Family Therapy & My Relationship with My Dad

When I was in my early 20s, I decided to focus on myself and my relationships, as I simultaneously started a career as a writer, journalist, and teacher. I got into Zen and Tibetan Buddhism; found a terrific therapist; and got to work forging a relationship with my dad. I don’t mean to make this sound neat, easy, and planned—it wasn’t. It was painful and confusing.

My father, who passed away in 2017, was an attorney at a large law firm, and I didn’t see him very much when I was younger. He traveled for work—a few days out of every week—and, when he was home, he was busy, stressed out, and removed.

I came home one day when I was in my early teens and his den, where he drank beer and watched television on the weekends, smelled like cigarette smoke. There was an ash tray filled with butts. My dad told me he lost a case—his first one ever—and he was worried about his job.

I didn’t know my dad very well until I confronted him in my 20s. He wasn’t experienced with emotional intimacy; his self-worth came from professional achievement. And he didn’t have a lot of relationships—my dad wasn’t close with his one sister, my late Aunt Helen, he had almost no individual friends, and he didn’t seem to have the energy or interest to get to know me, his youngest child.

So, when I was 23, I confronted my dad and asked him to tell me about his life. I can’t blame him for not seeming to like my efforts—I was aggressive and not terribly skilled at emotional intimacy, myself. To his credit, my father cooperated with my attempt to get to know him, even if I sometimes berated him for his shortcomings. One day, he told me he was sorry. “For what?” I asked him. “I don’t think I was a very good father,” he said. This was a powerful moment, a real break-through. A flash of openness.

During this time, my dad answered questions about his childhood and agreed to spend time with me. We went to movies and museums together. My dad and I had a lot in common: we both liked spicy food, Mel Brooks and Woody Allen movies, and we liked to talk about politics.

I didn’t approach my dad in the best way; I was relentless. But I’m proud of myself for having made the effort and for working on our relationship. We didn’t have a family therapist to help us—I didn’t even know that was an option at the time—but we did have the necessary ingredients to improve our relationship: we were motivated and willing to put in the time.

My dad died when he was about to turn 77 and I was 42, so I got close to 20 years of feeling pretty close with him. I wouldn’t trade that for anything.

I think about my experience with my dad a lot when I’m working with couples and family clients. It can be so messy and confusing to address challenging aspects of relationships. The challenges never go away—at least they didn’t with me and my dad—but they can become more workable. What I call ‘hot spots’—areas where we conflict with loved ones—don’t disappear, but they become less hot.

It’s a funny phrase, to ‘work on a relationship.’ The way that one works on a PhD dissertation, a jump shot, or a home improvement project. You tinker and fix; you address the problem areas. Building something takes time and patience as well as faith that it will get better with effort. That’s what couples and family therapy is all about, I think.

Sex, Psychotherapy, & the Nature of Play

I was recently scouting around for a personal therapist and expressed during a consultation that I wasn’t sure what my goals were—I was just looking to develop a relationship with a therapist and take it from there. The therapist said in response, “Okay, but therapy is about work. What would you like to change about yourself?”

I found this to be a thought-provoking idea, and one that I wasn’t sure I agreed with. Is therapy about work? At the time, I wasn’t looking to do work—I was looking to explore (even if, at previous times in my life when I sought therapy, I had been more goal-oriented.)

I thought about this conversation when I recently read famed British psychoanalyst D.W. Winnicott’s book, Playing and Reality, in which he writes that therapy, at its best, is more about ‘play’ than it is about ‘work.’ “Psychotherapy has to do with two people playing together,” writes Winnicott, “The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.”

For me, this is an exciting if slippery concept--what does it mean to play in therapy? And how does a therapist bring a client into a state of being able to play? I know that playfulness is a quality that I value—in relationships, in people, and in literature and art. I value it in therapy, as well, but I wasn’t sure in what ways I play as a therapist.

For clients struggling with depression or severe anxiety, playing is almost unimaginable—the same way that the thought of flirting with a romantic interest might be out of reach to a very shy person. When the stakes feel too high, playfulness eludes us. But, according to Winnicott, the process of therapy is about re-learning to play.

Winnicott writes that to make sense of one’s own life in a creative manner is a form of play called ‘creative living.’ “We find either that individuals live creatively and feel that life is worth living,” writes Winnicott, “or else they cannot live creatively and are doubtful about the value of living.”

