Sex Therapy Treatment for a Couple in a Sexless Relationship: EMDR and CBT Therapy, the Perfect Therapeutic Couple

A healthy sexual experience happens in the brain and the body (Wise, N., 2022), requiring therapeutic attention be given to both when there is some form of sexual dysfunction, sexual disconnection, sexual trauma, or sex addiction. Eye Movement Desensitization and Reprocessing Therapy (EMDR) processes information stored in the brain and held in the body. EMDR reduces vividness and emotion associated with trauma memories through bilaterial brain stimulation produced by bilateral eye movements, tactile stimulations, or audio tones. Processing includes information held in the brain and activity happening in the body (EMDR International Association [EMDRIA], 2024). Cognitive Behavioral Therapy (CBT) focuses on changing thinking patterns, developing healthy coping skills, and problem-solving in the here and now (American Psychological Association [APA], 2017). Healing the impact of past trauma wounds and processing current thought patterns provide an effective and holistic approach to treating sex therapy issues couples seek help to resolve. One of the best aspects of applying EMDR therapy is the ability to use some of a protocol, every step of a protocol, or a combination of an EMDR therapy protocol with other therapeutic modalities to help clients resolve their presenting issues.

Combining EMDR and CBT can be so effective as a duo, and therefore, can be referred to as a match made in heaven or the perfect therapeutic couple.

Sex Therapy with Couples

Sex therapy is a multidimensional approach that considers the biological, psychological, pharmacological, and relational aspects of sexual problems (Wikipedia, 2024). When a couple presents to therapy with a sexual issue, the first step is recommending they get evaluated by a medical professional for an overall physical health assessment to rule out or treat any existing medical conditions, such as chronic pain, menopause, low testosterone, diabetes, low estrogen, weight issues, etc. that may have an impact on their sexual health (Wheeler & Sheikh, 2024). The next step is to gather information to assess any current mental health diagnoses, such as depression or anxiety, and any physical or mental health medications that may impact sexual health, such as Selective Serotonin Reuptake Inhibitors (SSRIs) (Cleveland Clinic). Once medical and mental health diagnoses are treated and any effects from medication are determined, it is time to assess and address relational issues, such as poor communication, lack of physical affection, life balance, partnering in life responsibilities, parenting, and other non-sexual relational interactions. After relational and life balance issues are identified and addressed in therapy, and the couple seem balanced and healthy, it is time for the focus to be on the sexual issues in the relationship from a psychological approach.

A sex therapist is a licensed psychotherapist with specialized certification training to treat sexual issues(American Association of Sexuality Educators, Counselors and Therapists [AASECT.org], 2024). Sex therapy is psychotherapy, also referred to as “talk therapy,” that helps individuals and couples develop and maintain healthy sexual intimacy and provides treatment for sexual disorders and dysfunctions listed in the Diagnostic Statistical Manual of Mental Health Disorders (DSM-5-TR), such as Erectile Disorder(ED) (a male having difficulty obtaining and maintaining an erection) or Female Orgasmic Disorder (difficulty having or never having experienced an orgasm) (APA). Although identifying sexual dysfunction or sexual disorders that are negatively impacting a couple may be a quick and concise process for some couples, others are in a sexless relationship and struggle to identify the reason(s) why. Sexual issues are a sensitive topic for most couples coming to the therapeutic process. Shame, embarrassment, secrets, a history of abuse, lack of sexual education or experience, relationship problems, and stress can all impact sexual health and a person’s ability to talk about sex. As EMDR therapists, we can help identify and normalize the core issue(s) and offer them hope for resolution. EMDR’s Three-Prong Protocol, which addresses past memories, current triggers, and any future anticipatory anxiety, is a comprehensive way to address sex therapy issues (Nossardi, K., 2021) However, using CBT instead of EMDR to address any present and future triggers can also be extremely effective. The following case is an example of how trauma, thought patterns, communication, and behaviors can be addressed successfully with a combination of EMDR and CBT therapy that provides a positive outcome for the couple, making it possible for them to reengage sexually.

“As EMDR therapists, we can help identify and normalize the core issue(s) and offer them hope for resolution.”

Alyssa and Luke

This couple is in their mid-twenties and met in college during their senior year. Both recently completed their master’s degrees and shared that they enjoy their first “real jobs.” The couple shared that their parents paid their college tuition, allowing them to continue living at home for a year to save money. They both state that they are attracted to each other, have fun, and are excited about building a future together. They enjoy engaging in sex five to six times a week when they have opportunities in each other’s parent’s home and their cars, and once a month, they spend the weekend in a hotel together. Alyssa shares her concerns and frustration that about two months ago, Luke started rejecting her sexual advances, stopped initiating sex with her, makes excuses when she wants to book a hotel for the weekend, and has been irritable and sarcastic with her at times. When she asks him what is wrong, he apologizes, says he is stressed out at work, and promises to do better but does not make any changes.

