the partner or relationship.
The most common agreement involves an open relationship. The second most common is swinging relationships (either closed or open). The third is polyamorous relationships involving emotional and sexual involvements with other individuals or couples. It is crucial to have a clear and genuine dialogue/emotional agreement about what types of sexual relationships work for each partner and your relationship. Other couples follow the “don’t ask, don’t tell” guideline. An important guideline is to practice contraception and safe sex with EMA partners.
The third element is the issue of “red line” boundaries. What type of person or relationship would be harmful to your partner or your relationship? Common red lines include not falling in love with the EMA person, not having sex with the brother-in-law or next door neighbor, and not compare the EMA person with your spouse.
Many clinicians have a bias against non-traditional couples. The clinician questions their motivation and emphasizes the risk of destabilizing the person or primary relationship. The role of the clinician is to help the client make a “wise decision” about sexuality so that it has a positive rather than destructive role in your lives. It is not to judge or make decisions for the client or couple.
What is the Right Couple Sexual Style for You? – 2021
Most people begin as a romantic love/passionate sex/idealized couple. This very special phase (limerence) lasts between 6 months and if you’re lucky 2 years. The challenge is to create a couple sexual style which will enhance desire/pleasure/eroticism/satisfaction. The challenge for couples, married or cohabitating, straight or gay, is how to integrate intimacy and eroticism into your relationship, and how to balance your “sexual voice” (autonomy) with being an “intimate sexual team”. You develop a mutually comfortable level of intimacy, share non-demand pleasuring, value erotic scenarios and techniques, and maintain positive, realistic sexual expectations.
The four most common couple sexual styles (by order of frequency) are:
Contrary to “pop psych” there is not a “right” style which is best for all couples. Be aware that usually your couple sexual style is different than your relational style. Each partner needs to be aware of your preferences, feelings, and values and choose the balance of intimacy/eroticism and autonomy/coupleness which enhance sexual desire and satisfaction. Be aware of strengths and vulnerabilities of each couple sexual style so you choose which is right for you.
Complementary Couple Sexual Style
Complementary is the most common couple style because it balances each person’s sexual voice with being a securely bonded team. Each partner has the freedom to initiate a sexual encounter, say no, offer an alternative way to connect, value both intimacy and eroticism, and play out your preferred erotic and intercourse scenarios. What are the vulnerabilities (traps) for this sexual style? The two major traps are treating sex with “benign neglect”—sex falls into a routine pattern. The second trap is that when life changes, for example, having a baby, rather than valuing couple time, you fall into traditional parenting roles and lose erotic playfulness.
Traditional Couple Sexual Style
These couples follow traditional gender roles where sexual initiation and intercourse is the man’s domain while intimacy and affection is the woman’s domain. This is the most stable couple style, high on clarity and security, and low on drama and the need to negotiate sexual issues. The vulnerabilities are role rigidity and with aging the man finds it difficult to function sexually without her stimulation. Another trap is not dealing with sexual problems until they are chronic. The woman feels her need for intimate connection and validation are ignored and overwhelmed by his sexual agenda.
Best Friend Couple Sexual Style
Best Friend is the cultural ideal—the most intimate relationship. Sharing intimacy and eroticism with the same person, feeling accepted and loved for who you really are (warts and all), and maintaining a secure bond, are powerfully validating emotionally and sexually. However, this is a very risky sexual choice. You feel so close that you de-eroticize your partner. The woman feels disappointed in the man and relationship because he fails to meet unrealistically high expectations. There is so much emphasis on mutuality that you don’t take sexual risks and thus have low sexual frequency. The Best Friend sexual style is unable to be resilient when dealing with hard issues, such as an affair.
Emotionally Expressive Couple Sexual Style
Emotionally Expressive is the stuff of movies and love songs—vibrant, playful, erotic, high-energy sex. These couples use sex to heal emotional conflicts, take sexual risks, are experimental, and enjoy sexual fun and intensity. The traps are too much emotional and sexual drama drain your bond and threaten relationship stability, overemphasize sexual experimentation and eroticism at the expense of intimacy and security, use sex to avoid dealing with problems, and this level of intensity wears the partners out.