Working with clients to perceive their lives in a creative way requires both a sense of gamesmanship on the part of the therapist, as well as an active restraint. To me, playing as a therapist involves exploring relevant themes, helping clients to connect some dots, asking thoughtful questions rather than making statements, and, sometimes, using humor and irony to share with a client a sense of joyful awe at some instance of absurdity. Sometimes playing involves giving a bold and surprising homework assignment to a client.

As a psychotherapist with a specialization in sex, I wonder how Winnicott’s ideas relate to sex therapy. It seems to me that Winnicott’s thinking is essential to not only good sex therapy, but also good sex. He emphasizes the therapist creating an open space in which clients can explore. According to Winnicott, therapy isn’t about solving problems; it’s about learning to engage creatively.

Therapy can be like sex in a way. Ideally, the emphasis isn’t on achieving orgasm, it’s about having a healthy sense of play and discovery. Yes, we want sex to be erotically intense and gratifying, just as we want therapy to be meaningful and have impact (we are paying for this, aren’t we?) But this gratification and impact, in sex and in sex therapy, comes more from openness, presence, and a sense of willingness than it does from trying hard.

Sex shouldn’t feel like work. I guess therapy is work in the sense that progress is being made and it requires focus; but the spirit, I think, should be one of playfulness.

A Short Story that Might Help Your Marriage

Clients sometimes ask me for a book recommendation that might be helpful to our work together. Usually they want non-fiction—something by Esther Perel or Terry Real. But on occasion someone asks me to recommend a piece of fiction, which can be more difficult. Even more difficult is when it’s a couples therapy client. What novel or collection of short stories might help my clients to work on their relationships?

The fact is that literary fiction does not provide us many exemplary relationships from which we can get tips on how to improve or fortify our long-term romantic unions. “Happiness writes white,” goes an old French dictum: contentedness and consistently full hearts are barely legible on the page.   

I was thinking about this the other day while reading Benjamin Balint’s recent biography of Polish-Jewish writer, Bruno Schultz—not the first writer from whom most of us would seek marital advice—when I came across this passage: “Bruno Schulz believed that human weaknesses—carnal and otherwise—allow human beings to find companionship.” Schulz expressed the idea in a letter to a friend: “Without flaws they would stay locked inside themselves,” he wrote, “not needing anything. It takes their vices to give them flavor and attraction.” 

This idea put me in mind of “The Lady with the Little Dog,” a short story by Anton Chekhov that depicts with exuberant detail the process of Gurov, a philandering middle-aged banker, falling for and later deciding to commit to Annya, a married young woman he’s having an affair with. Gurov is getting older in Chekhov’s story, and after dozens of extramarital affairs throughout his adult life, the love he feels for Annya is crystalized as he sees himself in the mirror:

His head was beginning to turn gray. And it seemed strange to him that he had aged so much in those last years, had lost so much of his good looks. The shoulders on which his hands lay were warm and trembled. He felt compassion for this life, still so warm and beautiful, but probably already near the point where it would begin to fade and whither, like his own life. Why did she love him so? Women had always taken him to be other than he was and they had loved in him, not himself, but a man their imagination had created, whom they had greedily created all their lives; and, then, when they had noticed their mistake, they had still loved him. And not one of them had been happy with him. Time passed, he met women, became intimate, parted, but not once did he love; there was anything else, but not love. 

In this passage, I see the human weakness Schulz wrote about embodied in Gurov’s gray hair and fading good looks. Gurov has never really loved; his sudden awareness of his own vulnerability allows him to for the first time. 

I think this is a useful notion for those of us struggling in our marriages and long-term relationships. My mentor, the writer, George Saunders, used to talk about the irony that we don’t necessarily fall in love with people because of their prowess or talent; the moment of falling in love might happen when watching a partner clumsily trying to ice skate.

I wonder if, the longer we’re in a relationship, the harder it is to appreciate and care for our partner’s vulnerabilities and the easier it is to forget how much their love for us makes our own frailties more tolerable. If you have a partner, take a moment and consider their emotional vulnerability. Does that not make you feel more tenderly and loving towards them? And what better way to consider the nature of love than by reading some Chekhov?

Evan Imber-Black: Guru of Couples & Family Therapy

I was lucky to have known and studied with the eminent couples and family therapist, Evan Imber-Black, who died yesterday at the too-young age of 80. Dr. Imber-Black directed and taught in the Marriage and Family Therapy program at Mercy College, where I got my degree. She was an author and a pioneer in the field of family therapy. Dr. Imber-Black wrote books primarily about two themes: family rituals and family secrets.

To me, Dr. Imber-Black has been a mentor and a guide. A few months ago, I reached out to her for advice on a case I have and I began seeing her once a month for supervision. Talking with her has been greatly helpful and a pleasure.

