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​​​​Sex Therapy from a Systemic Lens

​​​​Rebecca Brennan

​​​​National University

​​​​Dr. Kiser

​​​​MFT-8310

​​​​2/8/2026

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Sex Therapy as a Field

​Sex therapy is a very important role in today’s culture. Sexual problems are more

abundant then in past generations (Belous, 2012).  Approximately 31% of men and 43% of

women report sexual issues in the last twelve months (Belous, 2012).  The issues reported are

lack of intimacy, sexual pain, problems becoming aroused, and inability to ejaculate (Belous,

2012). Sexual assault is on the rise and only 40% are reported (Belous, 2012). Rapes tend to

be committed 66% of the time by an someone the person knows (Belous, 2012).  Many women

have encountered sexual violence, about one in four (Department of Justice, 2007).

About 8% have a pornography addiction with most people spending an average of

eleven hours on pornography sites a week (Belous, 2012).  This increases the likelihood of

having an extra-marital affair, men more than women (Belous, 2012).  It is imperative that

marriage and family therapists have training in sexual violence, sexual therapy, and affairs.

Timeline see appendix

Systemic Thinkers

​Systemic therapists have to many times think “outside the box” to be able to work with

sexual issues for the couple. While the relationship is the most important thing, the

interventions need to be put into place to help the couple (Henderson, 2013). CBT couples

therapy is an effective tool with four elements “feedback, goal consensus, collaboration,

and positive regard” (Henderson, 2012 p.133). In essence, the client’s become

the therapist and they discover their problems through curiosity and collaboration to change

(Henderson, 2012). Systemic thinkers have adapted sexual therapy because sexual behavior is

Influenced by family systems and perceived notions (Hertlein, 2015). Sex has and always will be

effected by family values, rules, and experiences, therefore it has become a systemic issue

(Hertlein, 2015). Societal norms have changed throughout the years including what the DSM

constitutes as “normal” behavior (Hertlein, 2015). In 1973 homosexuality was taken out of the

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DSM and was no longer considered a mental health issue (Hertlein, 2015). As therapists it

is important to qualify “clinical judgement” (Hertlein, 2015). They do this by recognizing both

criteria and level of distress (Hertlein, 2015).

Similarities and Differences of Sex Therapy and Systemic Sex Therapy

​Sex therapy is the understanding of sex and the dysfunction surrounding it. Sex therapy

is talk therapy with interventions regarding the sexual dysfunctions the couple is having

(Tabatabaie, 2014). The goal is for the couple to leave therapy with improved sexual

relationship functioning (Tabatabaie, 2014). However, many therapists have noted that just

“sex therapy” often times does not fully improve the couples’ sexual relationship and it negates

to find underlying problems that may exist (Tabatabaie, 2014). The primary focus with sex

therapy is to work on “confidence, pleasure, and intimacy” (Tabatabaie, 2014 p.271). A model

often used is frisky rather than foolproof (Tabatabaie, 2014). The goal is achieved when the

couple agrees that they have developed satisfaction with their sexual relationship (Tabatabaie,

2014). There are several measures to be able to test sexual function from the “Sexual

Interaction Inventory, the Derogatis Sexual Functioning Inventory, the Golombok-Rust Inventory

of Sexual Satisfaction, the Sexual Experience Scales, and the Sexual Interaction System Scale”

(Tabatabaie, 2014 p. 273).  All have positive and negative results for determining the

effectiveness of sex therapy.

​Systemic sexual therapy has a different lens.  Sex therapy was not ever discussed in

psychotherapy until Alfred Kinsey looked at normal and abnormal sexual behavior starting in

the 1940’s and 1950’s (Wiley, 2010). Kinsey said that sexual problems can change within the

couple once the system of change is brought on through a systemic lens (Wiley, 2010).

When a therapist looks at client’s sexual problems from a systemic lens, they look at the couple

as a whole, not just their sexual problems. The therapist looks at attachment styles, interaction

with parents and how sex was talked about, genograms, intersystem domains, constructs within

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life cycles, and triangular theory of love (Hertlein, 2015).  Sex therapy from a systemic lens

is much more inclusive with the dynamics of the couple and the family (Hertlein, 2015).