Choosing the Right Style for You
A “wise” choice of a couple sexual style challenges you to weigh both emotional and practical factors, choosing not just for the short term but what brings sexual satisfaction over the long term. Choose a mutually acceptable sexual style which facilitates desire/pleasure/eroticism/satisfaction. You want sexuality to play a 15-20% role in enhancing relationship vitality and satisfaction. Emphasize the strengths of your chosen couple sexual style and be mindful of traps/vulnerabilities so these don’t subvert sexuality. You want to celebrate yourself as a sexual person and experience bonding as a sexual couple. Usually the relational and sexual styles are different. For most couples, the Best Friend relational style and the Complementary sexual style is the best decision.
Resource: McCarthy, B. & McCarthy, E. (2009). Developing Your Couple Sexual Style.
Three Styles of Arousal/Eroticism – 2021
Arousal/eroticism is an integral component in the desire/pleasure/eroticism/satisfaction mantra. There are three sexual arousal/eroticism styles (by frequency): (1) partner interaction arousal, (2) self-entrancement arousal, (3) role enactment arousal. Partner interaction arousal is based on the principle that the major aphrodisiac is an involved, aroused partner. This type of arousal is portrayed in R-rated movies; each partner’s arousal enhances the other’s. Partner interaction arousal is like a sexual dance where each partner has an integral role. It is an example of the “give to get” pleasure guideline. Almost all couples utilize partner interaction arousal.
Self-entrancement arousal is the second most common arousal/eroticism pattern. It is best illustrated by the traditional sensate focus exercises. The giving partner touches for himself rather than trying to second guess the preferences of the receiving partner.
The receiving partner is actively focused on her pleasure. She is active not passive, aware of her receptivity/responsivity pattern. As couples age, they are likely to increasingly utilize self-entrancement arousal. They are open to asynchronous scenarios, realizing that not all sex needs to be mutual.
Role Enactment arousal/eroticism is the most advocated (especially on the internet and in self-help articles) and contentious style. Role enactment arousal involves external resources to heighten the erotic charge including X-rated videos, sex toys, playing out erotic fantasies, and using BDSM scenarios. Clinically, the issue is whether role enactment arousal is the right fit for that couple. It is a good fit for the Emotionally Expressive couple sexual style, and a poor fit for the Best Friend and Traditional couple sexual styles. Many couples find role enactment arousal scenarios are intimidating rather than empowering. It raises self-consciousness, and there is nothing more anti-erotic than self-consciousness.
A majority of married men and women use erotic fantasies as a bridge to desire and to build erotic flow to orgasm. A common misunderstanding is that fantasy is an indicator of what the person really wants. In the great majority of cases, fantasy and behavior are very different domains. Commonly, acting out an erotic fantasy results in a “sexual dud”, and can rob the fantasy of its erotic charge.
The key is making a wise decision of what arousal/eroticism style (s) is the best fit for you. Some couples use all three styles. Commonly, couples use partner interaction arousal and augment that with self-entrancement arousal. On occasion some couples use role enactment arousal, but others are uncomfortable with that arousal style.
Choose what enhances eroticism for your relationship.
Resource: Metz, M., Epstein, N., & McCarthy, B. (2018). Cognitive-Behavioral Therapy for Sexual Dysfunction.
Sex Therapy with Individual Clients – 2021
Individuals -single, divorced, widowed-deserve for sexuality to have a 15-20% positive role in their lives, not a problematic or destabilizing role. The choice to marry or create a life partnership is a decision, not a mandate.
In terms of helping individuals make wise decisions about an emotional/sexual
relationship there are two core concepts-“circles of intimacy” and “guidelines for choosing a partner”.
Circles of intimacy involve the concept of five levels of relationship:
All five levels require effective contraception and practicing safe sex. The more intimate the relationship the more likely there will be stability and satisfaction, but also a higher risk of disappointment and hurt. A sexual friendship can be an important growth-inducing, meaningful relationship even though it does eventually end (some sexual friendships do evolve into a life partnership/marriage).
