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Ruth Cohn
The Stepladder Up: Restoring Loving Sexuality in Couples Healing From Childhood Sexual Abuse

…There was a single denominator that bound us together. We each had turned inward intensely. In searching through the panorama of our past, one thing emerged again and again: our relationship to and understanding and experience of love underlay everything else….We each of us had fallen down into meaning, if we cared to seek it out, and to climb with it out of that awful chasm into which we had been toppled. The experience of love was the stepladder up which we could climb.
- Brian Keenan (1992, p. 163), Hostage in Lebanon1

On the arduous path of recovery from childhood sexual trauma, the healing of sexuality is one of the most difficult and complex tasks. The sexual body being the physical locus of the trauma, the prospect of even beginning to address it, is to most survivors daunting at best. As many survivors’ trauma was at the hands of family members or other intimates, the entangled associations between emotional or relational closeness, sexuality and danger, are rife. It is no wonder that this work is arrived at last if at all.

I find the trauma literature about sexual recovery to be sorely impoverished. Similar to the early general sex therapy, sexual problems are viewed separately from the relationships in which they occur, and solutions, if helpful to some, are primarily mechanical. My reading has shown partners of survivors presented ascardboard cutouts, called upon to be patient, supportive and self sustaining through the difficult journey of trauma recovery. Certainly not my experience of them in the room.

In the years that I have been working with partners of childhood trauma survivors, I have observed them most often to be children of neglect.

They are sons and daughters of narcissistic, absent, alcoholic, depressed or traumatized caregivers. They grew up in the shadows and on their own: four year olds standing on chairs to wash a dish to eat from, doing laundry at age six; getting themselves up and out to school virtually from the time they started school; taking care of younger siblings. They were the infants of mothers who did not come, who gave up crying and withdrew into themselves. Their needs, thoughts and feelings were of no interest to anyone around them and went unspoken. They got jobs early and earned their own money in order to have anything at all. They had no experience of reliably counting on another person. With long histories of being patient and supportive, as adults they struggle with the rage, anxiety or despair of having disappeared doing it. At their cores, these partners carry the deeply embedded belief “I will never get what I need.” Their defenses largely spring from there.

For trauma survivors who are in partner relationships, which remarkable numbers of them are, sexual healing is not so simple as helping them to come safely home to their bodies. The survivor has unjustly and erroneously been tagged with having and causing all the problems, by the partner and often therapists too. It is the survivor who is “pathological” and pressured to change. And it is the survivor who commands the lion’s share of attention, consideration and sympathy. The partner, neglected first in the original family, has been neglected in the therapy, neglected in the literature and neglected by our field.

In the last five to ten years, the specialized field of trauma theory and practice has burst into a dramatic new phase . Through groundbreaking research and neurobiological study, the structure and function of the traumatized brain are slowly becoming known and understood, casting all the prior mainstays of trauma treatment to be called into question.2 The research is showing some of the precise alterations of the traumatized nervous system, well beyond disruptions in memory storage. The experience of trauma, overwhelming as it is to the psychological and physical organism, has the effect of turning off the left prefrontal cortex of the brain.3 Resultantly, the functions of time sequencing, creation of continuing autobiographical narrative, cognition, meaning-making and speech all located there, cease.

Trauma recovery involves state dependent work. The emotional and physiological states from when events occurred are revisited in processing of the trauma. Because of the disruption of the left prefrontal cortex, the traumatic event is experienced and logged through other means: visual, sensory, physical and emotional. And when in the state of re-experiencing, survivors may again be unable to speak or think. So if the main functions of verbal therapy: cognitive thought, meaning making and speech, are disabled in the moment of trauma, some depths of experience are inaccessible to it We are challenged to find creative therapeutic means of access.

In the groundswell of revamping modes of working with the traumatized, even the sacrosanct therapeutic relationship is being called into question. Long considered essential in trauma treatment and all psychotherapy, the current debate about how therapeutic it actually is, is a hot one. I continue to believe that the disrupted capacities to attach and to trust are the deepest wounds of trauma. They perhaps more than anything else perpetuate the survivor’s persistent pain and loneliness.

Another area of the frontal lobe affected by the traumatic shutdown is the orbital frontal cortex. This is the part of the brain responsible for “affect regulation” or the capacity to modulate the intensity and duration of emotional reactions, and to calm down after being upset. Additionally the overactive amygdala readily sends the body into fight/flight activation, with its accompanying anger, terror or “freeze” response.

The other way that children develop these self regulatory functions, through the mother’s soothing, comforting presence, has also most likely been deficient in the lives of these children. The resultant dysregulation makes for a chronic feeling of being emotionally out of control, and painful interpersonal difficulties. Partners frequently complain, “Can’t you just calm down?” or “Get over it!”

Addressing the wounding around attachment, the dysregulation of the physical and emotional body, and the creation of a satisfying, meaningful and integrated life in the world are the main tasks of healing.