Examples

​A sex therapist may take an evaluation of a couple and provide interventions to help

them improve their sexual intimacy such as sensate focus (Hertlein, 2015). Whereas, a

systemic sexual therapist may get a sexual history on each partner, do a genogram, and not

just look at the sexual issues, but may look at attachment styles secure, anxious, avoidant,

anxious avoidant (Hertlein, 2015). Attachment styles determine a lot for how a couple

engages with one another (Hertlein, 2015). For example, a secure person has low avoidance

and low anxiety, a person with anxious attachment style is highly anxious and has low

avoidance, a person with avoidant attachment style has high avoidance and low anxiety, and

a person with anxious avoidant has both high anxiety and high avoidance (Hertlein, 2015).

A systemic sex therapist believes that this translates to their sex life (Hertlein, 2015).

Modernist Models versus Postmodern

​Modernist models might describe sex in three stages “Human sexual response cycle”

which is “excitement, plateau, orgasm, and resolution” (Hertlein, 2015 p. 17). Traditional sex

therapy was not viewed as being systemic (Hertlein, 2015). However, after an article was

published “Integrating Sex and Marital Therapy: A Clinical Guide, in 1987”, therapists began to

view the importance of assimilation of sex in couples therapy (Hertlein, 2015). Many couples

therapists began to use an integrative approach (Hertlein, 2015).  MFT’s began to realize the

importance of sex relations with the couple’s intrinsic and exterior worlds (Hertlein, 2015).

The intersystem approach looks at all models biological, physiological, relationship patterns,

attachment, parental influence, culture, religion, and the like (Hertlein, 2015).

​Postmodern systems may look at the intersystem approach (Hertlein, 2015). This

incorporates the idea that different territory brings on different behavior (Hertlein, 2015).

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Postmodern theorists would incorporate theories of love and interaction and attachment

(Hertlein, 2015). Interdependence is where the partners learn to trust each other to meet

their needs (Hertlein, 2015). Attributional strategy is when the partner’s conduct leads to

motivation of the behavior (Hertlein, 2015). A husband may feel that he cannot perform sex

well, therefore he ejaculates early so the act is done quickly (Hertlein, 2015). Reframing this

for the couple could be very powerful so they can both get their needs met (Hertlein, 2015).

The triangular theory of love is “commitment, intimacy, and passion” (Hertlein, 2015 p.42).

All of the three issues are vital for continuing a healthy, loving relationship long term

(Hertlein, 2015). The differences here between systemic and sex therapy is a sex therapist

will focus on affection, whereas a systemic therapist would focus more on inwardness and

engagement (Hertlein, 2015). Negative thought patterns create a negative relationship, by

focusing on positive regard and positive bids, this can help the couple develop fondness for

one another which can enhance their sex life (Hertlein, 2015).

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​​​​References

Belous, C.K. et al. (2012). Revisiting the sexual genogram.  American Journal of

​Family Therapy, 40(4), 281-296.

Henderson, P. (2014). In praise of “ordinary “sex therapy. Sexual & Relationship

​Therapy, 29(1), 132-134.

Hertlein, K.M. et al. (2015). Systemic sex therapy.  New York, NY: Routledge.  

Tabatatabaie, A. (2014). “Does sex therapy work? How can we know?”

​Measuring outcomes in sex therapy. Sexual & Relationship Therapy,

​29(3), 269-279.

Wylie, K.R. et al. (2010). Original article: Working interactively using a systemic

​sex therapy model for common sexual problems within a modern health

​service setting. Sexologies, 19(4), 196-201.

U.S. Department of Justice. (2007). 2007 National Crime Victimization Survey.

​Washington, D.C. Government Printing Office.

Behavioral Methods in Couples Therapy

All behavior has a purpose and couples therapy is no different (Besharat, 2003). Behavioral therapists will manipulate family systems, even a change in one partner can manipulate the couple dynamic (Munichin, 1974). The couple tends to follow rules to keep the system in homeostasis (Barsharat, 2003). By breaking the rules, this aggravates the system which may allow change in the subsystem for the couple (Munichin, 1974).

In Behavioral therapy the couple generally presents as belligerent, bitter, detached, and enervate (Epstein, 2019). The research suggests that the more positive reactions the couple has either through communication or noncommunication, such as body language, the better the couple will feel towards one another and the stronger the relationship (Epstein, 2019).

