Home Family & Relationship Do You Want to Be a Psychotherapist Who Works with Couples? These Are the Basics You Should Know

Do You Want to Be a Psychotherapist Who Works with Couples? These Are the Basics You Should Know

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Falling in love brings the hope of re-living a union as perfect as the mother/baby relationship and the desire to be merged and never be alone. When lovers look into each other’s eyes they are seeking the reflected loving gaze of their mother’s eyes, a world of safety and intimacy. But they are also connected to the fear of loss and the possibility of disappointment, frustration and anger.

The unspoken contract between a couple is that they can share their unconscious fears and fantasies. A good relationship with the right psychological partner gives them each a chance to work through past difficulties and break repetitive patterns.

From the psychodynamic angle, one needs to understand the concepts of projective identification and unconscious collusive fit between the couple. A replay of Oedipal issues will also be present. Finding a balance between intimacy and autonomy is part of the couple’s work. Working with transference and countertransference is important.

From a cognitive and behavioural point of view, one will help the clients to reframe, change old habits, set goals and complete tasks.

Couples need to be able to understand and tolerate the difference in their needs and work through the issues when their needs become polarised. Anger, conflict and poor communication are major elements, It’s hard not to criticise or blame, to give up the power struggles and the wish to control.


Affairs are often seen as a reason to end a relationship, the cause of the breakup. But an affair is usually a symptom of something lacking in the relationship, something going wrong.

The reasons for having an affair are not just about sex. Other reasons include:

  • Lack of attention
  • Lack of affection
  • Lack of communication
  • Not feeling understood
  • Not feeling valued
  • A way out of the relationship

The relationship can recover from an affair if the underlying causes are explored, understood, and steps are taken towards change.

Getting over an affair takes time. The stages are similar to the stages of mourning. Healing comes after resignation, acceptance and letting go.

A broken vase can be expertly glued back together but you will always know it has been broken.

Good sex, bad sex, and no sex

Good sex

A fulfilling sexual relationship gives a couple a shared feeling of self-worth and validation, confirmation and unity. A long-lasting sexual relationship needs intimacy and commitment, but it also needs imagination and creativity to keep it from becoming stale. Good sex in a long-lasting relationship is primarily about mutual trust and respect. Chemistry and good technique are not enough in themselves.

Bad sex

Bad sex includes behaviour that is driven by compulsion. It can be addictive. It can be violent and debasing, sordid and shameful, bizarre and risky. There is a lack of mutual consent and imposed secrecy. Hatred is eroticised; boundaries are broken. Bad sex usually comes with a history of early deprivation and frustration, a desperate and narcissistic need for satisfaction or even punishment, expressed in the acting out of taboo desires and fantasies.

Sexual abuse

There is a general reluctance to confront the problems of sexual abuse because they touch primitive and fearful parts of our unconscious. Yet therapists need to be very aware of sexual abuse as it is quite common in the clients who present for therapy. Sexual abuse is a murky and tricky area to work with because the client has experienced a different reality and major boundaries have been transgressed. The victim may have contradictory and confusing feelings such as



GuiltFeeling special

The biggest loss when sexual abuse occurs in a family is the loss of innocence, of childhood and the loss of parents as good-enough fathers and mothers.

When sexual abuse occurs between father and daughter, or father and son, the mother is usually in denial. This denial may be conscious, as in “You’re lying”, or unconscious, as in “I won’t help you”.

Adult signs of childhood abuse

Adult victims of childhood abuse often show the symptoms of unresolved posttraumatic stress disorder. They may suffer from serious problems such as:

  • Depression
  • Eating disorders
  • Self-harm
  • Suicide attempts


Whatever the therapist’s personal opinion, it is essential that she does not jump to conclusions and suggest to the client that she/he may have been abused and has repressed the memory of the abuse. The client may then confess to a false memory of abuse in order to please the therapist.

The therapist needs to keep strong boundaries, be contained and safe and work sensitively and skilfully while remaining objective.

No sex

Bad sex leads to no sex. Sexual activity between couples ceases when sexual problems become unmanageable.

The causes of “no sex” is a range of sexual dysfunctions such as:


  • Erectile disorder
  • Premature ejaculation
  • Loss of desire


  • Inability to reach orgasm
  • Pain on intercourse
  • Vaginismus
  • Loss of desire

Sexual dysfunctions can have physical or psychological origins or a combination of both.

