272: Common Sexual Issues in Couples Therapy with Adrien Monti

Welcome back to The Couples Therapist Couch! This podcast is about the practice of Couples Therapy. Each week, Shane Birkel interviews an expert in the field of Couples Therapy to explore all about the world of relationships and how to be an amazing therapist.

In this episode, Shane talks with Adrien Monti about common sexual issues in couples therapy. Listen to the episode on Apple Podcasts, Spotify, and your other favorite podcast spots, and watch it on YouTube – follow and leave a 5-star review.

• Episode Summary & Player
• Show Notes
• The Couples Therapist Couch Summary
• Transcript

The Couples Therapist Couch 272: Common Sexual Issues in Couples Therapy with Adrien Monti

This episode is brought to you by Alma. Visit https://helloalma.com/dg/?utm_source=podcast&utm_medium=paid&utm_campaign=privatepractice to learn more

Get the Couples Therapy 101 course: https://www.couplestherapistcouch.com/

Join the Couples Therapist Inner Circle: https://www.couplestherapistcouch.com/inner-circle-new 

In this episode, Shane talks with Adrien Monti about common sexual issues in couples therapy. Rebecca is a Licensed Clinical Social Worker (LCSW), Couples Therapist, and AASECT Certified Sex Therapist. Hear how to become a sex therapist, how to get comfortable talking about sex with your clients, the most common issues when it comes to sex & couples therapy, when to refer your clients to a sex therapist, and whether you should schedule sex. Here's a small sample of what you'll hear in this episode:

• Rebuilding platonic physical affection
• Reevaluating when sex happens: considering your circadian rhythm
• The cultural myth that men always want sex
• Why sex therapy is such an important specialty
  
• The certification process for becoming a sex therapist (AASECT)

To learn more about Adrien Monti, visit:

InnerFlameCounseling.com

Show Notes

• 272: Common Sexual Issues in Couples Therapy with Adrien Monti
• This episode is brought to you by Alma. Visit https://helloalma.com/dg/?utm_source=podcast&utm_medium=paid&utm_campaign=privatepractice to learn more
• [0:10] Welcome to The Couples Therapist Couch 
• [0:59] Welcome, Adrien Monti, to the show!
• [1:27] What is Adrien's background and practice focus
• [2:22] How did she first learn about sex therapy
• [2:51] Why sex therapy is such an important specialty
• [3:50] The certification process for becoming a sex therapist (AASECT)
• [5:11] Training options for therapists interested in sex therapy
• [6:32] When to wear the "sex therapist hat" vs. "couples therapist hat"
• [7:15] The power of reflective listening when discussing sexual issues
• [8:43] Identifying patterns that feel satisfying in the moment but cause long-term damage
• [10:04] Understanding what sex means to each partner
• [10:57] The #1 reason couples seek sex therapy: desire discrepancy
• [11:50] What is "normal" when it comes to frequency and type of sex
• [13:16] Expanding the definition and menu of sexual activities
• [16:31] What does sex mean to you? Opening up the conversation
• [17:57] The "hunger vs. fullness" metaphor for sexual desire
• [19:35] This episode is brought to you by Alma. Visit https://helloalma.com/dg/?utm_source=podcast&utm_medium=paid&utm_campaign=privatepractice to learn more
• [20:33] Other common sexual issues: pain with sex
• [22:24] The importance of pursuing your own pleasure
• [24:20] Scheduling the opportunity for sex (not scheduling sex itself)
• [26:14] Rebuilding platonic physical affection
• [28:03] Reevaluating when sex happens: considering your circadian rhythm
• [29:46] Erectile Dysfunction (ED) and performance anxiety
• [32:10] The cultural myth that men always want sex
• [33:36] "Invite the erection to the party, but hold the party anyway"
• [35:00] Learning to give and receive pleasure
• [35:57] Gender differences in sexual self-knowledge
• [37:49] Unrealistic expectations from movies and media
• [40:10] Using structured dialogue to discuss sex in therapy
• [41:07] Celebrating small steps toward progress
• [42:32] Managing perpetual problems vs. solving them
• [43:27] How to bring sex into the conversation as a non-specialist
• [44:49] Operating within your scope of competence
• [46:43] Increasing therapist comfort level with sexual topics
• [48:36] When to refer to a sex therapist
• [49:55] Getting consultation from a sex therapist
• [51:16] Learn more about Adrien Monti, visit InnerFlameCounseling.com
• This episode is brought to you by Alma. Visit https://helloalma.com/dg/?utm_source=podcast&utm_medium=paid&utm_campaign=privatepractice to learn more

 

What is The Couples Therapist Couch?

This podcast is about the practice of Couples Therapy. Many of the episodes are interviews with leaders in the field of Relationships. The show is meant to help Therapists and Coaches learn how to help people to deepen their connection, but in the process it explores what is most needed for each of us to love, heal, and grow. Each week, Shane Birkel interviews an expert in the field of Couples Therapy to explore all about the world of relationships and how to be an amazing therapist.