I have found an ideal place to bring the key elements together, is in working with the couple, the survivor and his or her intimate partner. One of the most insidious sequelae of trauma is the compulsion to re-enact. We see it regularly in clients’ relationships with us. With lovers and spouses, traumatic transferences are in full bloom. Both partners readily project upon and “turn each other” into the dangerous characters of childhood, recreating the emotional and physical states experienced at the time of the traumatic event. Partners are continuously drawn into participating in the drama that is being re-enacted. The result is unlimited real life opportunities to work through the childhood material. The couple relationship, probably more than any other (including the relationship with the therapist,) holds the possibility of being therapeutic.

Trauma and the Body

From the beginning of traumatic stress study, when trauma was called “Shell Shock,” or “Battle Fatigue,” it was referred to as a “physioneurosis.”4 During and after the traumatic event, the impact on the entire organism is profound. By definition, trauma is overwhelming experience. It is greater than the normal capacity of the psyche and the body to contain and process, so usual physical and psychological functions are compromised or adapted to cope with it. The primitive parts of the brain are the first hit. The amygdala’s task is to screen incoming stimuli and distinguish the significant from the insignificant. In the face of danger, it activates the fight/flight response. The amygdala takes in sensory information through the body and the five senses, and moves it along to the hippocampus, which is the brain’s the filing system.

The hippocampus makes categories, filing information separately by subject. Under ordinary circumstances, the hippocampus moves the sorted and unprocessed information on to the left prefrontal cortex. As noted above, there reside the functions of meaning making; analytical and cognitive thinking; location in time and space, affect regulation, sense of continuous autobiographical narrative and verbalization. The capacity to regulate affect, to calm down after any sort of arousal, is also located there. This part of the brain, under usual circumstances processes the raw information received from the hippocampus, making it understandable, verbalizeable, and ready to be logged in memory as part of the ongoing narrative of life.

We now know that in trauma the overwhelmed brain is unable to carry out the usual processing sequence. The material stops at the hippocampus which fails to move it on to the prefrontal cortex. The traumatic sensory, bodily and emotional input; the images, sounds and smells, the bodily and tactile sensations, the speechless terror, helpless aloneness, all remain in raw form. Understanding the event, identifying with it; putting it in its chronological place in the past, and speaking about it, are impossible. The unprocessed material does not get put away.

The amygdala, once overwhelmed by such magnitude of danger, becomes overactive. Its sensitivity to danger becomes excessive. Sensory, physical and emotional stimuli reminiscent in some way of the trauma, easily activate the unprocessed past experience, which because of its timelessness may readily be re-experienced as if it were happening right now. Survival mode fight/flight reactions or the anticipation of danger, keep the survivor in a chronic state of hyperarousal. The event lives on and on in the traumatized body.

Trauma therapy consists largely of accessing the unprocessed, often dissociated material and processing it; integrating it into coherent autobiographical narrative; massive mourning; and relearning (or learning) how to live safely and relatedly, in the world. It is a monumental task. Because the material is so embedded in the sensory, bodily and emotional, activations or “triggering,” as well as accessing and working through, greatly involve the nonverbal and the somatic.

Relational capacities and the possibility of being physically and emotionally safe are essential to a harmonious home. The intimate partner is already involved in the survivor’s effort to create a satisfying life. Partners can touch, in ways that therapists cannot. The couple is an ideal place to advance the many objectives of healing work. It is certainly the place where sexual healing most readily takes place. And this, the couple relationship, is one that our clients get to keep when the therapy is done.

The Essential Conflict

…At the moment of trauma, almost by definition, the individual’s point of view counts for nothing. In rape, for example, the purpose of the attack is precisely to demonstrate contempt for the victim’s autonomy and dignity. The traumatic event thus destroys the belief that one can be oneself in relation to others (Herman, 1992, p. 53).5

Deep within what I have come to call the “traumatized couple,” is an essential conflict. The partner, as noted, carries the deeply held belief “I will never get what I need, I will never get enough, I will never be safely attached and taken care of.” Great anxiety inhabits this relentless belief, and generates layered defensive adaptations from childhood on. Defensive adaptations, or behaviors and interactional styles that protect the partner from the fear or pain of going ungratified, might include “I have to do it all myself,” withdrawing, or controlling to name a few.

The core belief of the sexual abuse survivor is “I don’t matter.” The experience of abuse has taught that one’s needs and feelings are irrelevant. The survivor has value only in terms of utility to the other. The “other” has the power and the value. The survivor exists merely to be of use. But that too is annihilation. As “object to be used” the survivor ceases to exist as herself/himself, and once the function is performed is tossed away. The demands of the other are threatening at the terrifying level of survival, of existence. The survivor’s defenses are constructed against just that, disappearing beneath the demand or control of the powerful other.

The core dynamic in the traumatized couple then, is this defining interaction: The partner brings desperate anxiety about getting essential needs met in order to stay alive. The survivor embodies the terror of worthless nonexistence in the face of such need. The partner’s anxiety about getting enough keeps the survivor ever vigilant and on guard for invisibility or being taken advantage of. Survivors tend to be exquisitely sensitive to even noverbal cues in body language, tense energy or subtle facial expressions. They defend against this. This defendedness re-enforces the partner’s dread of eternal hunger and loneliness, and the anxiety is heightened. The survivor experiences this intensifying anxiety as demand. Neither is ever safe to relax. The two keep each other triggered all the time.