In behavioral therapy, the therapist must understand human behavior to understand how the couple operates (Besharat, 2003). As therapists, we need to understand respondent, operant, and observational learning (Besharat, 2003). Basically, a human reacts a certain way due to their environment and experiences (Besharat, 2003). A great example would be watching how a person’s parents act in their marriage can be either a good or bad role model to emulate (Besharat, 2003). All people try to augment rewards and decrease costs (Besharat, 2003). The more positive the relationship is, the higher the reward and the more enjoyable it is for each partner (Besharat, 2003).

Cognitive Behavioral Therapy (CBT) focuses on problem solving, communication, skills training, and role playing (Mack, 2019). The next portion is to work on distortions and misconceptions about expectations of the couple (Dattilio, 2010). Once the couple can accept their partner as they are, the distortions dissipate (Mack, 2019). Some successful interventions have been joining, externalizing the problem, and building resilience (Mack, 2019).

Looking at family problems from a systemic lens, it is believed that children’s problems stem from marital problems (Fiese, 2019). A system is designed by how the parts of it interact (Fiese, 2019). For example, in a car, if it runs out of oil, eventually the engine starts to break down and stops functioning. The car does not break down by itself (Fiese, 2019). “A system is greater than the sum of its parts, open systems continuously have inputs and outputs to not create homeostasis, and negative feedback loops facilitate self-stabilization” (Fiese, 2019 p.4). A hostile or disconnected family was more likely to have conflicted children (Fiese, 2019). If the family is able to be open, cohesive, and adaptable, they were able to function better (Fiese, 2019).

Couples have a hard time differentiating between their thoughts and feelings, instead it is important to distinguish between how their partner is feeling and understanding that perspective (Epstein, 2002). In general systems theory, the system is defined by its elements (Fiese, 2019). In other words, all of the individuals within a family system have a role to play (Fiese, 2019). Open versus closed systems vary drastically (Fiese, 2019). A closed system is one which the couple has an adverse or detached communication style with themselves and also their children communicated this way (Fiese, 2019). In contrast, and open system is where the couple opened the system to communicate and be malleable, the entire family communicated allowing more information into the system. (Fiese, 2019). The two largest properties of an open system are “adaptability and cohesion” (Fiese, 2019).

By using these theories behavioral, cognitive behavioral, and systems in conjunction with each other is effective when working with the couple so they can understand how family systems work.  By understanding the behavior, it enlightens the couple to create a safe space to work on themselves in a cohesive manner. It is recommended that for distressed couples, a behavioral approach is ideal (Mack, 2019). For families needing youth coaching or with cognitive distortions, cognitive behavioral works well (Mack, 2019). Systems theory is helpful to understand the family dynamic with systems, subsystems, and hierarchies (Fiese, 2019).

References

Besharat, M.A. (2003). What are the main differences between behavioral and systems therapy

     with couples? A critical account. Journal of Contemporary Psychotherapy, 33, 109-127.

Dattilo, E. M. (2010). Cognitive behavioral therapy with couples and families: A comprehensive

     Guide for clinicians.  New York, New York: Guilford Press.

Epstein, N.B. & Baucom, D.H. (2002). Cognitive and emotional factors in couples’ relationships.

     In Enhanced cognitive-behavioral therapy for couples: A contextual approach (pp. 65-104).

     American Psychological Association.

Epstein, N.B. & Baucom, D.H. (2002). Behavioral factors in couples’ relationship problems. In

     Enhanced cognitive-behavioral therapy for couples: A contextual approach. (pp.27-63).

      American Psychological Association.

Mack, K.N. & Lebowitz, E.R. & Silverman W.K. (2019). Contemporary family

     Psychotherapy. Behavioral and cognitive-behavioral theories. APA handbook of

     contemporary family psychology: Foundations, methods, and contemporary issues

     across the lifespan. Vol 1. Pp 55-73. American Psychological Association.

Munuchin, S (1974). Families and Family Therapy. London: Tavistoc Publications.