Learn more about the Couples Therapy 101 course: https://www.couplestherapistcouch.com/

Find out more about the Couples Therapist Inner Circle: https://www.couplestherapistcouch.com/inner-circle-new

Transcript

Please note: this transcript is not 100% accurate.

00:00
I don't recommend scheduling sex because that sounds like too much pressure, but I absolutely recommend scheduling the opportunity for sex.

00:13
Welcome to The Couples Therapist Couch, the podcast for couples therapists, marriage counselors, and relationship coaches to explore the practice of couples therapy. And now your host, Shane Birkel.

00:30
Hey everybody. Welcome back to The Couples Therapist Couch. This is Shane Birkel, and this is the podcast that's all about the practice of couples therapy. Thank you so much for tuning in. I'm a licensed marriage and family therapist, and the goal of this podcast is to help you learn how to more effectively work with couples and possibly even learn how to have a better relationship. The episode this week is brought to you by Alma. They make it easy to get credentialed with major insurance plans at enhanced reimbursement rates.

00:59
Alma handles all of the paperwork and guarantees payment within two weeks. Visit HelloAlma.com or click on the link in the show notes to learn more. Hey everyone, welcome back to the Couples Therapist Couch. This is Shane Birkel and today I'm speaking with Adrie Monti, licensed clinical social worker, couples therapist, and ASEC certified sex therapist. Hey Adrien, welcome to the show. Hey Shane, thanks so much for having me on. I'm a big fan.

01:27
Oh, absolutely. I'm really excited for our conversation. We're going to be talking all about addressing common sexual issues in couples therapy. Why don't you tell everyone a little bit more about yourself? Sure, I am in solo private practice in Roanoke, Virginia. And when I decided I wanted to go into private practice, I really wanted an area of specialty and expertise that would be interesting and rewarding and marketable.

01:57
And I was really excited to stumble upon sex therapy as a specialty. I'd already been a clinical social worker for years and I didn't even really know that it was possible to become certified as a sex therapist. I want to tell you just a little bit about the process. Yeah, great. Yeah, I went to a great- find out about it?

02:22
You know, I just was thinking about possible areas of specialty and I started doing some research and I'll tell you what I really love about being a sex therapist. I think most therapists have had the experience of somebody confides in you, maybe something they've never told anybody, maybe something they are embarrassed about or ashamed of. And they have a great experience of feeling heard and supported and realizing that they're not alone.

02:51
And that happens all the time in the area of sex therapy, it's such a stigmatized topic. We live in such a sex negative culture. have so much opportunity to reach people and help people. Yeah. I think if you, especially if therapists don't have sex therapy training, right? There might be this way in which we're approaching it. It's not that we, it's not even that we don't want to talk about it, but it's like,

03:21
this thing in the back of our mind where, if the client doesn't bring it up, then I won't bring it up. Right. And exactly, exactly. And I do recommend if a therapist is comfortable talking about sex is open to it, to ask, to ask the question, do you have any sexual concerns you'd like to talk about in therapy or with couples? I just ask, how's your sex life? And I do just want to mention that there is no title protection.

03:50
around sex therapy, except for in the state of Florida, the other 49 states, anybody can call themselves a sex therapist, whether they are certified or not. Oh, interesting. Yeah, but I did want to go through the certification process. Yeah. So I got about 150 hours of classroom training. My program was all online, which was fantastic.

04:13
And then I was required to have 50 hours of clinical supervision while I accrued at least 300 clinical hours of working directly with clients with sexual issues. Wow. So it wasn't as extensive as getting licensed all over again, but it was about half as extensive as getting licensed all over again. It took 18 months. And for me, it was very rewarding and well worth it.

04:41
And that was through the it's AASCT. Yes, that is the certifying body. That is the American Association of Sexuality Educators, Counselors and Therapists. And then there are various training programs. Mine was through modern sex therapy institutes out of Miami, and I had a great experience with them. Great. Great. I think obviously, that would be the

05:11
Ideal in my mind if somebody wants to call themselves a sex therapist or they really want to focus on it more To really get some good training Are there are there other ways if someone's just thinking about it or they just want to? You know get a clap one class maybe to enhance their couples work or something like that

05:32
Absolutely. I think there's a lot of great information out there now. I think there's good podcasts, good books. It is definitely possible to have it be an area of interest to be self-taught and make it known that you're open to discussing these things. And honestly, if you're working with couples, it's pretty hard to avoid sex coming into the room. People bring it up. It's one of the biggest things that people have conflict and challenges around. So I think it's very

06:02
difficult to not talk about sex if you're a couples therapist. Yeah, definitely. And as a sex therapist, I'm curious, and maybe I'm maybe I'm just thinking about this to, you know, black and white thinking, but it's like, how do you you know, when you're working with couples, are there different times where you feel like you have your sex therapist hat on versus your couples therapist hat on? Or does it just feel like it kind of flows together?

06:32
I thought early on that there would be a clear distinction between the two and there really is not. People seek me out for traditional couples therapy who never talk about their sex life. Sometimes they open up about it when they get comfortable.