Animals in the wild romp and play, commune amongst each other, nurse their young and make love, in a state of safety. No creature makes love when endangered or in survival mode. Of course the constantly activated couple cannot have a satisfying and loving sexual relationship when their psychological survival, their sense of self and continuity of self, is forever at stake. Although this dynamic maintains unsafety, disequilibrum and disconnection in virtually all of the couple’s interactions, the sexual arena easily becomes emblematic, the focus of the disconnect.

The neglected child whose neglect included the absence of physical affection and touch, longs for the tangible, believable expression of connection via the body. Partners come to the relationship with a profound “skin hunger.” The abuse survivor whose sexual abuse epitomized nonexistence protects the integrity of self by guarding the body and refusing to be robbed of self any longer. Between them, sex becomes “the problem.”

But it is viewed as the survivor’s problem. It is somehow the survivor’s work to solve, even though the dynamic between them is what maintains the active trauma state on an ongoing basis: The desperation about getting, born of childhood deprivation, fuels the partner’s anxious desire. That urgency, experienced by the survivor as demand, activates the traumatic reaction to the danger of being controlled or overtaken, which in the abuse experience was tantamount to annihillation. The survivor’s autonomic response of fight, flight or freeze activates in the partner still greater fear of not getting. The terror grows the, the dynamic escalates and continues looping.

Viewed as the survivor’s problem they may opt to sleep in separate rooms or even houses, take “sexual vacations” or bitterly and hopelessly fight. The survivor may be sent off to treatment programs or dragged to sex therapists, while the partner patiently or impatiently measures “progress” by the change in their sexual relationship. These approaches may be designed by well meaning therapists.

The healing of the sexual wound and the inhibition of loving, intimate sexuality, is in the couple. There the triggering and the re-enactment of the trauma is continuous. Trauma resolution work must of course be done. But the essential healing of traumatized sexuality is in the relationship. And a significant amount of trauma work can in fact go on there.

Working With The Couple

My quest for an approach to work with the traumatized couple led me through the diverse literature of marital therapy. I found the ideal approach for work with these couples in Harville Hendrix5 Imago Relationship Therapy. Its remarkable and expeditious effectiveness with so complex a population, was unexpected to me.
Imago combines many elements, among them Attachment and Systems Theories, and Gestalt. It amalgamates the best of these and other approaches into a concise, structured one. The method utilizes a process called “Intentional Dialog” involving three steps: mirroring, validation and empathy described below.

Among the most pronounced symptoms of trauma are the dysregulation of affect; the experience of triggering, and dissociation. Affect dysregulation means that the orbital frontal cortex of the left brain has diminished capacity to modulate arousal. Trauma survivors are less able to contain and tolerate intense emotion. The ability to calm themselves down when emotionally activated, is impaired.

By triggering, we understand that experience, whether sensory or dynamic, even vaguely resembling aspects of the traumatic event, may activate the trauma response. Due to the failure of the time sequencing function of the brain, the trauma is re-experienced as if it were happening now. Dissociation or separating consciously from present events, is a common defensive response to triggering.

In the couple, where the experience of triggering is virtually continuous, defensive reactions of both partners may be dramatic or extreme. Due to difficulties in affect regulation, conflicts may be volatile or seemingly insoluble. Disappearing to safety via dissociation widens the gap between partners, recapitulating the childhood experience of both: the only resolution to overwhelming interpersonal experience is alone and away.

Imago’s Intentional Dialog’s structure appears to reset the traumatized brain.6 One partner speaks at a time, and the first task, mirroring, involves the listener precisely reflecting back the speaker’s words. Typically, neither partner had the early experience of seeing in the mother’s gaze, or hearing in her words or tone, who they are. So the mirroring itself has affirming and soothing functions.

The mirroring step requires of the listener, active thought simultaneous with containment of triggered emotions. Containing strong feelings and waiting one’s turn to respond, facilitate the gradual development of the capacity to regulate affect. The listener may not erupt into his or her own unbounded, possibly explosive emotional reactivity, but must listen, accurately mirror and wait for his or her turn. Each partner experiencing in turn, the other’s capacity to control intense defensive reactions, slowly begins to feel the safety requisite to moving toward the other. They become less fearful that they themselves or the other will be “out of control.” By active thought we mean that the listener, however emotionally and physically activated, must track the speaker in order to later demonstrate comprehension, by briefly summarizing the entire message. Thus the listener must remain present.

The second step in the dialog is called “validation.” Here the listener is asked to enter the speaker’s world, look out at the content of the message through the speaker’s eyes, and understand how the speaker’s logical mind works. It is in essence, an empathic decentering from one’s own subjectivity in order to enter the subjectivity of the other. An example of a survivor validating the partner might be:
It makes sense that you feel hurt by my inability to be sexual now,
because physical contact makes you feel loved by me.

