What happens behind the closed door in a sex therapist’s office? Do people get undressed? Do couples actually have sex in front of the therapist? How do you know when you could use the help of a sex therapist? In this episode, two therapists, Dr. Madeleine Castellanos and Dr. Erica Marchand, tell Kerri why seeing a sex therapist is a lot less intimidating than most people think.



00:00:04it's an experience of being able to tell your partner something that you've never been able to say before but that's very important to you it's an experience of roast that usually brings people closer ultimately
00:00:20I'm Carrie Miller and this is smart sex candid confident conversation about sexuality for women what happens behind the closed door in a sex therapist office do people get undressed do couples actually have sex in front of the therapist
00:00:37how do you know when you could use the help of a sex therapist in this podcast to therapist who specialize in sexuality a bit later will hear from dr. Erica Marshawn she's a psychologist who practices in Los Angeles and she'll talk to us about how to decide when a sex therapist could help but first dr. madland Castellanos is a new york-based psychiatrist petite straightforward quick to laugh Madeline knows this is a big step for couples
00:01:13you see a lot of couples in your practice right it is part of your practice trying to initiate or make those conversations between couples more fluid to take some of the embarrassment and shame out of it that's a great deal of what I do with a couple's because whenever there is anxiety listless take an example of anxiety that causes some erectile dysfunction and then there's a question like well maybe you're not attracted to me anymore and the entire Dynamic of their sexual interaction starts to become affected and there might be some avoidance because they're like you said embarrassment and now they're not talking about it or talking about it only in very reactive ways that it's emotionally charged and
00:02:02this is this will break down conversations immediately and so it's about facilitating okay well how can you communicate to your partner and how can you stop yourself from taking the most negative interpretation about what's happening in the moment because that's what people do if they immediately think of it must be that you don't like me and perhaps you never liked me and you must like other people much more and like where did you go where did you come up with us that's a proud of your on mine so it's pointing out hey let's find ways you both want the same thing really that's fine ways to talk about it to open up the conversation to decrease the anxiety to stop jumping to the worst possible conclusion because that is going to zap all the sexiness and eroticism right out of it you use the word anxiety quite a bit in our conversation that that sounds like it's a big roadblock in in a fulfilling sexual relationship is that true
00:03:01I think anxiety is the number one cause of sexual dysfunction is it really
00:03:09well so there's the normal performance anxiety that people experience there's also the the fact that the more you really really are invested in someone liking you and accepting you then the more anxious you are that you're going to do things right or that you're going to be able to please them so that they continue wanting to be with you so consequently I see men who have no trouble having erections with women that they care very little about in the moment they need a woman that they are so so crazy about they are so anxious because they just wanted to go so well that that's when they get erectile dysfunction there like I don't understand I really like her and it makes perfect sense to me when you think about how it's the anxiety aspect that is shutting down the arousal and making the problem solving part of your brain totally active while the more primitive limbic system is trying to just come and get things rolling but can't because it's in like
00:04:09ninja mode from anxiety can I ask you as a sex therapist how you how you begin to counsel couples on that
00:04:18I take a very extensive history of not only what the difficulty is that they're having right now but what's going on in their lives previously were their attitudes about sex and sexuality how do they feel about themselves and their own bodies have they learn about it and then I noticed what styles of communication do they have is there something that's keeping them from communicating do they want similar things or are they under two very different pages and there's very different approaches with some people it's a matter of just giving them a little bit of information and I've had couples it within two or three sessions they're good what is others really stay for months of work because it's about really finding how to reestablish of good communication with each other and correct the Dynamics unwinding some of the patterns that have been created through avoidance emotional
00:05:18reactivity so it does very a lot but I like to point out what how they're communicating with each other and I think most important is for each one to start to put themselves in the other person's shoes so that they can start to empathize with that person it really does facilitate communication and wanting happiness and success with your partner's you know what you sound like a really warm receptive person but it it's got to be a scary thing to come into a sex therapist as a couple
00:05:53thank you though thanks for the one part I imagine that it is and I tell people from the very first session I'm going to ask you about things that are very personal and you probably wouldn't discuss them with anybody anywhere and they can be very anxiety-provoking however I can only help you with what you bring into the session I'm going to encourage you to be as open and honest as you can because that's the way that I can best help you at doopy Doo couples think that this is going to be about coming in and taking off their clothes and having you doing some observation or something I have had quite a few people asked me on the phone if that's what's going to be happening and I what what do they ask ask sometimes it's
00:06:43it's not necessarily couples that think that that's going to happen to say why am I going to have to touch my partner and we can have to do things in the office and I explained in stock there be based we're going to be talking a lot about what's happening and I may send you home with exercises to do at home but you're not going to have to be taking off your clothes are doing anything explicit in the office