06:48
People seek me out exclusively for sex therapy and say everything's great in their relationship. And we get going a little further and lo and behold, there are some relationship dynamics that are contributing to some of the sexual challenges. So it is not cut and dry. And I am just uh willing to roll with wherever the clients are in terms of what they want to talk about. So I would want to just say to

07:15
therapists without a lot of training in sexuality who might be nervous talking about sex. This is my clinical perspective in general. You can never go wrong with reflective listening. huh. Great. Acting interested, acting curious. Tell me more about that. How does that affect you? How do you make sense of that? Um, it sounds like you have some strong beliefs around that. Where do you think they came from?

07:42
There are so many ways we know how to take people deeper and ask meaningful questions, whether or not we know very much about the topic we're inquiring about. And really what's important is what does it mean to the clients? Yeah, that's great. Yeah. Cause I think you're right. People do have a lot of hesitant, you know, I think people want to be polite or they don't want to be intrusive. Right. And I think that's a good.

08:12
you know, rule of thumb, especially for someone who's not a sex therapist, it's always good to, you know, I mean, it's always fine to follow the client's lead. Exactly. You know, if they're talking about it, means they want to talk about it. Yes, they're bringing it up and it's okay to ask questions and take it deeper. And one big piece I think about in terms of couples dynamics, I've found in couples therapy, a lot of what we are doing is

08:43
helping people identify what might feel satisfying in the moment, but does damage in the longterm. For example, it might be really satisfying to yell at your partner and tell them off, or it might feel really comfortable to just give them the silent treatment and ice them out. And over time, it's possible to learn, well, that might be easy right now, but that's not gonna ultimately get me what I want.

09:09
And a lot of sexual dynamics are the same way that when there's an argument, people can go to, I think there's something wrong with you and your sexuality. And that's why we're arguing or withdrawing, pulling back, being demanding, being negative, being critical. So much of it is shifting to what's going to get you what you want in the long term versus the thing that might actually be sabotaging you if you do in the short.

09:38
Yeah, that's great. I'd love for you to say a little bit more about that because I feel like, you know, oftentimes the sex isn't just about the sex perhaps. Yes. And asking some questions around what it means to people is really important. If your partner not wanting to have sex with you means they're not in the mood for sex. That's one thing if it means

10:04
I'm not desirable. I'm not lovable. They're interested in somebody else. Our relationship's falling apart. Well, then you're going to have a much different reaction. So sort of getting to the bottom of what assumptions are people making? Are you checking those assumptions out? It can be so helpful opening up that communication. Yeah. And I think there, there are often, you know, bigger themes at play. Like when we talk about

10:32
couples therapy dynamics. I mean, mean, like a really common one is like the pursuer distance or dynamic that we talk about often, where there's a cycle that emerges. Neither couple is necessarily doing anything wrong, but they're sort of both falling into this kind of pattern. And I think those kinds of things can play out with regards to sex, because it does have so much meaning for people.

10:57
And they can get really entrenched over time. Um, people can get kind of dug into their roles and it can be challenging to work through. And I will say the number one reason people seek me out is when there's a desire discrepancy in the couple. One person wants more sex than the other person or wants a different kind of sex than the other person.

11:21
And I like to really emphasize um it is healthy and normal to want lots of sex. It is healthy and normal to not want very much sex. I operate with a sex positive perspective, meaning if it's consensual and it's enjoyable, it's healthy. There's really no judgment. I like to liken it to music. There's a ton of different kind of music out there. Some of it's for you, some of it's not.

11:50
Some people like super mainstream top 40s. Some, some people like really fringe vinyl B size, it's a little more obscure and there's nothing wrong with any of that. But if it's not for you, it's not for you. It's all healthy and normal. Yeah, I love that. And, I, love, know, people put so much pressure on themselves, you know, to do things the right way, so to speak, or, or the question might come up like, well, how many times should we be having sex? What's the normal amount?

12:20
Right? if that answer exists. what I hear you saying, you can tell me if I'm wrong, what I hear you saying is, you know, there could be a couple who doesn't have sex at all. And if they're happy in their relationship, it's great. Or if they have sex once a month and they both agree, hey, this is great. This is good. This is what we want. Then that's a really healthy sex life and healthy relationship. But the discrepancy, I think, really brings to the forefront when, you know, one

12:48
one partner has a different perspective of what they're hoping for, what they want. And the other partner wants something different. Definitely. And one thing that is helpful to inquire about is what do you mean by sex? Oh great. Yeah, people will have difficulty speaking to this sometimes. uh And I will say when I'm working with

13:16
heterosexual couples, it is not uncommon that their definition of sex has narrowed over time to penetrative intercourse, maybe one or two positions, kind of a script that gets followed. And for some people, the variety reduces over time, decreases. And there's also this concept that I like to talk about of the

13:45
broader your menu and repertoire, the more likely you are to get to have more sex. And there are some sexual acts that take more energy that you might need to be in a certain head space for. And there might be lower bar sexual acts that can be a little more casual that are easier to do if you're tired or

14:11
don't have all the circumstances just right. And so kind of having a range, having a variety can be really helpful. And I do specifically ask people, do you give and receive oral? Do you do hand stuff? We might call this hand job or fingering. Do you do mutual masturbation? Do you make out? Do you fondle and caress each other? What is on the menu? What is your typical routine? m Yeah, that's great.