It is assumed that the sense or logic of the speaker is comprehensible from the speaker’s point of view. The listener need not agree, only recognize the validity of the speaker’s perspective. Partners learn the notion that they need not agree or be alike to be safe and understood. They need not be responsible for or do something about the other’s feeling.

For many, being seen and understood is completely new and introduces a previously unknown intimate experience. Coexisting and connecting with different feelings facilitates differentiation and a sense of separate and bounded self. Visiting each other’s worlds without having to reside there, makes for a breadth of emotional experience beyond each partner’s own narrow, survival focused context.

The dialog’s third and natural next step is called “empathy,” (although the preceding steps are also empathic.) In this step partners learn to read each other’s faces and body language, imagine each other’s experience enough to identify each other’s emotional states. The nature of trauma is that it is all consuming. Through the practice of empathy survivors may become interested, even curious about their significant others. And partners may become more interested or curious about themselves.

In the dialog, the two partners alternate “sending” and “receiving,” the receiver listening and utilizing the three steps. This is the form for discussion of all their problems and dynamics. Early in therapy the dialog may seem next to impossible for volatile partners to achieve, but with time and practice the process appears to strengthen and restore disrupted left brain capacities. We don’t yet know what is happening neuroanatomically. Research will show whether in fact the frontal lobes are changing. Survivors discover somewhere beneath the fear, their longing for contact. Couples experience growing feelings of mastery and control as they surmount these hurdles. Apart from the content, the process between them begins to develop verbalization and most essentially, safety.

Because triggering and re-enactment constantly refer both partners back to their families of origin, they get to know and understand each other’s story and its impact. They discover how much of their difficulty is the result of projection of their childhood experience onto each other. The other, both discover, is not in fact, the dangerous enemy, but is actually on one’s own side. They each slowly become able to disentangle the image of abusive or neglectful parents from the other partner, finding their way from living re-enactments of the past, to increasingly living in present time. They explore the myriad ways that their parents and perpetrators have inhabited their relationship. The two learn to identify their core dynamic in virtually all their difficult interactions.

Including The Body in Couple’s Therapy

There are many ways that we include the body in the couple’s work. The most obvious of course is touch. Partners are at liberty to touch in ways that therapists cannot. Clearly different survivors have different thresholds of tolerance for touch, and at different stages, so it must be cautiously utilized at the point in recovery when they are ready. When reliving a particularly painful childhood scene, the most healing response for a survivor may be to be held. Most likely the feelings were originally experienced while desperately alone. Being comforted and soothed through the body, introduces a new experience to the healing old-brain, that of being safe and cared for by another person while in such states.

John Gottman, the renowned marriage researcher, has studied “generic” couples for over 30 years. He writes:

My Data suggest that when the heart rate goes up to about 80 BPMfor a man and 90 BPM for a woman, the flooding process begins. At this level physiological arousal makes it hard to focus on what the other person is saying, which leads to increased defensiveness and hostility.7

That is among the general couple population. In the traumatized couple, where the survivor’s amygdala is overactive, the intensity of interactions may rapidly skyrocket. We use “time outs” to work with breathing, attempting to de-escalate levels of activation through the body.

With many couples, another effective way of bringing the client back to a workable baseline is again through touch. With previous agreement, during a moment of high activation the partner may place both hands on the survivor’s hands or knees while both do an exercise to slow their breathing. For many, the result is a sense of grounding, of calming and often the return to baseline heart rate and gradually to present time.

We make an effort to make conscious the communications of body language, how a facial expression or a body posture might function as a nonverbal cue or trigger. The heightened awareness of the traumatized nervous system, may mean detection of threat in even subtle physical energy or movement. Learning to understand the more and less obvious sources of activation, contributes to the couple’s understanding of each other and their dynamic.

The tone of voice and the quality of the gaze often have much more impact than the actual content of what is expressed. In the words of one Imago therapist "The words are just the noise of protest against the disruption in connection."8

We work on all these sensory levels to introduce the experience of safe contact to the dysregulated organism.

For many children of neglect, the result is alexithymia. The deprivation has been so extreme that they never learned to identify or name, let alone feel their emotions. (This may be equally true with survivors.) They may have no idea what they are feeling. Both partners come to understand that whenever there is a significant charge in their interaction, one or both is being visited by childhood experience. Perhaps early in the therapy, the only way to get in touch with what it is, is by becoming aware of the body sensations associated with the various feelings. Sensation may be a vehicle for contacting the childhood experience that has been activated. And it is always a way that these people come to feel more alive. Through the body they experience a coming “home” to the world of emotion. They also learn to observe in both self and other, the way the body relaxes and lets go, when one feels understood; how understanding and being understood are bound up with safety.

Finally, there are times when the emotion or sensation leads back to experiences that have no words. We may, in those moments stop and have the client draw a picture of what they are unable to say. We work with pictures, drawn and imagined, to help both partners identify and empathize with the hurt and angry child in each. They become increasingly able to distinguish past from present, and threatening historical figures from current reality. Being involved together to this extent in what each might have thought of as “individual work,” serves to forge an unexpected depth of intimacy.