Dr. Imber-Black used to say about marriage and family therapy, “One thing about this field, it’s never boring.” I found that notion inspiring, and I believe it to be true. I love couples and family therapy, because it’s an exciting privilege to talk with people about their lives, to be an outside resource mirroring back what I see playing out before me.

Every first session I have with a new couple client, I use an interview template that I got from Dr. Imber-Black. I start out by asking about who’s in the family, where they live, and what they do for a living. Then I ask them to describe the challenges that bring them in to see me. Shortly after, I ask them each to tell the story of how they met, and what attracted them to their partner.

When I started doing couples therapy, I used to have a print-out of the questions that I kept in a notebook on my lap. I would surreptitiously look down, to remind myself where I was in the elegant sequence of questions that Dr. Imber-Black had designed. At this point, I have internalized the questions; Dr. Imber-Black’s wisdom and experience have become a part of me.

One of the best aspects of Dr. Imber-Black’s teaching were the essays she assigned us to write. There was a real emphasis on what is called ‘the self of the therapist’; we had to apply what we’d learned of systems theory to ourselves and our own families. It was useful and cut deep.

I respected Dr. Imber-Black and I would work hard on the essays for her class. She had edited the most important academic journal about family therapy, Family Process, for the better part of a decade. She was a real intellectual, a seasoned editor, and an accomplished writer. I wanted to demonstrate to her in my writing that I understood what we were learning in class.

I wrote about my own family for the first essay I was assigned in Dr. Imber-Black’s course on family therapy. By assessing systems at play in my family of origin, I came to realize that my maternal grandfather’s sexism had trickled down into my mother’s point of view, and had, I believe, influenced how she parented myself and my siblings. 

This was revelatory for me. It was systems theory in practice: I was processing how the patriarchal system of our broader society had impacted my grandfather, and then impacted my mother, and then impacted me. Through the framework of Dr. Imber-Black’s essay assignment, I was able to, as she would say, ‘think systemically.’

As I reflect on what I learned from Dr. Imber-Black, I realize that I’ve maybe gotten too far away from systemic thought, which requires discipline and rigor. Dr. Imber-Black was a hardcore proponent of the Genogram—a clinical family tree that couples and family therapists create for each client to understand how family systems function and interact with societal systems. I want to get back in the habit of using a Genogram.

I would describe Dr. Imber-Black’s demeanor as tough and matter-of-fact. I never found her to be warm and fuzzy, though I did have the sense that we had a camaraderie. She kept me on my toes--I never felt too comfortable with her, I always felt like I had to be as real, honest, and thoughtful as I possibly could. I did feel warmth from and towards her, though.

In text messages, my fellow students and I still refer to Dr. Imber-Black by her initials, EIB. RIP EIB. I am grateful to have had you as a teacher and to carry you with me.  

Communication, Couples Therapy, & The Weekly Walk

I give homework to couples therapy clients after our first session, and it’s usually pretty basic. I might encourage couples to establish a weekly meeting where they divvy up domestic tasks and discuss finances. If sex is an issue, I might encourage couples to spend some time with one another physically, but agree beforehand that they’re not going to have intercourse (this can take the pressure off, as well as engender its own kind of eroticism.) Homework might be as simple as encouraging couples to offer one another more physical affection or to be more mindful of the tones they use around the house.

The homework I give that is most reliably effective, though, is to encourage couples to schedule a weekly walk of 30-45 minutes during which they talk about their relationship. I think the weekly walk is reliably successful because it’s scheduled, low-pressure, quality time for couples to spend without distraction; it’s a mutual gesture towards putting positive energy into their relationship; it's outdoors and in public, so the chance of an argument breaking out is significantly reduced; and it’s free. It doesn’t cost a dime.

The best part about the walk is that it’s a relaxed way to communicate about fraught and heavy issues. Too often, couples try to talk about serious topics when they’re feeling anxious—sometimes, one partner wants to have a serious talk about the future right at a moment of panic. Couples may try to discuss important stuff while one or both of them are at work, when they’re driving to dinner, or right before they go to sleep.

These aren’t good times to have serious conversations.

Choosing a good time to discuss a difficult topic is similarly important with parenting. A lot of times we might choose to talk to our kids about their behavior right at the moment that they’re misbehaving. Generally speaking, though, the best time for us to talk to kids about their misbehavior is when everyone is feeling good. That’s when we’re most likely to see and hear each other.

The weekly walk is the perfect time to discuss challenging topics with one’s partner.