A woman dealing with recovery from breast cancer or a man dealing with a stroke or traumatic brain injury needs to accept the “new normal”. Doing that in the context of a sexual friendship is more likely to be therapeutic than throwing yourself into a potential life partnership. This is also true of a client returning to dating after a divorce. You are not ready for a major life commitment.
Be aware that there are sexual friends who would be a disaster as a spouse. Likewise a lover relationship is great for 2 years, but trying to convert this to a life partnership leads to disappointment and anger. Accept and enjoy the relationship for what it is, don’t make it into something that is not the right fit.
In choosing a sexual friend we suggest the guidelines of someone you are comfortable with, trust, and are attracted to (in that order). Especially when you are experiencing sexual dysfunction, choose a partner you are comfortable with rather than feeling pressure to perform for. Also, trust that she (or he) has your best interest in mind and would not do something intentionally to hurt you. Finally, choose a sexual friend you are attracted to. A special trap for males is a relationship with a woman he is not attracted to so he can blame her for the sex problem. This is a self-defeating strategy and unfair to the sexual friend.
Choose a sexual friend you are comfortable with, trust, and are attracted to so you can rebuild sexual confidence. You deserve for sexuality to have a 15-20% positive role in your life and relationship.
In individual therapy, the positive role of masturbation and fantasy is emphasized as well as enhanced self-acceptance as a single person.
Resource: McCarthy, B. (2015). Sex Made Simple.
Sexual Trauma: Levels of Victimization – 2021
Resource: Maltz, W. (2012). The Sexual Healing Journey (3rd edition).
Fatally Flawed Marriages – 2021
Guidelines for Sex After 60 – 2021
Resource: McCarthy, B. & McCarthy, E. (2021). Couple Sexuality after 60.
Relapse Prevention Strategies and Guidelines – 2021
Resource: McCarthy, B. (2015). Sex Made Simple.
What Predicts Satisfying, Secure, and Sexual Marriages – 2021
A healthy marriage is satisfying, secure, and sexual. The following factors are predictive of a healthy marriage.
We encourage each spouse (or partner) to honestly assess (don’t give the socially desirable answer) each factor on a five-point scale:
++ A major strength
+ A positive factor
– A vulnerability
— A major vulnerability
Next, share and discuss these factors. Historical factors are to increase awareness, but are not in your control and are not changeable.
The pre-disposing factors are potentially changeable. You and your partner need to share strengths and vulnerabilities in assessing your challenges in creating and maintaining a healthy marriage.
The third category, process factors, is most in your control and the most changeable. Follow the guideline of factor 15, make wise decisions (those which make sense emotionally and practically and work in both the short and long term). A sign of an unhealthy marriage is choices which are emotional and short term, but not wise.
Remember, the focus of this assessment is to empower you to create a satisfying, secure, and sexual marriage. If you identify major personal and relational vulnerabilities, we encourage you to seek professional counseling to address these issues and give you the resources to create and maintain a healthy marriage. The sexual paradox is that sexual problems can destroy a loving marriage, but good sex cannot save a bad marriage.
Resource: McCarthy, B. & McCarthy, E. (2004) Getting It Right the First Time.
Personal Reflection Exercise – 2021
First, what are the sexual issues you are most interested in as a clinician?
Second, what kinds of clients and sex problems do you feel the most competent in addressing?
Third, in terms of professional values what kinds of clients and problems are you most comfortable with?
Fourth, in terms of personal values what kinds of clients and problems are you most comfortable with?
The hard issue is dealing with difficult clients and problems
First, what are the sexual issues and clients you are not interested in?
Second, what are the types of clients and sexual issues you are not competent to deal with?
Third, in terms of professional values, what kinds of clients and problems are you unable to deal with?
Fourth, and most difficult, in terms of personal values, what kinds of clients and problems are you unable to deal with?
Resources – 2021