The Phenylethelamine Effect

Nature designed us to be attracted to the same person long enough to procreate. In the early stages of relationship, all humans experience the secretion of a peptide called phenylethelamine (PEA) which spikes the natural testosterone level in both sexes. Ordinarily high desire individuals’ libido is yet higher, and ordinarily lower libido people experience an unusually (for them) high level of desire. They experience a pleasurable period where sex is frequent and intense. Eventually however, each returns to baseline. Nature is concerned about preserving the species, not lasting relationship. After some three to 18 months, roughly the time it takes to conceive, the PEA wears off. The intensity of the sexual charge fades, and the couple wonders “where did it go?” They might think there is something wrong with them, or that they are no longer “in love”. Generally, this phenomenon, experienced by all couples, is alarming and little understood.9

I have observed that the PEA effect overrides inhibitions caused by sexual trauma. Most traumatized couples I have seen look back on a honeymoon period, however brief, of higher desire “good sex.” It may be remembered more glowingly as it recedes further into the past. This might contribute to the partner’s belief that “you are withholding from me!” and confusion for both.

Psycho-education about trauma, relationship dynamics and sexuality are necessary therapeutic components. Knowing about PEA and other basic sexual information, can be tremendously normalizing and comforting. Each may be naturally inclined to ask “what is wrong with me?” For many of the traumatized, their only real sex “education” was the trauma itself. Learning about sex as clean, natural, or morally “good,” never happened. Similarly, many neglected partners never received positive learning about the body and its functions.

Distortions of belief and feeling regarding the body and the self, may be far from conscious. Apart from the abuse itself, one or both partners may have received distorted overt or covert messages about sex. One male partner stated: My mother taught me that men want sex and women hate it. What am I supposed to do with that? Deny my own natural desire, or resign myself to a life of imposing something hated on the woman I love? Of course I did nothing for many years. Then I went to prostitutes, about which I feel so ashamed.

Talking neutrally about sex, even the names of body parts, may also be a foreign and/or shameful experience. One male survivor said: "Until I was fifteen I did not know that women had nipples. I didn’t even know that I had nipples. Talking about sex or even referring to parts of the body by name makes me want to go straight through the roof. I feel so uncomfortable and ashamed."

Many of the sexual difficulties experienced by the general, nontraumatized population may be misunderstood in these couples, as sequelae of the abuse. They simply do not know what “normal” sexual difficulties are. They do not know that many women tend to be seduced or initially “turned on” largely by emotional and non-physical actions or verbalizations; that expressions of care and respect may be women’s “foreplay.” There may be collusion in the couple in the belief that “something is wrong” with a woman who doesn’t walk around sexually aroused, or spontaneously heat up. Often survivors have been tagged with “disorders of desire” for some time, and there is a history of anger and criticism in the couple about this. General information about all aspects of sexuality are immensely normalizing, as is repeatedly reiterating that the sexual difficulty is a dynamic. It is nobody’s “fault.”

In general the ability to talk about sex is a prognostic factor of successful relationship.10 Long before addressing the actual sexual relationship, we slowly broach the possibility of safely “talking” about sex.

Sexual Recovery

Approaching sexual recovery in the traumatized couple may be delicate and the survivor must be somewhat advanced in the processing of the trauma. Most often these couples present after the partner has been sexually frustrated for some time. The partner is hopeless, desperate and angry; the survivor guilty and terrified. They each shoulder the residue of childhood, and the sedimentary rock of their shared layered dynamics. Usually attributing it to sexual abuse, they both feel helplessness, a grinding preoccupation and a distance growing between them.

Sexual recovery is more than anything work on safety and trust. The core belief of the adult child of neglect being “I’ll never get what I need,” the expectation is “I will disappear.” The pervading belief of the survivor of sexual trauma being “I don’t matter,” the expectation is to be controlled or overtaken. Similar in their childhood experience, their worst fear, or the epitome of unsafety to each is a bit different. The survivor’s fear in relationship is of being powerless and without control again. In the partnership a “safe” distance and dynamic of patterned defensive behavior prevail. The effort to control sex, becomes a part of that. Although the struggle around sex is one expression of the larger dynamic, it comes to develop a life of its own.

The partner, whose terror is the prospect of never being gratified, may be bitterly anxious, frustrated or pessimistic. The focus of unmet need becomes the absence of sex, and a lifetime’s pain of neglect may be explained by that. Re-enacting the family scene, the each insure that their greatest fear is realized. The partner becoming increasingly and righteously frustrated by the reality of never getting gratified sexually, might exude a bitterness, grabby demand, or the implication that this is the source of all his/her profound unhappiness. The absence of sex becomes the absence of everything, The survivor replaces the self-centered, ungratifying mother of childhood.

The survivor experiences that again sex is what matters, and is back in the family nightmare where there was no true existence as a person, but only as someone’s “needs gratifier.” The mutual triggering is constant, deep within their dynamic, far beyond obvious. The defenses of each: fight, flight, caretaking, withdrawal, are ever at play as both are endangered at the level of self, and therefore survival.