I believe it’s important to find new and creative ways to elevate one’s relationship. Starting couples therapy and taking a weekly walk are similarly valuable in that, by initiating both, you’re acknowledging that relationships are hard, and harmonious ones take a lot of effort and attention, as well as learning and experimentation.

I often joke that if everyone would just take a weekly walk with their partner, I would be out of business as a couples therapist. I sometimes believe that to be true.

Kafka, Existential Psychotherapy, & the Search for Meaning

In his stories, novels, and parables, Franz Kafka captures how strange, hard, and bewildering it is to be alive. He writes about the feeling of being too late, that one has missed their chance; about the experience of being other; about the futility of depending on authority figures for help and guidance; and about the hope and challenge of finding one’s own path.

This is all to say that Kafka is a wonderful and important writer, one to whom I go back again and again because of how illuminating, serious, and funny his work is. In Kafka, there’s no space for petty concerns—as an author, he had little interest in gossip or politics. He barely even wrote about sex. Kafka was interested primarily in humans’ relationship to themselves and to the universe. Kafka found humor and pathos in the deepest pains of being alive.

In one of his aphorisms, Kafka wrote, ‘Never again, psychology!’ I’m not sure exactly what he meant by this, but I think he wanted to go beyond the workings of the human brain to tell stories from an even broader—an almost biblical—perspective.

Still, I can’t help but interpret his works in a psychological way. In The Trial, for example, the protagonist is accused of committing a crime, but he can’t find out what the crime is. To me, this captures something about a person’s fundamental uncertainty about who they are and whether or not they’re good or bad, guilty or innocent. I feel like there’s something about intergenerational trauma in there.

And in The Metamorphosis, Joseph K.’s first thought when he realizes he’s transformed overnight into a dung beetle is that he has to call in sick to work. To me, this feels deeply psychological. Kafka captures how we’re so caught up in the mundane that we are numb to the fundamental absurdity of human life.

In my office in Manhattan’s Financial District, I keep a couple hundred of my books on shelves behind my therapist chair. I love being surrounded by my books while I do therapy. I enjoy noticing clients scan my books and I am delighted when they ask about them. I value books and reading; by displaying my books, I guess I’m asserting that value.

The author most represented on my bookshelves is Kafka.

Existentialism is a philosophical exploration of the meaning and purpose of human life. Kafka was not explicitly an existentialist—he died two decades before the term was coined in 1940s France—but he is widely seen as a precursor to existentialist writers and thinkers. Existentialist philosophy inspired the great psychologist Irvin Yalom to create Existential Psychotherapy. I find a lot of wisdom and guidance in Yalom’s work.

When I’m doing my best as a therapist, I’m partnering with my clients to transcend the mundane and confront the absurd, painful, and awe-inspiring phenomenon of human life. Beneath any conversation I’m having with clients is the question: how do we make meaning in our time on earth? Having Kafka’s books on the shelves behind me is a reminder to broaden the scope of my work as a therapist.

What turns you on? Part Two.

In my last post, I talked about Jack Morin’s idea of the core erotic theme (CET): the notion that each person has a single dramatic concept that drives all of their erotic fantasies. According to Morin in his excellent book, The Erotic Mind, exploring one’s CET is one key to leading a richer, more satisfying sex life.

Morin wrote that our CET has roots in unresolved childhood struggles. According to him, the dramatic engine that drives our fantasies is an urge to resolve some frustration or problem that has stayed with us over the years. That’s how deep our childhood wounds are; decades into adulthood, we’re still trying to undo them.

Morin’s idea helps to explain why sex can be such a compulsion for many of us. Each time we pursue our CET, we’re scratching the deepest of itches.

The attraction equation is another of Morin’s ideas that helps us to understand our CET. The equation is: attraction + obstacles=excitement.

Some people, for example, might get turned on by being ignored by a lover, and trying to gain that lover’s attention. By trying to get attention from a lover who ignores us, we may be working to overcome a childhood obstacle to feeling loved. Every time we play this scenario out, we’re giving ourselves a chance to try to get the love that we want. If it’s too easy—if our lover does not ignore us but instead easily gives us the love we want—we are not given the chance to overcome our childhood struggle. We need the obstacle.

The concept of the CET makes me think of the similar urges behind entrepreneurial ambition and artistic creation—which may also be an attempt to heal some wound from childhood (see Orson Welles’ “Citizen Kane” for example)—and sex.

Understanding our CET helps us to nurture and tend to our turn-ons and to better understand ourselves. I agree with Morin—better understanding our turn-ons helps us to communicate them to our partners.