00:07:05and of course there's the calls that I get from guys who I think you're just looking for perhaps surrogates or escorts or something and I quickly tell them I'm sorry this is I'm not really who you're looking for what kind of exercises might you send a couple home with
00:07:21show sensate Focus exercises which are the classic Masters and Johnson's technique for Sex Therapy are really Progressive exercises that start off with touch and they they help the couples reconnect physically in Progressive ways so that there's no they're not the pressure of having to have penetration from the very beginning so it really helps address anxiety and through the process you first start touching very gently on their neutral parts of the body and then see what thoughts come up when we process those and then in subsequent session they progressed on to getting closer and closer to having sex and eventually having sex. You know what the difficulty that they are having some exercises can be the sensate focus exercises there are many times that I will give people instructions on changing the way that they masturbate or exploring different ways of masturbating or focusing on their Sensations in a different way
00:08:21Walter masturbating because that may help with anxiety when people are sometimes lost and anxious. Supply, am I pleasing my partner do they like this one if you would keep my erection so I'm teaching them to focus on the pleasure aspect to be really connected in their bodies serve like a sexual mindfulness really
00:08:40that's a great phrase sexual mindfulness I mean you're bringing your bringing this sense of enrichment and wholeness into an area of Our Lives I don't think we connect with that often enough
00:08:56I think that's why I ended up doing what I do because all of the Sixers sexuality was still and sexual medicines for the outcasts of orphaned out outside of medicine I thought how can I be a doctor and not be able to talk to my patients about sex when I have this woman in my office saying I'm just getting divorced and I don't know if I've ever had an orgasm but my husband was not a very good lover and didn't really want to talk to me about it so what do I do now and I thought this woman needs help and why shouldn't I speak to her about sex and why shouldn't I help her in Rich for life and explore what's good for her because that's going to translate into healthy relationships probably more stable family whose and overall doesn't have benefits society and always I mean that's exactly what this are you've articulated exactly what are project
00:09:56you know having these kinds of enriching experiences and how that influences your overall idea of what it is to be a whole happy person exactly you can't separate that part of you it is you it is Life Energy they are one in the same it's how you Channel it and I think to think about sexuality any other way is to not give it the credit that it's due
00:10:27this is such a vital part of my life I mean when you think about having a healthy sexuality it gives you Vitality I mean we know that physically with their tongues benefits mean 50% less heart attack risk protection against dementia better-looking skin lower blood pressure better stress levels in your eyesight better because your blood flows better everything gets better when you have a healthy sex life so it is not a separate part of our physiology of our health and for anybody that treated that way it's really doing a disservice to it
00:11:11dr. Madeleine Castellanos want to hear what she said on being ruthless about pleasure you can find that podcast on iTunes or wherever you get your podcast
00:11:22now to dr. Erica Marchand on how to know when it might be time to see a sex therapist she's a Los angeles-based psychologist with a warm open expression she sympathetic without being syrupy and she two uses humor the diffuse the initials squirming is couples might feel when they sit down in her office it's an intimidating decision after all is a private things we often only share with a partner or a close friend Eric and knows how intimidating making that first appointment with a sex therapist can be
00:11:58I think I'm a very basic level its content that's pretty personal and private for people and I think on one level a lot of people are just concerned about the process of talking about something so personal and so intimate with a stranger or talking about it with anybody I think that's probably the number one thing that gets in the way the other thing that happens is if somebody's never been to therapy for sexual concerns they might not know what happens I've had a fair number of people wondering if there's actually sexual stuff that happens in the session like like you're going to ask them to have sex right exactly I'm going to ask them to masturbate right there on the couch or a hundred percent never the case why do people think this
00:12:54well I think media's one part of it we have a lot of really great TV and movie content out there that shows kind of stylized movie versions of what might happen in Sex Therapy and then also I think people might confuse things like Masters and Johnson research for example you know the Masters of Sex show that I would right now if I wanted her exam fault it's great yeah and they did amazing work but I think sometimes people also might confuse that type of thing and also that time and place in history with what might happen today so I think they're just a lot of of fears out there about what they might what people might have to reveal and what you know they might be asked to do that are fairly uncomfortable in addition to its just content that people are inherently private about most people think those are some of the biggest barriers I should ask you though why why wouldn't you ask people to
00:13:54you know demonstrate maybe what's what they feel isn't going right sexually I mean why isn't that done that is a great question actually I think the most fundamental answer is legal and ethical boundaries of being a psychologist which is what I am it's just outside what I can do really legally but then just go with my license to be physical with people or to ask people to do physical things there's really fine line and a lot of concern about you know people's rights and well-being in in therapy but outside of that I think your questions a great one because there are other kinds of professionals bodyworkers there is sex sexuality therapist to aren't psychologists are or who people who don't fall under the same as a colon legal guidelines who specifically do work with couples on body and physical what am I trying to say