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Rebecca Brennan-MFT-8308-Dr. Kraus-11/17/24

      A couple’s sex life is the language of how their relationship is going (Thorngren, 1999). Intimacy is about looking for appreciation from someone who has a low level of differentiation (Thorngren, 1999). By the couple having intimacy, it allows a relief from the anxiety they feel from a low level of differentiation (Thorngren, 1999).  Both partners Jamal and Ebony seem to have a low level of differentiation. Jamal shows this by seeking approval from Ebony through sex to relieve his high stress, he is desperate to calm his anxieties with Ebony by suggesting she take a pill so she could be more intimate with him (Thorngren, 1999).  He is thinking less about himself and more about the relationship because of his desperate need for connection. The couples’ language is disengaged. Ebony, in contrast, is withholding sex to try to get her power back (Regas, 2019). She has an acute reactivity to the situation by shutting down (Regas, 1999). People who are differentiated are flexible with change (Regas, 1999). The reptilian brain is very reactive, as opposed to the cerebral cortex which can reason (Regas, 1999). People who are differentiated have the ability to calm themselves down quickly when there is abundant stress (Regas, 1999). The answer to the question is, yes, absolutely the couple can be helped and does not need to settle for a poor sex life. By bringing up problems in the marriage, it creates improvement in connection (Hardy, 2018). The crucible theory is to bring up the difficulties in the marriage, like a problem with sexual connection, can bring affirmative results to the couple (Hardy, 2018). The couple becomes more motivated to work around their gridlocked issue (Hardy, 2018). The therapist uses “collaborative confrontation” as a means to generate advancement in their relationship (Hardy, 2018). Ultimately, this allows the couple to address each other and have a new level of consideration for their problems (Hardy, 2018). 

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The ability for the couple to be able to handle adversity is directly correlated with how differentiated the couple is (Sauerherber, 2014). A couple who is differentiated can keep their emotions in check, separate from their family of origin, while still creating a close connection with their partner and creating autonomy (Sauerherber, 2014). The couple must define first who they are, then who they are as a couple (Sauerherber, 2014).   “Mindful differentiation has six components 1) connection 2) non-anxious presence 3) non-reactivity 4) emotional triangles 5) change back messages 6) tolerating discomfort for growth” (Regas, 2019. P75). To be differentiated, it requires the person to be mature enough to be able to look within themselves (Regas, 2019). They can do this by creating healthy boundaries and have a guide to be able to check themselves (Regas, 2019).   

Running head-Vignette 4 References Hardy, N. R. & Fisher, A.R. (2018). Attachment versus differentiation: The contemporary couples therapy debate. Family Process, 57, 557-571. Regas, S. (2019). Infidelity, self-differentiation, and intimacy: The mindful differentiation model of couples therapy. In P.J. Pitta & C.C. Datchi (Eds.), Integrative couple and family therapies: Treatment models for complex clinical issues. 43-56. Washington, DC: American Psychological Association., J.D. et al. (2014). Counseling Muslim couples from a Bowen Family Systems perspective. The Family Journal: Counseling and Therapy for Couples and Families, 22(2), 231-239. Thorngren, J.M. & Christensen, T.M. (1999). An interview with David Schnarch.  The Family Journal: Counseling and Therapy for Couples and Families, 7(2), 187-194.   

Vulnerability and the Role it Plays in Couples

Rebecca Brennan-National University-MFT-830—Dr. Kraus-10/13/2024

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      Marriage is about an emotional bond (Johnson, 2006). It is about an emotional connection, which others refer to it as “love” (Johnson, 2006).  The therapy process starts with how couples connect with emotion (Johnson, 2006). Statistically, people who are in relationships tend to have less anxiety, fewer illnesses, are less depressed, and have overall better physical health than people who are not in relationships (Johnson, 2006). When people are isolated from others, it is physically worse for them than if they smoked cigarettes (Johnson, 2006). In other words, connection is a huge part of the human condition both mentally and physically (Johnson, 2006).  Starting from birth, connection is a vital part of development (Johnson, 2006). When young children reached out to their parents for help and were hurt in the process, or worse were rejected, the child was taught a lesson (Johnson, 2006). Past experiences told them that it was not safe to reach out for help (Johnson, 2006). Later when that person decided to get married they tended to struggle to reach out for help and did not feel it was safe to do so (Johnson, 2006). Accessing empathy is scary for the couple and many people may be reluctant to feel safe enough to do so given their past experiences (Johnson, 2006).   In attachment theory, John Bowlby discusses from infancy, children do not appreciate the rejection of their mother (Johnson, 2006). When the children did not get the response from their mother, they became so angry that they forced a response, thinking that some response was better than none (Johnson, 2006).  If their needs continued to go unmet, they withdrew and believed their mother or other people did not care about them and became depressed (Johnson, 2006). People want to know if someone is there for them and if they actually matter