Common feelings are anxiety, anger, guilt and shame.

Loss of desire

Loss of desire is the most common sexual problem and affects both men and women.

Desire is a subtle and complex phenomenon that can be affected by a wide range of factors. These include

  • Illness, medication, addiction.
  • Childbirth, relationship problems, affairs
  • Work problems, family problems, bereavement
  • Anger, anxiety, guilt, shame
  • Unconscious conflicts

In the context of the relationship, loss of desire may be a powerful way of expressing anger and resentment. In this particular power struggle, the person who does not want sex holds the power and is punishing their partner, whether consciously or unconsciously.

Lack of time appears to be a major reason for the loss of desire. People lead such busy and stressful lives that sex is no longer prioritised. Couples who live together with equal gender roles end up like flatmates or siblings. There is no gender differentiation.

Sex therapy: sensate focus

Sensate Focus is the most widely used technique in sex therapy and is used to treat all sexual dysfunctions. It was pioneered by Masters and Johnson in the US in 1966. It is also extremely useful as a diagnostic tool, both physical and psychological.

Sensate Focus is a de-sensitisation and gradual exposure process, involving a series of exercises that the couple agree to do on a regular basis at home and discuss afterwards with the therapist.

The first step is to check any physical causes of the dysfunction.

The couple needs to be motivated enough to make a commitment to each other and to the therapy in terms of time and application. The process usually takes a minimum of three months.

The first rule of Sensate Focus is for the couple to agree not to have sexual intercourse for the foreseeable future.

Some couples will say that they are not having intercourse anyway. The difference is that this is an agreed contract between them. The ban on intercourse removes any pressure from, and expectation of, sex. It can be very liberating for the couple because they can have physical contact without fear or anxiety about intercourse.

Sensate Focus is literally about getting back in touch with the senses, focusing on touch, sight, smell, taste and sound. It is sensual, not sexual. There is no goal, no pressure, no expectation, no need to perform, and no right or wrong. The emphasis is on getting in touch with sensations and feelings and discovering what it is like to become close and intimate again.

Each partner will give the other equal time and attention, equal giving and receiving, and equal responsibility.

Throughout the exercises, the couple is given permission to learn what gives them pleasure before giving pleasure to their partner.

It is a process that removes a major source of anxiety, helps to build trust and intimacy and improves the level of communication.

  • The couple needs to put aside one hour during which they will not be interrupted.
  • They are going to take turns to touch, stroke and caress each other from top to toe, first the back of the body, then the front, from head to foot without touching the genitals, buttocks or breasts.
  • When the first person has completed the task (20–30 minutes) the partners change over.
  • It is essential that the partners have an equal amount of time.

Working with Sensate Focus and exploring the resistances will usually be extremely effective for most couples, especially those presenting with loss of desire because it offers them the chance to break old habits and find the trust and intimacy they have lost.

Sometimes just a temporary ban on intercourse is liberating enough for a couple to get back in touch with each other physically and emotionally so that they can go from no sex to good sex with a deeper understanding of giving and receiving pleasure.

Final thoughts

Working with couples is not about saving the relationship. It is about making a choice. There are three possibilities.

  • Can they make changes? (risky).
  • Will they stick to the status quo (familiar)
  • Will they separate? (traumatic).

You cannot redecorate the house if the foundations need work.

It’s like dentistry. How bad is the decay? Do you need a filling? Root canal? A crown? Are you at risk of losing the tooth? It’s painful but it will get worse if ignored.

Couples’ work is like playing in a mixed doubles tennis match when one is used to the longer rallies of one-to-one. One needs to think quickly, instinctively and intuitively, as well as countertransferentially. Understanding the action and reaction in the here and now is crucial – the therapist is an observer, facilitator and interpreter of the relationship and must remain impartial and non-judgmental with clear boundaries.

Working with couples is a most satisfying and enriching experience. In a Winnicottian sense, the consulting room becomes a safe and creative place in which to explore and play with the very subtle and complex interchanges and feelings that make up a relationship between a couple, and their relationships with the therapist. Still in the spirit of Winnicott, although one certainly needs proper training in order to work with couples, one just needs to be “good enough”.

Carol Martin-Sperry is a sex therapist and the author of three books about couples and sex. Carol is a fellow of the British Association for Counselling and Psychotherapy. 


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