00:14:54on the physical component of sex I think that's the right way to say it and it can be really really helpful for people because if you are able to have Hands-On in the moment observation and feedback about what's happening between you and your partner sometimes it's really helpful and sometimes it's more helpful than going home doing homework exercises and coming back in talking about it in a session which is what I sent to do with people so it's a great it's a great question in people differ in whether they would want to do that and how comfortable they are with that but sometimes it can be really helpful Erica how often do people show couples show up in your office having not had sex for you know a really long time
00:15:39frequently frequently you know I was looking through your other podcasts just before the show or just before the interview here and I was noticing that you had the woman who wrote wanting Lori watching sex again yeah yeah yeah yeah and I was thinking that is the number one thing that couples show up to my office for and it's not uncommon for people to show up not having sex for a year or more somehow yeah it happens a lot I mean I want one of the things that dr. Watson told me was that within a couple of years of third of all couples are in a sexless marriage and I thought these are probably couples who never would have dreamt you know what the beginning of the relationship when you're having lots of sex and intimacy that they would find themselves in that place so soon no
00:16:39number is really surprising even to be it and within a few years right I think you're absolutely right I don't think anybody ever expect so that's going to be there situation but then so many things can happen in a relationship everybody's busy these days that's one thing kids are another thing that happened that puts a lot of time pressure and changes things in terms of roles in a relationship frequently too I think for a lot of us were used to the idea that our sex life is driven by spontaneous desire that we're going to be either we're always going to feel the way that we feel about her partner in terms of looking over at them and wanting to have sex with them sort of automatically like it is at the beginning of the relationship for a lot of people and so when that inevitably changes because it does most couples over time I think we can be
00:17:39got a little bit of a loss about how to go about maintaining a sex life then if that if that's not happening anymore there's a way that I can feel less natural to continue having sex and that's that's a big part of what I do with people you know in the years of a relationship most people have the experience of having conflict having disagreement you know we all realize the way that are partners aren't perfect and I are going to meet our needs exactly the way we thought they were stuck at the beginning of the race in relation to really thought I know I can change him or her or tell them to find earring yeah right and all that stuff becomes water under the bridge and I think some some of that creates distance between people that there that can decreased people's you know desire willingness are open as having sex with e
00:18:39weather that can happen to our couples when you're working with a couple and by the way how long what's the average length of time that you would work with a couple yeah you know I can give you the average but I will say that it varies widely in my practice I think the average length of therapy is about 6 months 6 to 9 months if I'm remembering right just looking at my own numbers and that will vary from person to person but I will say that it varies pretty widely some people come and have a relatively specific concern and not a lot of other relationship issues going on and for those people that might be shorter term therapy other people come in and have more stuff going on maybe there's been sexual trauma maybe it's been years since they've had sex maybe there's also a lot of other underlying conflict in her feelings and to get through
00:19:39a lot of kind of entrenched relationship behaviors that haven't been helpful and that those are longer-term that's longer-term where do you find that once you've been working with couples for a while you know they're saying things to one another that with it that they've never said before that they've been afraid to say to each other yes I do frequently frequently people will say that it's
00:20:12it was there is sort of comfortable in the process of therapy it's the contained it's the containment of of how the conversation goes in the room that allows people to say things that they wouldn't have said before it to that and then also I think in the process of couples therapy ideally people start to feel a little bit safer with their Partners emotionally so so start to trust other partner understands them their partner is going to respond in a way that constructive so people can open up a little bit more and be more vulnerable and trust that it's going to go okay but yeah that happens all the time
00:20:52it happens all the time I think it can be a really beautiful thing I think sometimes partners are afraid of that like what's going to come out in therapy but I don't know are we opening up a can of worms yeah and truly it sometimes the things that get said can be surprising and and potentially disappointing or unintentionally hurtful or just really sensitive and we have to work through them but I think often it's a really it's an experience of being able to tell your partner something that you've never been able to say before but that's very important to you it's an experience roast that usually brings people closer ultimately I was remembering that Lori Watson told me that she and her husband laugh a lot during sex and I I was thinking that maybe the playfulness of sex starts to diminish you know the longer you're in a relationship and it starts to be influenced by all the other stuff that's