This is where sexual healing work is. When this perpetually running dynamic becomes conscious and transformed into something safe, the nervous system moves from constant activation to a quieter, more modulated baseline state, where intimacy gradually becomes possible.

In the therapy, the couple and therapist explore this dynamic in all its many manifestations for a long time. Although the couple may arrive thinking the “problem” is sex, there is much to do before going near it. Because the core dynamic shows up everywhere in the relationship, the magnitude of the sexual “problem” is diminished. It is not so very different from all the other manifestations of the same thing. So we begin with all those other things, and all the while, we are in fact also working on the sexual problem. Bringing sex down to size, may be a great relief to both, even though the desired sexual relationship is still a ways off. And once we begin specifically targeting the sexual relationship, it feels like what we’ve been doing all along.

We work to develop understanding and empathy; the experience of being known, accepted, even treasured for who one is. Both partners’ anger moves into a range where they can recognize triggering and work through it. Couples come to know slowly over time, how it feels to be interpersonally safe. Ultimately sexual experimentation springs from that safety.

My experience has generally been that we work on the relationship and creating safety for on the average about a year and a half (weekly 90 minute sessions.) After about that long the couple has become much closer and the volatility level has dramatically decreased. They have come a long way in being able to share feeling, make contact and trust one another. The subject of sex usually comes up organically at about that time. Not that it never does earlier, but focusing on it directly usually takes about that long.

We begin by talking a lot about sex: the sexual history of each, the messages they each absorbed in their respective families. They review their shared sexual history and what they most fear will happen again. They begin to talk about what has happened inside of each of them during the terrible triggery moments they’ve shared, what their innermost thoughts and feelings were. We talk about what they each want. It becomes increasingly tolerable or even acceptable to talk about sex. With the deepening of this dialog, it becomes a matter of time before sexual activity begins.
For the most part the sexual activity emerges out of the growing closeness and safety. Of course we continue to talk about it. And as we continue with the work on this and other things, sexuality becomes integrated into the rest of the relationship and life together.

There is no substitute for trauma resolution work. Survivors must have at least a foundation of recovery to be able to undertake the relational and ultimately sexual work. The winning combination is the Imago Relationship therapy and concurrent good, solid individual trauma therapy. A support group for the partners is invaluable, especially around the subject of sex. As a man in my partners’ group once said:

Where else can I go and talk about my frustration about not making love with my wife in several years? The complementary work each engages in outside the couple, contributes to a sense of shared responsibility and care around their joint healing. One partner, whose sexual relationship had become pretty much what he had always hoped for stated:

I used to think my wife had a sexual problem.Now I know that we had a sexual problem.

This is perhaps some of the most difficult and painstaking work I have ever been part of. I am sure I can say the same for the couples involved. But it is surely as deeply rewarding for all.

A Word about Antidepressants

I believe one of the most under-rated symptoms of depression, and the one that has perhaps the most impact on relationship is the often unbearable irritability. Treating the depression can make a significant difference in the day to day life of the couple, as well as facilitating the use of the couple’s and all other therapy. The SSRI antidepressants are now viewed as a tremendous boon to the treatment of Post Traumatic Stress Disorder. It is also well known that diminished libido and sexual dysfunction are a common side effect.

It is easy for clinicians to minimize the survivor and the couple’s frustration and further loss in the area of sexual intimacy, in the interests of managing the depression. The fact is that orgasm and sexual energy may in fact not be a small price to pay for relief from depression. The clinician is reminded to be knowledgeable and sensitive in the use of antidepressants. Couples need to be apprised of the possibility of significant loss in the area of sexuality. Couple’s therapists should make a point of knowing what if any medications may be part of the larger sexual picture. Some of the newer medications have less or even none of this side effect and may be worth trying first. Other non-pharmaceutical treatment options are also being studied.

Interestingly, my experience has been that seriously depressed clients show significant improvement as they become connected with their intimate partners. I was also curious to run across a study recently11 showing couple’s therapy to be superior to medication in the treatment of depression. This of course is not news to researchers like Dean Ornish12 and Paul Pearsall13 who have long expounded on the many healing properties of intimate relatedness.

The Stepladder Up

An illustrative case example is the story of Dennis and Joanne. Before they started therapy with me, Joanne had been in body oriented trauma therapy for some years. Joanne’s therapy was with a highly idealized, male therapist. During that period, her relationship with her husband had grown increasingly estranged. Their sexual relationship had stopped almost immediately after the incest work began. As Joanne’s therapy deepened, eventually becoming the centerpiece of her life, the relationship with her therapist gradually displaced her relationship with her husband. Dennis felt more and more like the lonely, outcast payer of the therapy bills, while Joanne experienced him as distantly unsupportive. She and Dennis lived essentially parallel lives, interacting primarily as co-parents of their children.

Joanne had a history of violent and sadistic sexual abuse. The oldest of many siblings, she took over for her distracted alcoholic mother. She felt responsible for what happened to the other children, two of whom died in childhood.

Joanne was an angry, critical and depressed woman for whom relationships in general were difficult. In spite of her over-responsibility in relation to others, she was inclined toward defensiveness and blame. Inside, however, she felt chronically guilty, worthless, unlovable and insignificant.