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(Johnson, 2006). How a relationship maintains itself is really how the couple responds to one another’s emotional needs (Johnson, 2006). The therapist is recreating an attachment bond with the couple they have never had, including with their own parents (Johnson, 2006). It is created by the couple to not only be seen, but heard, and understood by one another (Johnson, 2006).  In addition to attachment, the couple has a tremendous amount of shame surrounding their connection (Johnson, 2006). When the couple starts to pull away from each other, the shame they feel may bring on the feeling of I am not enough for my partner (Johnson, 2006). This develops a negative cycle that many couples stay stuck in (Johnson, 2006). Shame is about disconnection from others (Brown, 2010). Most people do not discuss shame because they are unsure where it comes from (Brown, 2010). People in general will avoid discussing shame because it is such a difficult topic (Brown, 2010). Of the few who were actually able to discuss shame, they had a sense of feeling worthy (Brown, 2010). The characteristics of someone who had the ability to connect had “courage, compassion, connection, as a result of authenticity” (Brown, 2010). People who felt they were worth it felt their vulnerability was something that allowed them to be alluring (Brown, 2010). Most are unable to deal with their vulnerabilities and instead numb them through substances, food, gambling or other distractions (Brown, 2010). The problem is when you numb feelings, you also numb joy or gratitude (Brown, 2010). What makes people feel better is to blame others rather than own their own part in not being able to be vulnerable (Brown, 2010). The hardest thing to do is to love another human being without any guarantee that things will work out, especially if our mothers could not do the same (Brown, 2010).  

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The couple can start this journey first by working with the therapist and building an alliance for both people in the relationship with the therapist by telling their story (Johnson, 2020). Then the alliance needs to be built with the couple (Johnson, 2020). The therapist then creates validation for both parties by developing empathy and understanding (Johnson, 2020). This creates a culture of feeling worthy and caring (Johnson, 2020). It allows the partner to feelseen, heard, and understood by the other partner in that they are not alone in their journey and will not be criticized or judged for how they feel (Johnson, 2020).   The therapist must get to know how culturally every person feels about vulnerability and connection, the therapist is not the expert in the room (Johnson, 2020). Even though attachment styles seem to be universal women tend to be more accepting of emotions than men do (Johnson, 2020). The couple can explain how culturally they feel about vulnerability, worthiness, and how emotions were dealt with in their family of origin (Johnson, 2020). If worthiness, connection, and emotions were not existent or the person was told they can not have certain emotions, this could be the reason that the couple is in a negative- feedback cycle (Johnson, 2020).  

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      When practicing EFCT, emotionally focused couples therapy, the couple can look at each other to not only hear their feelings, but see them (Johnson, 2020). The therapist will create a safe place for the couple to divulge their real feelings for each other maybe for the first time ever in their lives and the other spouse can receive that emotion to create a safe place for their partner (Johnson, 2020). The listening partner needs to validate their partner so that they feel heard, understood and seen (Johnson, 2020). In EFCT, the therapist will “1) recognize the problem 2) recognize the negative pattern the couple uses to cope 3) recognizing the emotions surrounding the problem 4) reframe the problem” (Johnson, 2006).  The sequence of events usually cause anger in the one of the partners (Johnson, 2006). This is not the primary emotion as the root is generally fear, fear of losing their partner (Johnson, 2006). The fear of losing brings on shame regarding the threat of losing connection (Johnson, 2006). The other partner shuts down from the freeze response because they do not see their partner’s anger as them trying to hold on to them, but rather them having contempt (Johnson, 2006). It is important to note that the formula will help couples who are willing to go through the journey and trust the process that they too will have a connection like they have never been able to have.

References: Brown, B. (2010). The Power of Vulnerability. Ted Talk. Johnson, S. (2006). Are you there for me?: Understanding the foundations of couple conflict  Psychotherapy Networker, 30(5). Johnson, S. (2020). The practice of Emotionally Focused Couple Therapy; Creating Connection.  (3rd Ed). New York, NY. Routledge.