When Luke was questioned about managing work and life stress, he shared that he exercises, has good health, sleeps well, has social times with friends, enjoys learning new things, spends time with his dog, does not have any financial stressors, and has a close relationship with his family. He was then challenged about his reason for avoiding sexual activity due to all of the ways he manages stress effectively with good self-care and close relationships. He was asked directly if he was viewing porn and masturbating; he said occasionally but has not in the last six months. He was then asked if he was having an affair, and he said, “Absolutely not; I love Alyssa.” Based on everything he has said and all of the issues that have been ruled out, it seems like he is behaving like he is angry with Alyssa and punishing her in some way. The question was posed, “What has Alyssa done to hurt you?” With a surprised look, he said, “I guess I didn’t realize how much she hurt me until you just said that.” He looked at Alyssa and said, “You told me I had a small penis, and so I don’t know how we can stay together if I can’t ever satisfy you sexually.” Alyssa was stunned and said, “I never told you that! What are you talking about? When?” Luke said, “You know, remember the last time we had sex, you were on top and told me Dustin (Alyssa’s ex-boyfriend) had such a big one, it made you uncomfortable to be on top, but it is easy with me.” She replied, “I was giving you a compliment! Your penis is not small, it is perfect, I never said it was small. I can’t believe this! Why didn’t you talk to me about this? So, this is why you have pulled away from me?” Luke said, “I am having a difficult time believing you because it was very clearly communicated to me that my penis is small, regardless of what you say.” As the session progressed, the issue was discussed at length, leading Alyssa to cry and apologize to Luke for hurting his feelings, and Luke apologized for hurting her by not talking to her about it and shutting down by withdrawing from her sexually. Luke also said, “It just really bothers me, and I can’t seem to get over it. I have no sexual desire and feel anxious in my chest all the time.” Luke agreed to do EMDR after being given some psycho-education and possible ways EMDR may be able to help him process what he has been and is experiencing.

The application of a standard EMDR Therapy Protocol involved two sessions that included Phases 1–History-Taking, and Phase 2– Preparing the Client and Identifying the Target. The third EMDR-focused session was 90 minutes long, and Phases 3 through 7 were completed. The session note is on the previous page and includes the target and processing information. Notice the emotions and somatic areas that were also targeted with bilateral tactile stimulation in addition to the memory and negative beliefs.

Phase 8 was the focus of the fourth EMDR session to evaluate Luke’s level of stress related to the issue and to review the results from the EMDR processing session. Luke shared he felt so much better, felt embarrassed that he didn’t talk to Alyssa about what she said sooner, and believes she didn’t mean to hurt him and did not think his penis was small. Based on these results, the next step was discussing continuing to use good communication skills in the relationship as a couple and reviewing the CBT ABCD Log to process the triggering intrusive memories if he experiences them in the future. He was provided psychoeducation that explained he will not always know when an intrusive thought about this event will happen. He can’t always identify what triggers them, but he can process them quickly instead of dwelling on them. A review of his experience of dwelling led to negative emotions and behaviors based on what he believed Alyssa was saying to him, causing him to avoid her and be unkind to her at times. Below is the ABCD Thought Log Luke completed. He could see the negative self-talk he engaged in and how his self-talk and cognitive distortion of catastrophizing (this event has to lead to the end of the relationship) led to the consequences of negative emotions and behaviors. Then Luke identified positive statements that he believes to be true and will quote them to dispute any negative thoughts that come to mind about the issue in the future as a healthy way to cope with the intrusive thoughts about the impact of trauma from Alyssa’s comments.

Processing the negative past memory with EMDR, providing communication skills that included understanding and apology addressed the present, and then providing a CBT technique to process intrusive thoughts that may appear in the future successfully addressed the couple’s presenting issue. Although the use of CBT in combination with EMDR is effective, using an EMDR Future Template exercise may have also been helpful for Luke to reengage sexually with Alyssa. He and Alyssa had already engaged sexually twice in the past week with no issues arising, so the future template exercise was not necessary. If Luke was having difficulty re-engaging in sex, a Future Template Exercise targeting him imagining a sexual experience with Alyssa might have been helpful. Below is an example of a possible Future Template that would process Luke’s anticipatory anxiety.

“Although the use of CBT in combination with EMDR is effective, using an EMDR Future Template exercise may have also been helpful for Luke to reengage sexually with Alyssa.”

ABCD Thought Log

Activating Event

Intrusive thoughts about the time Alyssa talked about my penis during sex.

Belief

Negative self-talk, such as, Alyssa thinks my penis is small. I will never be able to satisfy her sexually. I will never be enough for her. I will have to end this relationship at some point.

Consequences

Feeling sad, angry, and overwhelmed. Behaviors included avoidance and stopping initiating or responding to Alyssa’s initiation of sex. Verbally abusive to Alyssa at times.