Perhaps more than any other survivor I have known, Joanne struggled with the feeling of “I don’t matter.” She had felt utterly hated and worthless to her parents, so it made no sense that Dennis or anyone would want to be around her at all. She gave up a lucrative career to stay home with her children, and worked hard to be a good mother. Typical of many stay-at-home moms, she received little validation from anywhere.

Dennis, also an oldest child, was the only physically healthy child among four siblings. His twin sister had been seriously ill, dying at the age of six. His younger sister was seriously developmentally disabled and was ultimately institutionalized. The youngest had asthma, skin problems, and a long series of lesser ailments. Dennis felt that as the only “perfect” one, his task was to stay out of the way of his worried and preoccupied parents and to do what he could to make things better. But because he could not, of course, make things better, he felt helpless, like a colossal failure. By being good, Dennis succeeded in needing nothing from his parents, convincing himself that he was fine even though they didn’t seem to see him at all.

Joanne was proud and resentful, and felt rather superior about doing her diligent therapy work. Dennis was a successful high-level businessman with a quiet, unemotional demeanor. The only feelings he claimed to be aware of were his sadness and anger at the complete lack of sexual intimacy with his wife throughout the entire decade of his thirties. He described going to bed every night during those ten years thinking and hoping, “Maybe tonight.” But eventually he ran out of hope.

As is typical of traumatized couples, Joanne had been viewed as the one with the pain. Dennis had lived with her much as he had lived with his parents-- trying desperately to figure out how to be helpful but not knowing how. As he had with his parents, he longed for Joanne to give him guidance and feedback. Without it, he constantly felt as though he were “blowing it.” Joanne felt burdened by having to tell him how to help her and by having to give him feedback about how he was doing. She felt once again that she had to “do it all” herself, as she had throughout her childhood.

The first months of therapy were volatile; the couple had barely talked in years. There was a collusion between them in viewing Joanne as the one who was suffering and who needed all the support; Dennis was supposed to learn how to give it to her and to be able to “meet her needs.” He’d had a lifetime of training in this, and so he attempted to fix the situation, while his own need remained submerged. “All he wanted” was something resembling a sexual relationship which, to him, seemed like a modest desire.

Our first task was to pry them away from the belief that Joanne was the one with the problem and that Dennis needed to learn to accommodate to it. As we explored their dynamics in the context of Dennis’ childhood experience, Dennis began to make contact with his own deep grief. He revisited the death of his sister when he was six. He remembered being excluded from the funeral, left at home confused and alone, as no one would talk about the death. He remembered the long hours of driving on Sundays to visit his other sister, Angie, in the institution: the surreal scenes there of Downs syndrome and disfigured children howling and defecating in the visiting area.

Dennis recounted one haunting scene from when he was seven, of taking Angie out for ice cream. As the family rode in the car together enjoying their ice cream, Angie could not seem to find her mouth. He recalled watching in horror as she shoved the whole ice cream cone angrily into her forehead. Nobody spoke, just as nobody ever spoke about the disturbing and confusing things that happened all the time. He remembered most his desperation to figure out how to bring joy to his overwhelmed, depressed parents. This was the first time in his life that Dennis encountered and expressed his own feelings. He too had a childhood filled with pain. Much as he rebelled against it, it moved him to feel himself. Ironically, Joanne’s response was to feel slowly drawn to him.

The couple’s therapy process was agonizing. There was much rage and conflict between the partners, who seemed unable to grasp that they lived in “different and separate worlds.” They believed that one person must be right and the other one just must be screwed up. Nonetheless, they immediately took to the structure of the dialogue, which helped them to use containment and self-modulation to deal with Joanne’s intense anger and Dennis’ panic.

One of the ways Joanne responded to Dennis’s stories of his childhood was to badger him to get his own therapy to “deal with his stuff.” His frenzied attempts to make things OK for her, along with his pleas that she tell him how to do so, felt to Joanna like an endless mandate to attend to Dennis’ anxiety. His indirect, largely tacit urgency about not getting enough attention and care made her feel trapped by ceaseless demand, which reminded her of her abusive father.

The pain and depression Joanne felt as she worked on her incest made Dennis anxious. He felt compelled to help her in order to keep her from being completely lost to him. His desperate effort to “help” gnawed at her. With abandonment typically being part of the sexual abuse matrix, Dennis’ apparent helplessness activated in Joanne her childhood experience of being left alone and having to do it all herself. Evocative of her mother helplessly standing by as she was abused, she re-experienced the “inescapable shock situation” of being threatened, trapped without help and without options. She also sensed that Dennis was not so much concerned about her as he was desperate to reassure himself, to fix her so that he could feel effective. Her response was further anger and withdrawal, which made him all the more anxious and demanding. The loop of mutual triggering was endless. Dennis balked at the suggestion of individual therapy for himself for some time. Feeling it connoted that he was “broken” he persistently refused it until much later.