Communicating our turn-ons to a partner or partners is one wonderful form of intimacy. If you can turn to your partner to explore and satisfy your deepest sexual desires, you will feel closer to them.

One of the biggest challenges I face as a couples therapist is in helping some clients to overcome the shame they may feel about sharing their sexual desires. It’s such a vulnerable and scary thing to do, to tell your loved one about your erotic fantasies.

I often encourage clients who are looking to connect more sexually to ask one another “What turns you on?” or “What do you fantasize about when you masturbate?” It can be most effective for them to ask these questions when engaged in foreplay—my experience is that it can be easier to share when in the heat of the moment. Even then, though, it can be quite challenging for many of us to share our fantasies.

What turns you on? Part One.

Sussing out what turns clients on is often important in sex therapy. I have clients who come in because they don’t know whether or not acting on their turn-ons is morally acceptable. Others see me because they can’t achieve or maintain an erection (commonly known as erectile dysfunction—I prefer the term, ‘erectile unpredictability.’) And lots of couple clients come in because one partner is dissatisfied with the amount of sex they’re having. In all of these cases—and in others—it’s valuable to talk about what turns clients on.

In a previous post, I mentioned the sexual menu, introduced by Suzanne Iasenza in her terrific book, Transforming Sexual Narratives. With the sexual menu, clients make a list of five or six items that come to mind when they think of the word ‘erotic.’ This is a great way to get people to start thinking about what turns them on.

For many of us, it takes time to open up about what really turns us on. Many of us keep our true desires hidden, even from ourselves.

Some good places to start in thinking about what turns you on is thinking about what pornography you watch, or which fantasies you indulge in, when you masturbate. You also might mentally travel back to your childhood and adolescence, to think about the nature of your earliest fantasies.

In my favorite sex therapy book, The Erotic Mind, the author, the late sex therapist, Jack Morin, encourages readers to think about their ‘peak sexual experiences’—the most powerful and pleasurable sexual experiences they’ve had. By examining these, we can begin to gauge what scenarios, situations, and dynamics really excite us.

Morin introduces another useful concept in The Erotic Mind. He poses that, “our most compelling turn-ons are shaped by one unifying scenario that I call the core erotic theme (CET). The CET is core because it occupies a place at the heart of each individual’s eroticism. And it’s thematic in the sense that an infinite array of storylines, characters, and plot twists can all be inspired by a simple, yet profoundly meaningful, dramatic concept.”

Let’s pause there—what does Morin mean by ‘dramatic concept’? I guess he means that most of the time, when we fantasize, there is a situation or relationship dynamic at the fantasy’s core. For some of us, it might mean that we want to dominate another person. Others may wish to be dominated. Some of us may get turned on by the thought of another person treating us kindly. In any case, at least, according to Morin, there is usually some kind of story at the center of our fantasies.

The concept of the CET becomes more fascinating, and more psychological, as Morin continues. “Hidden within your CET,” writes Morin, “is a formula for transforming unfinished emotional business from childhood and adolescence into excitation and pleasure.”

So, according to Morin, what excites us sexually is resolving ‘unfinished emotional business from our childhood and adolescence?’

This is the first part of a series of blogs I’m posting on erotic turn-ons. I’ll be posting another one—picking up right here—later this week.

Fear and Expecting in NYC

Lots of couples seek therapy when they start planning for a family. It makes sense: the prospect of having a child brings up new and long-standing issues in couples.  

When working with family planning clients, the most common thing that comes up is a reckoning with the imbalance, in heterosexual relationships, between the burdens placed on an expectant mother and those placed on an expectant father. In addition to the physical burden the expectant mother takes on, there are also often greater societal expectations: from having to readjust one’s relationship to alcohol to, sometimes, an expectation of working less once the baby comes. The expectant mother is also the one with all the doctor’s visits. To state the obvious: pregnancy has a bigger impact on the mother than it does on the father.

How can a couple reconcile this? Does it help when the non-pregnant partner takes up a greater portion of domestic chores to try to make up the difference? Should the non-pregnant partner start giving the pregnant or hoping-to-be-pregnant partner nightly back and foot massages?

The short answer is: yeah, probably. But that still might not bridge the gap. Figuring out how to bridge the gap is one way that couples therapy can be quite helpful. It’s useful for both partners to share how they’re feeling in a way that no one feels blamed or maligned. Couples therapy gives both partners the chance to express how they feel and to ask for what they need, before and after the baby comes.

