Sex Therapy with Survivors of Sexual Abuse

Tenet 4: Use Standardized Techniques In a Fixed Sequence

Another tenet of traditional sex therapy was the importance of using a fixed series of behavioral techniques.  Sex therapists relied heavily on "sensate focus" exercises that were developed by William Masters and Virginia Johnson³.  Versions of these techniques   exist in the standard treatments for low sex desire, pre-orgasmia, premature ejaculation, and impotence.  These structured step-by-step behavioral exercises were designed to improve self-awareness, sexual stimulation, and partner communication.  Through working with survivors, however, we have learned that sex therapy techniques need to be expanded, modified, and individualized.  Time must be spent teaching appropriate developmental skills and pacing therapy to prevent retraumatization.

One day in 1980, the bulb on my little projector broke and I could not show Fred and Lucy the tape on the first level of sensate focus exercises.  Instead I gave them a handout and complete verbal instructions.  They were to take turns lying down and massaging each other in the nude.  The next week they came back and reported on how it went.  Lucy said the exercise was all right, but Fred's belt buckle kept hurting her as she passed over it.  Even though they had been given specific instructions to take their clothes off, Lucy, an incest survivor, said she never heard them.  Instead, she adapted the technique to make it less threatening.

Standardized techniques performed in a fixed sequence generally don't work for survivors because these techniques fail to respect the important needs survivors have for creating safety, pacing experiences, and being in control of what's happening.  Just being able to sit, breathe, feel relaxed, and stay present while touching one's own body can be a challenge.

Survivors need a lot of options for exercises that offer opportunities to heal without being overwhelmed.  I rely on the techniques for relearning touch described in my book The Sexual Healing Journey.  These techniques can easily be modified, adapted, and rearranged in different sequences by survivors themselves.

It is essential that sex therapists assess a client's readiness before suggesting a particular sex therapy exercise.  I often find that a client's curiosity about an exercise is a good indicator of readiness to try it.  Starting, stopping, and shifting among different techniques.  Nudity, genital exploration and exchanging sexual touch with a partner are often advanced challenges, generally not appropriate to suggest in the early stages of therapy.

Sexual healing is generally an advanced type of healing work for survivors, less important than issues such as overcoming depression, improving self-esteem, resolving family-of-origin issues, and securing physical safety and health to name a few.  Any sex therapy therefore needs to take a back seat to general recovery issues that might arise.  Sex therapy needs to be integrated with other aspects of resolving sexual abuse.

Tenet 5: More Sex Is Better

In traditional sex therapy, the main criteria by which we judged success was how regularly and frequently clients were having sex.  I used to ask lots of questions about frequency and evaluated success by how much a couple conformed to the national average of engaging in sexual activity once or twice a week.  Ths focus on quantity often ignored issues of quality.  Working with survivors taught me that with physical and sexual interaction, high quality is more important than large quantity.

Jeannie, a 35-year-old survivor of childhood molestation, and her boyfriend, Dan, sought therapy to address sexual intimacy
problems.  They planned to marry in the next year.  It was concerning both of them that Jeannie would "check out" during sex.  "I feel like I'm making love to a rag doll," Dan lamented.  She agreed to sex to please him, fearing he would end the relationship if she declined too often.

For Jeannie, more sex brought on more problems of dissociation.  The sexual contact she was having was getting in the way of her recovery from sexual abuse and her ability to create an honest intimacy with Dan.  In therapy, as the reality of what was going on emerged, the couple decided to take a vacation from sex for awhile.  Jeannie needed time and permission to validate her inner experience.  The break from sex enabled her to honor her real feelings, learn new skills, and eventually be able to say yes to it without anxiety.  Jeannie also learned that Dan loved her for herself, supported her getting in touch with her inner feelings, and viewed sexual interaction as less important than emotional intimacy and honesty.

When survivors progress in healing and start having sexual relations more regularly, it's not uncommon for the frequency of their sexual interactions to vary. To ensure positive sexual experiences, survivors often need to give themselves a safe, comforting envirornment and plenty of time for intimate relating.  Sex emerges from mutual good feelings and a sense of emotional connection between partners.  The high quality and specialness of sexual encounters become more significant than how often they occur.

Tenet 6: An Athoritative Behavioral Goal-Focused Style Works Best

In traditional sex therapy, the therapist's role was primarily to present a program of exercises and help clients follow that program to achieve functioning.  Therapists offered sex education and worked to improve couples' communication.  The therapist was the authority, suggesting techniques, pacing interventions, and monitoring progress.  Little attention was paid to how a therapist's style might be influencing the progress of therapy.  Working with survivors has taught many sex therapists that their therapeutic style is as important as any intervention.

For many survivors, sex is one of the most difficult areas to address in recovery Just hearing the word "sex," or saying it can bring on a minor panic attack.  Survivors can easily unconsciously project feelings toward the offender and the abuse onto the therapist and the sexual counseling.  After all, therapists seem invested in survivors being sexual, and the process of therapy strains a survivor's sense of control and protection.  This high potential for negative transference needs to be addressed if sex therapy with survivors is to be successful.

To minimize negative transference, I suggest therapists adopt the following premise: Do the opposite of what happened in the abuse.  For instance, because the victim was dominated and disempowered in abuse, it makes sense that therapy should focus on empowering the client and respecting his or her reactions to it.  Therapists need to explain techniques and interventions, encouraging clients to exercise choice at all times.  Suggestions, not directions or prescriptions, should be given.  Rather than admonish clients for their resistances and relapses, therapists should reframe these as inevitable, seek to understand, and work with them.

Because sexual abuse involved a traumatic violation of boundaries, it's important that sex therapists be extremely good at maintaining clear emotional and physical boundaries.  Talking about sex can stir up sexual feelings.  It's inappropriate to combine sex-focused sessions with touch.

Several years ago, I was appalled when a prominent sex therapist told me how she held and rubbed her female client's hand during a session to demonstrate different stroking techniques for masturbation.  Therapy needs to be a safe place physically and psychologically for everyone, at all times.

It's also important for sex therapists not to dominate the content and course of therapy.  Personally, I find I'm most effective when I establish a therapeutic relationship with the client in which we're working together.  The client sets the pace and direction and presents the content; I provide encouragement, support, guidance, creative ideas, insight, information and resources.

The Value of Change

There is no question that the challenge of treating survivors has revolutionized and improved the practice of sex therapy Personally, I know that the changes I have made in how I perceive and practice sex therapy have made me a better therapist with all of my clients, regardless of whether they were abused.  Other sex therapists seem to agree that the practice of sex therapy has become more client centered and respectful of individual needs and differences.  Learning about the dynamics of sexual trauma has helped therapists become more aware of the conditions necessary for sex to be positive and life affirming for everyone.

Endnotes

¹ This is a pseudonym, as are all names in this article.

² For more information on techniques, see The Sexual Healing Journey, HarperCollins, 1991.

³ For a description of these techniques, see William Masters et al., Masters and Johnson on Sex and Human Loving, Little Brown and Co., 1986.

Wendy Maltz, M.S.W., is clinical director of Maltz Counseling Associates. She is the author of the Sexual Healing journey: A Guide for Survivors of Sexual Abuse and Caution: Treating Sexual Abuse Can Be Hazardous to Your Love Life.

Last updated: 8/05

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