How Asking About Satisfaction Can Guide Your Treatment Plan

Very often therapists ask me how much to focus on the sex issues in therapy, and how much to focus on the relational issues. This is a very important question, because of course the sexual and relational aspects of sex issues are intertwined. Therapists who don’t feel comfortable discussing sex in therapy will focus on the relational issues, thereby missing multiple rich opportunities to help, but focusing on the sex issues to the exclusion of relational dynamics would almost always be totally unproductive.

If you’ve watched my Will Lily workshop, you’ll know that the final question I ask on my introductory sex issues assessment is “When a sexual encounter is over, do you feel satisfied? Would you do it again?”

This question is a little broader than the others I ask in the assessment. Instead of pinpointing a specific issue, or pointing to an immediate and urgent intervention, it invites the client to take a broader view, to step back and assess the sexual encounter as a whole. Often by the time you ask this question you have a pretty good idea of the answer, but this question points to exactly where the distress is, so you know where to focus once the urgent matters are addressed.

It can also be very interesting when you get an answer that surprises you. It’s a cue to ask more questions and rethink some of your assumptions.

Your clients’ answers to the satisfaction question are also important because they open the door to looking at the relational distress. Satisfaction resides at the intersection between sex issues and relational issues. When you ask this question you have already gathered quite a bit of specific information about sex, and now you will learn how all together affects the clients and their relationship. The answer to the question about satisfaction will shape your long-term treatment plan as you help the clients understand the sex issues in the context of the relationship, and vice-versa.

One question you can’t fail to ask your clients

I know from experience as a therapist how difficult working with desire discrepancy can be. Some of the most distressed, frustrated, angry, hurt couples I’ve worked with have been struggling with all the difficult feelings that come with mismatched desire.

There is just so much to be upset about. We invent a lot of stories about why one partner might want sex more often than the other, usually judgmental or dire things about ourselves, our partner, or our relationship. We feel trapped, frightened, depressed, and things start to feel complicated and tangled very quickly. The clients feel hopeless. After a few months of therapy, the therapist often begins to feel hopeless too. But I’ve worked hard to figure out how to be more effective with these couples, and I’ve developed some tools that make dealing with desire discrepancy much, much easier.

I want to show you how well these tools can work by walking you through a story from my therapy room. This is the true story of a couple that had almost given up hope of fixing their desire discrepancy, and how I was able to restore their hope within just the first ten minutes of my time with them.

When the couple walked into my office, they didn’t believe I would be able to help them.

I couldn’t blame them for that. Their relationship had been floundering for years as they bounced from one therapist to another. Their therapists, they told me, always wanted to talk about improving communication. This wasn’t unhelpful, exactly—they had learned to communicate better—but it failed to address the root of their distress. Even a sex therapist hadn’t been able to shift the problem. Over time, they had come to fear that their relationship was unfixable.

The wife was weeping in my office, blaming herself for not wanting sex. Why dont I want sex? What is wrong with me?  she wondered. Her husband wanted to be supportive, but he was afraid that his wife wasn’t attracted to him anymore, or that he was bad lover. I could feel their despair, and I wondered how painful it must be for them to live with these feelings, day‐in and day‐out.

But after I heard their story, I was able to determine within five minutes a very likely root cause of the desire discrepancy, a root cause which no other practitioner had brought up with the couple. With a few more minutes of discussion, I had explained my theory and made an appropriate referral. I was able to see hope begin to bloom between them, and they left my office so much happier than they had arrived.

How was I able to do this? By asking the right questions. Using the assessment tool I run through with all my clients, and which I share in my free video workshop, I was able to identify the root of the problem as unresolved sex pain.

Imagine what it must be like to have pain be a regular feature of the most intimate moments between two partners. Imagine the harm that can do to a relationship and an intimate connection. Imagine the strength of the love between partners butting up against the body’s wise and very adaptive drive to protect itself. How could desire possibly bloom?

The really sad aspect of this to me is that none of the therapists they had seen before had known to ask about sex pain! In my further questioning, the couple told me they had even consulted an ob/gyn and STILL they experienced unresolved sex pain. Of course, it is helpful to know how to work with sex pain, but that’s not rocket science. There are a handful of very common causes and there are specialists who work very effectively with most of those. There are also specialists whose job is to identify and treat unusual or difficult-to-treat causes.

But in this couple’s case, I was the first to ask about sex pain, form a theory based on the description of symptoms, and inquire whether they had consulted a pelvic floor physical therapist. When they did, the pain began to improve. Over the course of several months of steady improvement, their relationship recovered, buoyed by hope and positive results. Therapy with me simply supported this progress. The couple and the physical therapist did all the work.

Are you thinking “Sure, but she’s a specialist, I know nothing about sex pain and could never do that?” Not true!! I have explained to thousands of therapists, including generalists, specialists, and students, how to use my brief assessment tool and what to do with the findings. I am 100% confident that each and every one of them would have come to the same conclusion I did, and made the same referral.

You can too. If you haven’t already, sign up for my video workshop. It will help you get a strong head start dealing with any sex issue. And if you’re ready to go deeper, to begin helping clients ease distress in this extremely vulnerable area, consider giving my online course a try. It’s a full toolkit for assessing and treating sex issues, packed with robust, flexible interventions that you can put into practice right away. No matter your level of experience, it will help you stretch your limits, increase your potential, and grow as a therapist.