14:40
And can you say more about, you know, how can couples use these ideas if they brought in their menu or brought in their repertoire? How does that help them, you know, improve their sex life? Yeah, well, for some people, intercourse may not be their favorite thing, or it may be a high bar. For the person receiving penetration, um you got to be in a certain headspace.

15:10
to want to take another person's body part inside of your body. And it might be that you're not quite there. And for the person doing the penetration, it takes energy to be able to perform. There might be performance anxiety. So having some options that might feel less pressure, less stress, more accessible can be really helpful. It's also important to keep in mind with heterosexual couples,

15:39
equivalent of the penis is the clitoris. The vaginal canal is not actually nearly as sensitive, probably because it's also the birth canal. So it's not uncommon for some women that that penetrative intercourse is not really where they get their most pleasurable stimulation. So the act that is the most pleasurable for him

16:04
may not be for her. And if that is sort of a one way street where all their activity is leading, she might not want to get on that street. And if there's the idea of, there's multiple roads you can take, it doesn't always have to end in one place, that can be freeing, that can be helpful. It is true that you need to have penetrative intercourse to conceive. But outside of that,

16:31
ah There can be a lot of options on the table. And from my perspective, if somebody is getting aroused, if somebody is getting pleasure, maybe somebody is having an orgasm, that is sex. That is a sexual encounter. Yeah, that's great. And I want to go back to this, back to the topic of desire discrepancy. You know, how would you begin, like if someone was reporting that that was the situation for them?

16:58
How would you begin to sort of begin, open up the conversation perhaps to kind of get into some of these things that we're talking about now? Yeah, great question. I like to open with what does sex mean to you? How do you hope to feel emotionally during sex? Sometimes somebody will say it is how I feel the most love and connection and it's how I show my love and connection.

17:29
And it can be really eye-opening if the partner says, it's a fun physical act, but it's not what makes me feel the most care and connection. I feel that in different ways. We tend to assume that our partner thinks the way we think and uncovering the differences can help us have different interpretations. I also like to use the metaphor of um

17:57
Like you're talking about eating a meal, how hungry versus how full are you? And if somebody just doesn't have as much sexual appetite, if they're just feeling stuffed full metaphorically and you present them the most delicious meal in the world, they're not gonna wanna eat that meal. And it isn't because they don't love the meal, it's not their favorite meal. I would say one of the biggest things I hear from the lower desire partner is I wish my partner could know it's not about him or her.

18:26
Yeah. It's about my appetite, my desire, getting my body and mind where it needs to go. It's not a rejection.

18:36
Yeah, that's great. And I think there's so much potential to explore when you open up the conversation like that, because it is so there are all these feelings coming up in the moment for people about like related to the meaning that they're making up about what's happening, know, feelings of rejection or feelings of resentment or feelings, you know, of disappointment. And, you know, I think that

19:06
it just feels so much more heavy. they're not even conscious of what's happening on the emotional level, you know, it makes everything feel more like, well, we're just broken and we're never going to be able to get better or something. Absolutely. And people think everybody else is having great sex. And I can promise you it's not true. of people are struggling. There are a lot of challenges around this.

19:35
Building a private practice can be challenging. Filing all of the right paperwork is time consuming and tedious. And even after you're done, it can take months to get credentialed and start seeing clients. That's why Alma makes it easy and financially rewarding to accept insurance. When you join Alma, you can get credentialed within 45 days and access enhanced reimbursement rates with major payers. They also handle all of the paperwork from eligibility checks to claim submissions.

20:03
and guarantee payment within two weeks of each appointment. Plus, when you join Alma, you'll get access to time-saving tools for intakes, scheduling, treatment plans, progress notes, and more in their included platform. Alma helps you spend less time on administrative work and more time offering great care to your clients. Visit helloalma.com or click the link in the show notes to learn more. We could get more into desire discrepancy and how to navigate those conversations.

20:33
But what are some of the other issues, the common issues that you address in couples uh in sex therapy? Yeah, I am just gonna touch on a few of these that I encounter a lot. And one, and this is a little more common in women is pain with sex.

20:58
I don't think there are a lot of rules when it comes to sex, but the idea that you should not do anything that hurts is very, very important. I have worked with multiple women who tried to push through. And again, it's about doing the easy thing in the moment, believe it or not. I don't want to make a fuss. I don't want to hurt my partner's feelings. I can just stick with this and it'll be okay. And I think about, um,

21:29
how much a pain response can be conditioning over time. mean, I think about like rats getting electric shocks. Like if you want to not like sex anymore, pairing it with a pain response is a way that we'll get there. And I've worked with some women who had pelvic floor physical therapy, which you almost definitely need a medical intervention if there's pain just to figure out what's going on.