Some of what comes up for expectant couples feels specific to living in New York City. Couples often aren’t sure whether they should stay in the city to raise their kids, or if they should move to the suburbs or back to their hometowns. Choosing where to give birth seems harder in New York than it does in other places—there are so many options. There’s also the expense of raising a child in NYC. It’s not cheap! Couples who are struggling to get by in the first place often can’t quite fathom how they’re going to afford it, no matter how much they love living here. These are all items that couples may find it helpful to hash out in therapy.

One challenge that I’ve seen come up for couples is answering the question of who will sacrifice more professionally when the child comes. The partner who makes less money—be they male, female, or non-binary—is often terrified that they’ll become the default primary care giver, in charge of cooking, cleaning, picking up, and dropping off. They fear that their professional dreams and ambitions will dry up, vanish, disappear forever.

Couples therapy can be extremely helpful in sorting through these concerns.

One final reason that expecting or hopeful couples come to see me is because they want to work on some aspect of their relationship that they find troubling before the baby arrives. Some want to improve their ability to resolve conflict, for example, and others want to nurture a healthier sex life.

I have not yet touched on the challenges of infertility and IVF treatment. I see a lot of clients facing those challenges, but I will save that for another post.

I love working with expecting families in part because I love being a parent myself. I’m in the process of raising two young kids in New York City and it’s been a challenging but joyous experience. I love brainstorming with couples how they can best make it work and helping them to express their fears, needs, and desires.

Meditation & Therapy

When I was 23, I moved back to the Chicago area from Prague, where I had been living and teaching for a year. I realized while in Prague that I had been actively avoiding myself for years, through various means. It was time to get to know myself.

I found a therapist, Alice White, a woman my mother’s age, who pointed out things that I had never seen about myself. She told me I had a nervous laugh. When I complained about a job I had writing for a small PR firm, she told me I should be happy to be getting paid to write. She guided me through decisions I had to make and helped me sort through my experiences as a child and teenager. She was kind but direct. She helped me grow up; I needed her feedback.

At the same time that I was seeing Alice, one of my close friends gave me a book called Entering the Stream: An Introduction to the Buddha and His Teachings. It’s a collection of essays about Buddhism and meditation, and I found the book’s ideas enormously exciting. I was drawn to Buddhist philosophy, including the idea of samsara, suffering borne from duality, and the goal of trying to live in the here and now.

My friend and I began going to Shambhala, a retreat center with a location on the North side of Chicago. I connected to meditation right away, even though it was challenging. My goals while meditating were so simple. As an anxious 24-year-old deciding what path to take with his life, it was a relief to just focus on my outbreath and try to gain distance from my thoughts.

I went to several retreats at Shambhala, during which we meditated for six or seven hours a day. Practicing meditation, especially with a group, made me feel like I was becoming the person I wanted to be. I felt as though I was somehow rapidly maturing, becoming more grounded and more in touch with myself. I remember friends commenting that I seemed happier and, well, different.

This is all to say that I think talk therapy and sitting meditation can really complement one another. Meditation and meeting with my therapist both helped me to know and understand myself. Knowing and understanding myself were the first steps in becoming the person I wanted to become.

Nowadays, I enjoy incorporating meditation into my practice as a therapist. When clients are interested, I like to spend the first 5 or 10 minutes of the session meditating. Then we can talk about what came up while we were sitting.

In 2022, I took an excellent 8-week meditation course in the method, Mindfulness Based Stress Reduction (MBSR) at the Insight Center with a terrific teacher, Elaine Retholtz. Through that class, I got a glimpse of my experience in my early 20s (I’m 48 now.) Since then, I’ve been recommending it to clients when it seems that they could benefit.

Meditation is scientifically proven to help people with insomnia, anxiety, and depression. I recommend getting started by taking a class, going to a group, or finding a good teacher. It’s the best way I know of to work on oneself and I think it’s best to get started with a community of fellow travelers.

What is Sex Therapy?

Dossie Easton, author of what is commonly known as the polyamory bible, The Ethical Slut, recently told me that, back in the 70s, she was the only ‘out-of-the-closet BDSM therapist in San Francisco.’ “I even got written up in the Chronicle about it,” she said. “And now there’s tons, which makes me very happy.”  

It’s true—cities like San Francisco and New York City nowadays have lots of kink-positive, LGBTQIA+ allied sex therapists.

This is all to say that sex therapy, as we know it today, is a newish field. Many people don’t even know what sex therapy is.