Although he was extraordinarily successful in other areas of his life, Dennis walked around feeling terribly sad. He attributed his sadness to the years of sexual rejection. Joanne, feeling blamed for all the pain in his life, felt a coercive pressure to make him feel better, which of course meant having sex with him. Around the fifth month of therapy, Joanne raised the subject of a car accident that had happened early in their relationship. They had been driving on a winding mountain road, and Dennis had failed to see a stop sign. A large truck had barreled downhill into the passenger side of the car where Joanne was sitting. She was badly hurt and spent a month in the hospital. Dennis, himself unhurt, was plagued with guilt and a sense of urgency about caring for her.

Physically, Joanne slowly healed, but she continued to feel enraged. The accident represented a breach of trust, a horrendous betrayal by Dennis, who seemed utterly focused on his own bad feelings about himself. He soothed himself by nursing her. His urgent need to secure the relationship made Joanne feel like he was using her. He had been too defensive to ever listen to her feelings about this. She felt more than ever that her life did not matter to Dennis. In turn, Dennis felt entitled to nothing from Joanne Both had carried these feelings with them for 13 years.

We spent weeks in dialogue about the accident. It was the first time they had ever listened to and understood each other’s complex feelings about it. Neither had comprehended its pivotal symbolic and concrete meanings. After a lot of hard work on this, both felt relieved. Joanne received the heartfelt apology for having been hurt and betrayed that she had longed for since her abusive childhood. Something let go in her about feeling she didn’t matter. She became more emotionally generous with him. The couple’s dynamic began to soften, and the edge of hostility and criticism began to dissolve. A new level of empathy, compassion, and mutual appreciation emerged. Joanne began to give Dennis more positive feedback, and he slowly became calmer and more secure. As a result, he was less inclined to pull on her for attention and care. When Dennis decreased his demands on Joanne, she wanted to give to him and be with him more.

Around the 10th month of therapy, Joanne came home one weekend afternoon to find that Dennis had been cleaning. He had spent many hours doing strenuous housework because he wanted to acknowledge Joanne by giving her something that would have meaning and value to her. This made Joanne feel incredibly validated and acknowledged, deeply touching her profound wound of insignificance and invisibility. Previously, she had complained that her only value to Dennis was insofar as she could be used, sexually or otherwise. Dennis’ housework made Joanne feel that her daily contributions as a homemaker were significant to him, that he actually saw her and noticed what she did.

Within weeks we began to talk about sexuality. Joanne wanted first to discuss her nightly avoidance of going to bed. The couple began to explore their past sexual dynamics by seeking, first and foremost, to understand each other, recognizing that understanding makes possible behavior changes and, ultimately, safety. They went on to sharing their sexual histories. They had never before disclosed feelings about their respective or shared sexual experiences. They discussed the direct and indirect messages they had received from their parents about sexuality. They talked about their hopes for their sexual relationship as well as their fears about it.

At around the 13th month of therapy, Joanne began to have dreams about leaving home. This began the period of anxiety that often comes when one moves into a life of connection. The anxiety is about individuation, the loss of the familiar, the breaking of family rules, guilt over having what no one else in the family had. Dennis too, experienced this anxiety. They began to withdraw from each other, and they become more edgy with one another than they’d been in a while. This worried them. However, this was an expected developmental period in their work together, and it was important for me to normalize their experiences and to help them stay in the process. They worked through their guilt and fears about changing, continued to talk about sex, and worked to consolidate and integrate the closeness they’d achieved.

Eighteen months after therapy had begun, Dennis and Joanne began to experiment sexually and then slowly began to make love. Although Joanne had worked long and hard on her trauma in individual therapy, the sexual healing came largely through her work with Dennis. The longer she experienced him as emotionally, behaviorally, and physically safe, the more she became open to him. As he experienced her as available to him, he relaxed about his sexual needs. As their core dynamic changed, so also did their sexual relationship.

For the next month or two, I continued to check in with them weekly to see how their sexual relationship was going. Their reports continued to be brief and positive. At a certain point, their responses took the tone of, “Why are you asking us about this?” They truly were off on their own.

Dennis re-discovered his natural libido. No longer driven by anxiety, and having as much opportunity as he wanted to be sexual with Joanne, he was surprised and rather humbled to discover that his libido was not as high as he‘d previously thought. The couple discovered that once their sexual relationship was a healthy one, its relative importance in their now richly intimate relationship was significantly diminished.

Soon thereafter, Dennis went though a difficult spell professionally, which left him feeling distracted and depressed. During a session, Joanne lamented, “Now that I am feeling that sexuality is integrated into who I am, I want to explore it more. I am frustrated that we don’t make love more often.” Remembering that he had sat in the same chair a year before, wishing for that very problem, Dennis laughed.


The observations in this paper leave unanswered many questions about how trauma is processed; how attachment might shape affect regulation in the healing process or how creating connection and safety between partners affects the physiology of the trauma response; and what are the neuroanatomical effects of individuation and empathy. There is yet much to be learned. The field of traumatic stress study is currently examining what constitutes resiliency and growth after traumatic life experiences. It is certain, however, that a central feature is love, true and intimate love, which along with work, constitute the key elements of health that Freud suggested a century ago.


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© 2001