21:55
There's such good treatment out there, but sometimes the physical issue is resolved, but there's still a fear and anxiety response around the pain. And one way to work with that is for the woman to make sure she is really pursuing her own pleasure in sexual activities. If she is waiting there, tense and frozen, fearful that there's going to be pain, that's a very stressful experience.

22:24
that's likely to lead to more tension and pain. Whereas if she is kind of mentally and physically going after something enjoyable, that can be a really helpful mental shift. And what does that mean? Does that mean that she's communicating that or does that mean? Talking about what she wants. One woman I worked with, it was that she really needed federal stimulation while they were doing other things so that she was getting pleasure.

22:52
The other thing that I do talk to people about is, believe it or not, your largest sexual organ is your brain. And it's not always that helpful to think about what we don't want to be thinking about. I don't want to think about, it going to hurt? I don't want to think about, am I going to be embarrassed? I don't want to think about the pile of laundry. Like, no, what do you want to think about? And I will ask people, and I'll say it just like this. I'm not going to ask you to tell me what it is. oh

23:22
but can you think some really sexy thoughts? If you want to think thoughts that will turn you on and get you in the mood, is that something you know how to do? And a lot of people will say, yes, absolutely. But if somebody doesn't know how to do that, that might be something they want to explore and learn because it can be so helpful to have stuff you do want to think about to keep you in the right head space. Yeah. When you say that too, I'm thinking about how

23:51
there's this kind of stereotype, I guess you could say, where one partner needs emotional connection to feel sexual, and the other partner needs sexual connection to feel the emotional connection. And people get stuck in this. And I think that the emotional safety, you know, is part of that. If somebody could, perhaps in the communication with the couple communicating with each other,

24:20
If the partner with less desire could share, know, what is like my ideal day look like? Just not even related to sex. Just sort of like, are the things that make me feel emotionally safe? What are the things that make me feel like I'm grateful to my partner? Like those types of things, like leading into it so that they can set themselves up for success. That is such a good point, Shane. And I often tell people,

24:50
I don't recommend scheduling sex because that sounds like too much pressure, but I absolutely recommend scheduling the opportunity for sex. In our busy lives, things that don't go on the calendar or fall into the category of somewhat protected time often go to the end of the list and just don't even happen. So scheduling, we're going to have this time to connect and be close and have

25:18
privacy and maybe we're gonna hold each other and take a nap and maybe it's gonna be more Having that time is really important Yeah, yeah, that's great and and With the idea of pain, you know to go back to something you were saying before like sex doesn't have to mean intercourse Absolutely, right and so that would be an important conversation too about like

25:45
What are the things right now with whatever each of us is experiencing? What are the things that feel like not painful? What are the things that are options, right? If we're scheduling this opportunity, it doesn't have to mean that it's going to lead to intercourse or anything like that. It just means like we could just kiss and cuddle and whatever and just kind of take it slow to make sure we will feel safe along the way.

26:14
Absolutely, that's so critical. And I will say when I meet with a couple who haven't had sex in a while, a lot of times, the platonic physical affection has really decreased, because they don't want to give each other the wrong message. Right? There can be this idea of I don't want if I kiss my partner, I don't want them to think I'm seducing them. And then I'm going to have to reject them and put a stop to it. And that's going to be sad.

26:41
So just getting communication of, oh there's some reason sex isn't happening right now, but can you kiss and hug and snuggle or do these things and understand that it's not gonna lead there? Is that okay? And sometimes opening that door can really warm things up, help people feel closer and more connected. The idea of if you're not having sex, you don't get any physical warmth and affection is so much more harsh than

27:09
there are a lot of things you can do even if certain items are not on the table. Yeah, that's great. And for the person who wants more physical connection, I've heard other sex therapists say something like, well, you know, they almost prescribe, like, I don't want you to have sex at all for the next two weeks or something like that. And if

27:34
If the partner with lower desire knows that, they can feel safe and comfortable to give hugs or to suggest cuddling if they think about it. And so that you kind of rebuild that physical connection, but they have the safety to know it's not going to lead to something more or something like that. But the communication around that is so important, because then the couple can really make up meaning about it that feels a lot more connected with each other. Absolutely.

28:03
Yeah. Something else I would say when I talk about making time for sex, know, scheduling opportunities, so to speak. Some people I meet with kind of have this checklist in their mind of I've got to do all these things before I can have fun and relax and sex is in the fun category. So all this other stuff has to happen. And I encourage reevaluating that.

28:28
because if it's meaningful and helpful to your relationship, if it puts you in a better mood for the rest of the day, maybe put it sooner on the list than uh once everything else is accomplished. The other thing I think is so helpful to consider, and not everybody has the luxury of free time in their lives, but I think it's helpful to consider your circadian rhythm.

28:53
and when you feel the most energized and best during the day. And most people I talk to, this is not at night when they're getting in bed ready to go to sleep. However, that is the stereotypical time to have sex. So not wanting to have sex when you're exhausted makes sense. When somebody's not wanting it, we really want to think there's probably a bunch of good reasons and we want to investigate those.