When I was in graduate school for marriage and family therapy, for example, I was surprised when I learned that I could have an emphasis in Sex Therapy. I was thrilled about it, as well as a little embarrassed. I remember sheepishly telling my internship advisor, “I know that it’s weird, maybe, but I’d like to focus on sex therapy.”

“It’s not weird,” she said to me.

And, of course, it’s not. But I had somehow been enculturated to believe that I shouldn’t want to spend my days reading and talking about sex—I should keep that to myself.

I’m so grateful that I followed my instinct, not my fear or shame, because I really love conducting sex therapy.

Which brings me to the question I’m posing here: What is sex therapy? And who should go see a sex therapist?

While there are credentials a sex therapist can have—AASECT Certification is pretty much the highest level, though you can also get a PhD in Human Sexuality or a related field—my sense is that a sex therapist (or a good one, at least) is a licensed therapist who has the following: significant training and education in human anatomy, sexual attitudes, practices, and beliefs; an open-minded attitude about all of the above; years of supervised experience conducting sex therapy; and skill and comfort in constructively discussing sex and all that comes with it.

That education and experience is important. Personally, I have trained and consulted with some of the biggest names in the field including Ian Kerner, Suzanne Iasenza, and Daniel Watter. I also continue to get sex therapy supervision with renowned sex therapist, Jillien Kahn. Sex therapy is intimate and delicate, and, on the part of the therapist, it requires a lot of knowledge, experience, and tact. We need all the training we can get. 

People seek sex therapy for so many different reasons. They might want sex therapy because of a sexual challenge they’re facing. That might include having a low libido, erectile unpredictability (more commonly known as erectile dysfunction), vaginal dryness, desire discrepancy (one partner wants sex more than the other.) Sometimes people want to explore their kinks and fantasies, and they don’t know how to share them with their partner. Sometimes people want to explore consensual non-monogamy, and they don’t know how to get started.

I think that at the core of many of the sex therapy cases I see is, in one sense or another, some desire to better understand one’s sexuality and some guidance in doing so. So much of my work is about being present with people as they explore, discuss, and consider who they are sexually.  

No Place to Hide

I once read—I can’t for the life of me remember where—that one reason people get married is to have someone else witness their life. I can relate to this. I want as many people to witness my life as I can get, and I think that has something to do with my getting married and having kids. I like having people close to me hold me accountable for my behavior and the decisions that I make.

I think there’s a similar dynamic at play in going to see a therapist. By going to a therapist, you’re forced to spend time with yourself and witness your own life. So often we pack our lives and schedules so we don’t have to face ourselves! At least I do. But a good therapist makes space for us to get to know ourselves.

I met a therapist at a gathering recently who expressed that she prefers seeing couples and families to seeing individuals. “The more people there are,” she told me, “the less places there are to hide.”

I relate to this idea, too. When I’m treating couples and families, I get the same sense of partnership and collaboration as I do with individuals, plus I get a more dynamic sense of the clients. Having two or more clients present brings a level of reality to the therapy room that is harder to access when it’s just one client.

With individual clients, I find myself wanting to meet their supporting cast of characters. I’m left to imagine individual clients’ spouses, their children, and their parents. In family therapy, I try to get those people into the therapy room and meet them in the flesh.

I love the fluidity of couples and family therapy and the sense of bringing everything out into the open. Family and relationship dynamics can be stubborn; they don’t change easily. But once you start having a weekly therapy conversation about what each family member wants done differently, things start to shift around.

In couples therapy, the mask comes off, whether or not clients want it to. We see them get triggered, get their feelings hurt, lose their tempers. We get to watch the same dynamics that play out at home happen right in front of us.

A lot of times couples come to see me because their arguments aren’t getting them anywhere and they need a new element to help them progress in their relationship. This is a great reason to see a couples therapist. After I spend enough time with a couple, I can tell them what I see playing out in front of me. I know I’m not supposed to be the referee as a couples therapist, but sometimes it helps to express when I think one member of a couple is being unfair, bullying, or disingenuous. A lot of the time I’m just as lost as the couples are when they argue in front of me, but I can help bring them back to their original intentions and feelings. When I’m at my best as a therapist, I can get angry clients to admit that they’re really scared, or clients who are feeling embittered to admit that they’re really deeply hurt. Sometimes I can get them to see each other and to see themselves.  

Couples and family therapy can be fun and light, but it’s often more intense than individual therapy. This is what that therapist meant when she said ‘there are fewer places to hide.’ There’s no hiding in the couples and family therapy room, even from oneself.

Erectile Dysfunction or Erectile Unpredictability?