00:21:52going on in your lives I mean is this something that you talk to couples about you know restoring that sense of playfulness to make sex fun yes absolutely you know it's so funny that you say that I was just talking to a couple about this yesterday and it is a thing that comes up over and over again for a lot of my couples what happens is a process that looks something like we used to have sex something happened in our relationship either either something identifiable or just slowly over time we stopped having as much sex and had more difficulties and then stopped having sex all together and then sex becomes this big looming thing and it's an obligation and it's something that we're not doing and it's something that they're all these bad feelings around and it just becomes very heavy and waited and unpleasant to think about so I talked with people about a I talk with people about what they want their sex life to look like to read
00:22:52to what what are the adjectives that would describe what you actually want and what people will often say is I want it to be pleasurable I wanted to be you know easy wanted to be happy I want to be playful I want to be spontaneous and so getting a sense of what people actually want helps us know the direction that we're going so this is what we're aiming for and within that then I try to ask people to identify so if you could think of some activities that would be playful or pleasurable or fun and spontaneous what would those be and it doesn't have to be intercourse right it is even have to be sexual but are there things that they can imagine doing together that are somewhat physical that would embody those qualities that they're looking for that sometimes a place that we start at times too there's a kind of a classic set of exercises and Sex Therapy called sensate Focus that were developed by
00:23:52Masters and Johnson actually and there is a series of touch exercises where couples will make a date with each other to get together and at the beginning anyway touch each other just you know kind of like giving a massage but not like you have to really try to give her professional massage but to touch each other in a way that's just pleasurable there's no sex involved you have your clothes on there's nothing there's nothing pressured or demanding about the situation you're not trying to get anywhere and for a lot of people that can be a place to start of reintroducing non-pressure tune on demand touch into their life as a couple in a way that feels easy and is likely to be pleasurable so there's a there's a couple of routes there and there's more more than that but there are a few routes to get there but those are some of the things that I use a lot are there any games that you recommend
00:24:52for couples you know I don't even really mean sex toys just they're kind of fun games that lighten things up in the bedroom I love that idea you know I don't have any games in particular that I recommend to people I will often tell people who are wanting to feel more and have more newness and excitement and more passion for their relationship and their partner I will talk with him about what something fun and knew that you guys could do together that would be a little bit exciting like do you want to go ride roller coasters and do you know it's part of your date and see you want to take a surfing lesson together as part of your date you know stuff that is exciting and a little bit scary and the name that you have to really you know we work together to do sometimes that's something that helps people feel differently and new it in new ways to wear their Partners in terms of specific game
00:25:52is in the bedroom I don't have anything structure that I use that's a really interesting idea though we've been we've been thinking about this Erica my partner and I and we've developed a game we call pillow play oh it's essentially these little cards that have fun and sexy sayings on numb and you slip one of them under the pillow of your beloved maybe in the morning maybe in the afternoon and you let the anticipation build up a little bit and then then the partner opens the card that night and you proceeded to do what's on the card that it's kind of physical and fun do you like the idea bad and it's kind of a surprise and you know I love that in you get to sort of anticipate and think about what it is and then you just go for it whatever is on the card that was so mean that those people are on board that's really great I like that a lot I'm glad
00:26:52see the anticipate you've picked up exactly and what we we've been thinking about the anticipation is such a big part of the pleasure of sex and I feel like people forget it you know when when you're dating years are gone I feel like people forget about how much fun that anticipation is yes yes it's so true if it starts to feel mundane sex can start to feel mundane or just you know for people for people who are having sex in a relationship I think sometimes it just feel sort of readily available and and and familiar who aren't having sex the there's not a lot of anticipation there because there are problems but yeah the anticipation is so he I think that you know everybody knows that feeling of the deliciousness of Desiring something that you can't quite have yet for your or you're going to have later it's a big part of the pleasure that happens old family from
00:27:52getting at or experiencing are having it
00:27:56psychologist and sex therapist Erica Marshawn and see the books she recommends for couples go to smart sex. Org that's where you can also sign up for our smart sex newsletter and if you like these podcast we ask that you spread the word about smart sex by reviewing and sharing it
00:28:18smart sex. Org was created by Me Carrie Miller and Mike of Enthusiast in Chief Teresa McFarland Tiffany Hanson is director of content and podcast production the amazing Jennifer Larson is our lead producer Lisa ormonde helps us with editing we record smart sex at the on being studios in Minneapolis special special things to Krista Tippett Trent Gillis and Chris eagle and a big shout-out to Clockwork in Minneapolis for their digital design and strategy check them out at Clockwork. Com find out everything you always wanted to know about sex and weren't afraid to ask at smart sex. Org sign up for our newsletter and will tell you when and where are the next smart sex Salon is happening

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