Dispute

What do I know the truth is? Alyssa did not say what I interpreted she said. She was trying to compliment me. She was not trying to say I was not enough in any way. She was enjoying sex with me and expressing it when she compared me to Dustin. I know I am fine the way I am (his Positive Cognition was installed with bilateral brain stimulation during the EMDR processing session).

This leads to positive feelings of happiness, love, and contentment. Positive behaviors will continue to include initiating sex and responding to sexual advances, and speaking kindly to Alyssa.

Future Template for Anticipatory Anxiety

Today’s Beginning SUD: 7

Begin BLS while imaging a future scenario (perhaps in the form of watching a movie scene) when he and Alyssa are having a sexual experience.

When asked “What do you notice?”, Luke says, “We are having a great time, and then Alyssa gets on top of me and I start to panic and lose my erection.”

Reprocess Luke’s Future Concerns:

I will be anxious about the size of my penis.

I will lose my erection when I have sex with Alyssa.

Alyssa will not be satisfied sexually.

Install Positive Cognitions (Truth Statements):

BLS while imagining the same sexual experience he noticed prior to reprocessing concerns. Luke’s Truth Statements: I know my penis is not small.

I have never lost an erection during sex in the past, so there is a small chance of it happening in the future.

Alyssa tells me my penis is perfect and that she is satisfied with our sexual experiences, and I believe her.

BLS Targeting the Same Image of a Sexual Experience

When asked, “What do you notice?”, Luke says, “We are having sex, Alyssa is on top, I am keeping an erection, and we are kissing and telling each other how much we love each other and how good this feels. We have a great time, and we both orgasm.”

Ending SUD: 0 VOC Truth Statements:

NOTE: If the SUD is not 0, using BLS while targeting the future sexual experience and a concern can prepare Luke to face the concern and reduce his anxiety and reduce the SUD further. During the processing of the future experience, Luke could imagine what he would do if the concern became a reality, which would increase his confidence and reduce the probability of continued avoidance.

Assessing the need for an EMDR Therapy Future Template Protocol in the session after a bilateral processing session is important to help the client with any anticipatory anxiety. The future template is part of the Three-Pronged EMDR Protocol that addresses the past disturbing memory, the present-day situation, and then the future for any anticipatory anxiety. In the case of Luke and Alyssa, the focus was on one event, so the First, Worst, and Remaining EMDR therapy Template was also unnecessary.

Exploration and Flexibility are Essential for Sex Therapy to be Effective

Exploration by asking several direct questions and purposeful flexibility to apply EMDR therapy with CBT therapy or other therapeutic modalities helps an EMDR clinician assist a couple to have better outcomes related to resolving their sex therapy needs. A sexless relationship is one of the most prevalent reasons couples decide to seek therapy, and as in the case of Alyssa and Luke, sexual dysfunction or a sexual disorder is not always the root cause. For this couple, Luke was traumatized due to his interpretation of a statement spoken to him by Alyssa during sex that led to a faulty belief and cognitive distortion, which led to negative emotions and behaviors impacting his sexual desire.

* Names and certain identifying information were changed for confidentiality.

Article written by Dr. Crystal Hollenbeck for EMDRIA.org

Hollenbeck, C. (2024, November). Sex Therapy Treatment for a Couple in a Sexless Relationship: EMDR and CBT Therapy, the Perfect Therapeutic Couple. Go With That Magazine, 29(4), 12-18.

References

Wise, N. (2022). Why Good Sex Matters: Learning how to work the sexual brain-body connection. Psychology Today. Retrieved from: www.psychologytoday.com/us/blog/why-good-sex-matters/202212/learning-how-work-the-sexual-brain-body-connection

EMDR International Association (EMDRIA). 2024. What is EMDR therapy? Retrieved from: www.emdria.org/about-emdr-therapy

American Psychological Association (APA). (2017). What is Cognitive Behavioral Therapy? Society of Clinical Psychology Division 12. Retrieved from: www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral

Wikipedia. Sex Therapy. Retrieved from: https://en.wikipedia.org/wiki/Sex_therapy

Wheeler, R. and Sheikh, Z. (2024, March 15). Health conditions that can harm your sex life. WebMD. Retrieved from: www.webmd.com/sex-relationships/ss/slideshow-conditions-affect-sex

Cleveland Clinic. (2020, December 11). Depression and Sex. Retrieved from: https://my.clevelandclinic.org/health/diseases/9296-sexual-problems-anddepression-

American Association of Sexuality Educators, Counselors and Therapists (AASECT). (2024). AASECT Certified Sex Therapist. Retrieved from: www.aasect.org/aasect-certified-sex-therapist-0

American Psychiatric Association (APA). (2022). Sexual Dysfunctions. Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Nossardi, K. (2021, November 5). Target lists, treatment plans, and the three-pronged protocol: part three in a three-part series. EMDR Education and Training Center. Retrieved from: https://emdreducationandtrainingcenter.com/history-taking/2198/