Sometimes male clients come to see me because they have trouble achieving and maintaining erections. That can be the primary reason they come in or it can be just one factor amongst several. Either way, we end up talking about a lot more than their erections.

Clients usually refer to the challenge as erectile dysfunction, or ED, but on the more progressive side of the sex therapy field, it’s more commonly referred to as erectile unpredictability. I also prefer the term, ‘erectile unpredictability.’ The word ‘dysfunction’ feeds the narrative that clients who struggle with erections are in some way ‘broken,’ a word I’ve heard several clients with erectile unpredictability use to describe themselves. A person may not have as much control over their ability to get an erection as they’d like, but they’re in no way broken. Experiencing erectile challenges may mean that a client needs to feel really comfortable with their partner in order to be intimate. It may mean that they are subconsciously protecting themselves from some perceived risk. And it may mean that they could use more practice sharing their sexual desires with a partner.

When a client comes to see me with erectile unpredictability, I often start out by coaching them on the more practical aspects of their experience. I sometimes urge them to take Viagra or Cialis to help them gain more confidence in the short-term. I always encourage them to engage in more ‘outercourse’ with their partner and to de-centralize the penis in their sexual encounters. But this is only the beginning of the work.

My general approach is psychodynamic and holistic; I explore the client’s previous sexual experiences, when they’ve had positive sexual encounters with partners, what their erections are like when they masturbate. Sometimes, non-sexual factors—traumatic experiences from their childhood, for example—play into their erectile challenges.

There’s a Yiddish proverb I like that goes: “Sleep faster! We need your pillows.” Working towards understanding and improving one’s erectile unpredictability has a similar quality as an attempt to ‘sleep faster’: one cannot will themself to having more consistent erections. It doesn’t come through direct effort. It comes from being open, self-accepting, curious, and exploratory. Success also comes from seeing the challenge as relational; erectile unpredictability often dissipates when a client has the warm support and cooperation of their partner.

A terrific book and resource on this topic is the edifying and highly readable The Existential Importance of the Penis in which renowned sex therapist Dan Watter applies the ideas of Irvin Yalom, creator of Existential Psychotherapy, to the practice of sex therapy.

How to Improve Your Sex Life

One common reason couples come to see me is that they want to improve their sex lives. Often times, one partner wants sex more than the other. The reasons why members of a couple aren’t having sex are often mysterious, especially to the couples themselves. Sometimes, one member of the couple is unhappy in their own life and this unhappiness makes them feel unsafe and unwilling to share their sexuality with their partner. Sometimes, couples have fallen into sexual ruts: they play out the same ‘sex script’ (a term made popular by the wonderful writer and therapist, Ian Kerner, in his book So Tell Me About the Last Time You Had Sex) every time they do it, and that script may have been written to please one partner more than the other. Sometimes sex never came very easily to the couple.

Those are just a few of the many reasons that couples don’t connect sexually—it’s usually some combination of multiple factors. Cases in which couples are trying to improve their sex lives are some of my favorite to treat. If couples are coming to see me, that means they’re willing to put in the effort, and that willingness, plus a bit of patience (and a good therapist), are what it takes to make meaningful progress in improving one’s intimate life.

As with all cases, I take a holistic approach when working with couple clients who want to improve their sex lives. In sex therapy, we’re not always talking about the sex itself, because there are so many other factors that impact the health of one’s sex life. We begin by talking about each individual’s history, their mental health, their relationship history, and the couple’s relationship dynamics outside of sex. We discuss how sex was talked about in their families of origin—there’s often so much shame around the act—and I take a sexual history for each partner.

We begin exploring the clients’ erotic templates by discussing the couple’s peak sexual experiences; this is an approach described by the late sexologist Jack Morin in his seminal book The Erotic Mind. By examining a couple’s best sexual experiences, we begin thinking about what turns them both on and where their desires converge.

We eventually move on to the “sexual menu,” an idea that renowned sex therapist Suzanne Iasenza (a mentor of mine) introduced in her excellent book Transforming Sexual Narratives. The sexual menu involves clients making a list of whatever comes to their minds when they think about the word ‘erotic.’ They then share their list with me, item by item, and we discuss in detail what about their list excites them. This gives all of us a better sense of what might be the keys to the clients’ sexual hearts.

For some of us, our innermost sexual desires are too private, too precious and delicate to talk about. That’s fine, too. The hope is that beginning to talk about and explore these things in therapy will help clients become comfortable enough to introduce their fantasies and desires in the bedroom. Once couples gain the freedom to really explore what turns them on, sex will naturally happen more often and with greater pleasure.