29:20
Yeah, that's such a great point. mean, especially people who are working, who have kids who it's like they don't have any time for themselves until the end of the day. Yeah. And then, you know, like you said, like, you're just you're getting in bed and you're exhausted. It's just for a lot of people, it's just not the time that's going to feel like you want to be sexy. know? Absolutely. Yeah, that is a dilemma. Yeah.

29:46
Want to speak a little bit about one of the most common challenges that men experience, which is erectile dysfunction. And I've come to believe, uh working with men over time that a really big cause of erectile dysfunction is erectile dysfunction. Once, once it happens, even once it's possible to get so nervous and anxious and worried about it.

30:13
that it can kind of become a self fulfilling prophecy, unfortunately. Interesting. This is another topic that it's so important to have that communication. Because if you have a partner interpreting, well, you're not attracted to me, or are you thinking about somebody else? Or basically, if the partner is getting mad and having a negative emotional reaction, now the pressure is even greater to perform. Yeah, absolutely.

30:45
which is super stressful. And also why it's so helpful to work with these things in a couple settings so that we can get to the bottom of what are some of these assumptions? Can we clear up some of these assumptions? Usually the person who's experiencing ED will say, I really want sex, I'm really attracted to you. It's really frustrating to me that my body is not cooperating 100%. Yeah. Well, and again, to go back to your

31:14
something you said earlier, if we're defining a successful sexual encounter by intercourse that lasts a certain amount of time or all of these things, whatever uh people think that is normal, quote unquote, it just does feel like so much more pressure, right? Whereas,

31:41
If there's a lot of acceptance about like, it doesn't matter if you get completely hard while we're having sex. It's more like, how do we define success? whatever happens happens as long as we're communicating well and we're saying what feels good and we're connected with each other. That should be the definition of success rather than this looking like we're performing a certain way or something like that. ah

32:10
Absolutely. That is so true. And one cultural myth that I think really negatively impacts men is that they always want sex and they're always up for it. And the reality is you're not a machine, you're a human being. And for somebody who is struggling with performance anxiety, I talk about how, um, if you're tired, if you're not feeling well,

32:39
if you and your partner aren't getting along. Basically, if there's a reason you're not in the mood, don't try to push through because that might not go very well. It's really okay to say no and wait for a better time. Yeah. Yeah, that's great. Yeah, there are medications that are helpful and effective for ED, but it's only one piece of the puzzle if it is

33:08
brought on by anxiety. It's also important, of course, to get medically checked out to make sure there's not a physical cause. But when it is anxiety, to add to what you were saying, Shane, the thing that can be so helpful is when both people believe they're going to be able to have an enjoyable time, whether or not it looks the way they thought it was going to look.

33:36
that they can be flexible, that they can pivot. And one way I like to say it is, by all means, invite the erection to the party. But if the erection does not come to the party, or leaves early, you still hold the party, and everybody can still have a good time. Yeah, that's great. That's great. Yeah, and I imagine, for a lot of people,

34:02
they just get so in their head or so worried about what their partner thinks that they're not having these conversations. that when they come to sex therapy, they're actually talking about things for the first time. being able, know, the way you and I are talking about it just feels like so much less pressure, I think, if the couple can begin to sort of approach it that way.

34:31
Yeah, that's so true. Another important mindset for people to have is that in good sexual encounters, both people are able to give and receive. And that doesn't have to be mutual every time, but ideally that's something both partners are capable of. I'm really surprised how many people I work with who uh

35:00
don't really know how to pursue their own pleasure and enjoyment. They're worried about, I doing it right? How do I look? What if I look unattractive in this position? It's very performative instead of, I'm gonna pursue what's really fun and hot for me and my arousal and excitement is gonna be contagious and help move this forward for both of us.

35:28
I think sometimes when somebody doesn't know what they want and they just hope their partner will magically know and give it to them. That's a real setup for failure. Of course. Yeah. That can be a gender difference too. I will say culturally and physically, I think it is a little more the norm that, uh, boys and young men figure out how their body works.

35:57
They learn how to masturbate. They do it. They have experience. And it's not unusual that women do not really figure that out. It is easier to find and figure out a penis than a clitoris. Even for the owner of these parts, there is that difference. And so when two people come together and one person's had plenty of practice with how his body receives pleasure and the other person, it's a little more mysterious or in the dark.

36:26
I can't even tell you how many women have seemed embarrassed that they need clitoral stimulation to have an orgasm. There's this sense of it's something wrong with me. It's so like I'm such a pain. I'm so extra. I'm so over the top that I need this thing. And it's like, that's like a man needing his penis stimulated. Like it is extremely normal and to be expected. And if you need to use

36:53
toys to get there, if you need certain positions to get there, whatever you need, how great that there's something that works for you. Yeah. Yeah. And I think our society does a really bad job of educating people about that kind of thing, you know, where people, a lot of people grow up and they have no idea about the different options for creating pleasure for themselves. Yeah.

37:21
Yeah, and there's guilt and shame around exploring. There are so many ways that people can pick up on negative messages around sex, around their body. There can be a lot of barriers in place for people. Yeah, and maybe this is influenced by the movies or something like that, but there's this sort of, I think a lot of people have this expectation that

37:49
you know, we're going to fall in love and then everything with sex is just going to fall into place and we're going to want the same things and we're not even, you know, we don't even need to talk about it. We're just going it's just going to like, we're just going to melt together and it's going to feel perfect and it's going to happen, you know, happen, you know, at the same time together. And it's like, you know, I, I, I don't, just don't think that's the reality.

38:15
Uh, it's so not the reality. And one thing that drives me crazy on TV and in movies is the very minimal amount of foreplay. It is really cut. First, um, many sexual encounters in the media start with people having a conflict or a fight, which is not super realistic in real life. A lot of people don't want to have sex with somebody they're mad at. I'm going to say that is pretty common. So there'll be some kind of conflict or fight.

38:44
and then maybe like a longing look and maybe a kiss and then they're having sex against a wall. It's just like, come on, this, is not how it goes. Right. Right. And I think it's just one more thing that can add shame for people like, well, our sex doesn't look like that. Our sex doesn't look like what we saw in the movies. So what's wrong with us? What are we doing wrong? Yes. And

39:11
I've talked to people who are really embarrassed that it takes them a while to work up a sexual appetite. takes them a while to get there. And it's like, well, if you're having fun and you have the time, ideally that's a pretty good way to spend that time. That's not something to be embarrassed about. That's normal. It takes what it takes. Yeah. Yeah. It's so helpful to hear you normalize these things. And I feel like

39:40
It's such a huge opportunity for couples when they can begin to communicate openly and sort of realize like, it's okay to talk about what feels good or what works or what doesn't work and to, you know, just have so much more knowledge around what works for each other. Well, and you're, so good, Shane at talking about having a clear speaker role and a clear listener role. And it can be so helpful to.

40:10
use some kind of structure along those lines in sessions when helping couples talk about sex. I use the Amago Dialogue. Most couples therapy models have, there's the Gottman-Rapapur. I mean, the developmental model uses the initiator-inquirer. How do you get one person talking, one person listening, and then they take turns so that they're not reacting off each other and having the same conversation they have at home that doesn't?

40:40
lead anywhere good. Yeah, that's great. And the acceptance of, you know, one person's reality might be very different than the other person's reality. And that's okay. But we have to take turns to sort of share that with each other. We don't want to get it mixed up by both trying to figure out what's right or wrong, so to speak. Absolutely. And the other piece that comes up a lot in couples therapy anyway,

41:07
that applies to sex is when one person really wants a change from their partner, the best thing they can do is look for tiny steps toward progress and celebrate the heck out of those. And sometimes they do just the opposite. I will give you an example of a higher desire partner who feels like they've been starving for sex, and their partner finally initiates and instead of rewarding them and moving toward that,

41:35
They really want to reject them so that the partner can know how bad this rejection feels. Yeah. This is something that might be very satisfying in the moment, but will not get them what they want in the long term. Yeah. Yeah. Yeah, that's great. mean, we could probably have a whole other conversation about like, you know, even just focusing on the higher desire partner and the emotional experience of it.

42:03
And what do you do with those emotions? And how do you explore those for yourself as an individual? But also, how do you communicate about that in a healthy way instead of going to that place that feels like punishing or resentful or something like that? Absolutely. There's a lot there for a lot of people. Yes. And the Gottmans talk about how many problems in a long-term relationship are

42:32
You manage them, but you're not ultimately going to solve them. A desire discrepancy often falls into that category that you may not ever want exactly the same amount of sex, exactly the same kind of sex, but how do you address the emotional and communication dynamics and ideally move things closer over time? Yeah, this is great. This is so helpful. I want it.

43:00
I know you sort of touched on it at the beginning, I want to, as we begin to wrap up, I want to make sure we hit this point again. For people who don't have sex therapy training, they're working with couples, what are some good questions or ways to bring this into the conversation at the beginning just to sort of make the couple feel safe to talk about it? ah And should we include it in our...

43:27
a question in our paperwork. Great question. do. on the first meeting. How should people think about that who are not sex therapists? Yeah. My initial paperwork is not terribly extensive, but I do ask two questions about sex. The first one is something along the lines of how satisfied do you feel with your sex life?

43:53
And the second one is, you have any sexual concerns you would like to address in couples therapy? So often I have some amount of information coming in the door and then I will ask the question of how's your sex life? And I think just that gives permission to be able to talk about it in the room. And then when somebody brings it up,

44:20
It's important not to move away from it or shut it down, but simply to ask follow-up questions. And I will say most therapists are very conscious of wanting to operate within their scope of competence, which of course we all want to do that. But sometimes I think sex takes on this additional importance in our mind that maybe isn't necessary. For example, I don't have any training in grief counseling.

44:49
But if somebody tells me they've had a loss, I can say, I'm so sorry to hear that. What did that mean to you? How are you doing? Are you noticing that it's impacting you? I mean, I can ask a lot of follow up questions without being an expert in that area. So I would liken it to that. Now, if that was somebody's primary concern, I might refer out, but people are whole people.

45:18
Most everybody is going to have some kind of sexual concern at some point across their entire lifespan. So being able to ask questions, be interested, be curious, and the other thing, normalize. Yeah, just not to act too shocked or alarmed. um And people think when it comes to sex, they are not normal. They are broken. There is something wrong with them. I

45:44
always take the operating assumption of people do things that make sense. And there's probably really good reasons why they are where they are with sex. For example, I'll sometimes have somebody say, I don't know what's wrong with me. I just haven't wanted sex in a while. And then we talk about the nature of the sex. And it sounds like not enjoyable sex. It's like, it's normal to not want something

46:13
that you don't like or enjoy. Yeah. So just taking the assumption that there's really good reasons for people's behavior, you can help them find out what they are and make sense of themselves instead of we're going to uncover this big trauma or pathology and figure out what's wrong with you. I don't operate that way at all. Yeah. No, I love that. And I think it's something that all therapists should

46:43
work on for themselves, whether it's take a training or, you know, cause all of us have ways in which we've been socialized that can make sex difficult, even for us to, you know, if a couple starts talking in great detail about it, the therapist might start becoming very uncomfortable. I, and I think like you're saying, like we, we want to approach it. We don't want to make clients feel like

47:09
it's too hard for us to handle because then they won't bring it up again. Yes. And we have to increase our comfort level again by either taking a training or working on ourselves. But we want to be able to navigate it just like any other topic, just like if we're talking about finances or parenting or doing the dishes or whatever, it's sort of like that reflective listing that you talked about. How do we stay present? How do we

47:38
you know, realize this doesn't, you know, we want to be supportive and accepting so that the couple can keep communicating about it. And that's such a good point, Shane. And we're not in most of these areas. We're not solving the problem. We're not giving the answers. We're opening the communication so that they can come to what works for them. So asking questions like, what have you already tried? How did that go? What went well or not well about that?

48:07
We don't really have to, and we shouldn't really guide them anywhere. It's about what works for them. Yeah, that's great. And are there any thoughts about when is it the right time perhaps to refer to a sex therapist? From my perspective, most couples therapists are going to be skilled at opening up

48:36
communication, exploring, interpersonal dynamics, underlying beliefs. I recommend, and let me say this too, it depends on the sex therapist, but one thing I really enjoy doing is working with an individual or a couple for just a few sessions to do a deep dive into the sexual issues.

48:58
knowing that they're going to go back to their regular therapist or keep their regular therapist. So sometimes you can have that kind of short term collaboration that can be really beneficial. Yeah, that's great. But in general, I would consider referring out if a sexual concern is the primary issue and opening up the communication, the relational dynamics does not seem to be shifting the issue.

49:26
There's some research that indicates that a certain amount of couples, once they improve their relationship and their communication, their sex life will improve. And others will need specific interventions, recommendations, guidance, and so on. And so hopefully that becomes clear over time. Yeah. Yeah, that's great. When I would encourage people, you know, and I've done this a few times before, where I have

49:55
actually like paid, I've been working with a couple and I've paid a sex therapist to do like a consultation with me and I'll sort of ask them, I'll tell them what's going on. I've been working with this case. Here's what I'm struggling with, whatever. And they can kind of give me some guidance about either tell me what I could do differently with the couple or ah say, yeah, this is probably a good case where you want to refer to for them to a

50:23
sex therapist or something. Yeah, I think getting consultation is always wonderful. I love it when people consult with me. I will also just add if a couple has a sexual issue that does make you really uncomfortable and you don't want to try to work through that and you don't enjoy working with them or talking about it. You don't have to. I mean, that's one of the nice things if you're in a private practice setting, you kind of get to choose. Is this a good case for me? oh

50:53
And if you're having negative or judgmental or off putting feelings, and that's not the case for you, that's really okay. Not all therapists have to be comfortable talking about all kinds of sex. Yeah, yeah, that's great. This is super helpful. Thank you so much, Adrian. Where can people find you? If they're interested to learn more?

51:16
Yeah. Well, if you Google my name, Adrien Monti Roanoke, Virginia, I should come right up. It is not a big city. And the name of my practice is Inner Flame Counseling. So my website is www.InnerFlameCounseling.com. I'm licensed to see clients only in the state of Virginia, but I love to do consultation or speaking engagements anywhere. Oh, great.

51:45
Good, good. Well, thank you so much. This has been super helpful and yeah, hopefully we can catch up again soon. Thank you, Shane. It's really been a pleasure and I appreciate the opportunity. Yeah, absolutely. The episode this week is brought to you by Alma. They make it easy to get credentialed with major insurance plans at enhanced reimbursement rates. Alma handles all of the paperwork and guarantees payment within two weeks. Visit HelloAlma.com or click on the link in the show notes to learn more.

52:14
Thank you again, everybody. This is Shane Birkel and this is The Couples Therapist Couch podcast. It's all about the practice of couples therapy. hope you have a great week and we'll see you next time. Bye, everybody!