EMR systems were designed for scheduling, billing, HIPAA-compliant records, and claims processing. For most practices, they are probably essential. But they were not necessarily designed with couples therapy in mind.
Behind the closed doors of a therapy practice, science and spiritual traditions are not adversaries. In fact, knowing how to ensure that your belief system is compatible with counseling can transform your experience and strengthen your bond.
I have been interested in psychology since I was about 14. I wanted to understand myself, my family, and my surroundings. So, becoming a therapist was quite an obvious choice for me. I started working with large groups, then moved to families, then couples. In particular, I was interested in interracial, intercultural, inter-religious couples and families - families in cultural transition. What is sexuality in the culture, and how does it enter into the family culture and the couple's relationship?
Many people come into therapy with a desire to talk about the present: the promotion they didn't get, the stress they feel as parents, their frustration with that friend they can't stand but are still keeping around. But mostly, they want to talk about their relationships. What's wrong with them, how to make them better, confirmation that they are in fact not crazy and that it really isn't a lot to ask of their partner to do ( insert task here).
To start, resentment is a complex emotion rooted in anger and typically involves feeling slighted in some way. In my clinical experience, because of a sense of being slighted, mistreated, or wronged, many people direct their resentment toward someone else and focus on that person and the mistreatment. And since I am a sex and couples therapist, in my office, someone else is typically their partner.
I practice what I call breakup therapy - a short-term treatment I developed for couples who want to end their relationships without bitterness. The premise is counterintuitive: Instead of looking forward toward separate futures, we look backward at the relationship itself. It's structured to look at the beginning, middle and end of their time together with exercises that focus on both their gratitude as well as their resentment.
During one session, the male partner rushed into my office and handed me a printout of his exchange with ChatGPT. I shared a knowing glance with his wife before skimming it over. The transcript included his version of an argument they'd had alongside ChatGPT's commentary. ChatGPT reinforced his view, labeling his wife's communication as "highly problematic," "abusive," and even suggesting traits of "narcissistic personality disorder."
Recently, we saw Art, a play whose premise centers on three sophisticated, middle-aged friends who descend hell-ward in a bitter fight that tears the otherwise resilient fabric of their friendship. The trio's scorching verbal combat ignites when one of them acquires a "work of art" consisting of a contentless, blank-white canvas, which he purchased for the profligate sum of 300,000 dollars!
We recently participated in a weekend symposium focused on the intersections of imagination, neuroscience, art, and psychedelics at the UC San Diego Imaginarium. Viewing our couples' therapy work from this perspective was exciting and inspiring, and it reaffirmed something we have always known: The couples that stay vibrant, resilient, and deeply connected are the ones that remain curious about each other and creative and imaginative about their relationship. They don't just love one another. They are present and mindful, and they imagine and play together.
When you're with the right person, it's effortless (wrong). Never go to bed angry (also wrong). Relationship advice is often centered on the idea that we shouldn't experience frustration with each other, a sentiment that sounds nice, in theory. In reality, that goal keeps us repeating the same patterns and wondering why we keep having the same fight; why our partner still doesn't understand us; or why we feel alone.
One of my specialties is working with clients in individual therapy in combination with their experience in couples therapy. Oftentimes, when two people engage in couples therapy, the work starts out on communication and relationship dynamics, but eventually, we get to a point where we realize that the work that really needs to be done to improve the relationship is individual work.
Our nervous systems are built for survival, not harmony. In conflict, the body doesn't ask, " What will preserve this relationship?" It asks, "What will keep me safe?" In a flash, the brain floods with adrenaline and cortisol. Muscles tighten, voices rise. One partner lunges forward, fighting to win; the other freezes or flees. And for some, safety comes from fawning-placating, over-apologizing, surrendering just to stop the discomfort.
Usually people approach couples therapy as a last resort to salvage their relationship that has been deteriorating for 2 to 3 years, according to research. 1 Yet, many leave without tangible results. While the therapist you've chosen might not be a good fit, there might also be things that aren't about the therapist, their treatment approach, or their experience, so you can influence them to make therapy more successful and efficient.
The year was 2014. I (Assael) was a young, exhausted father of two small kids and a couples therapist, married just three years. One night I was reading Mating in Captivity by psychotherapist Esther Perel when I came across a line that stopped me cold: "Most people are going to have two pr three marriages or committed relationships in their adult life. Some of us will h ave them with the same person." That sentence puzzled me, haunted me, and eventually inspired me.
But let me tell you a secret: Sexual problems are rarely about sex itself. They're about the silent scripts we carry: those insidious beliefs, 10 or 12 of them, all variations on the theme of "I'm not good enough." These internal narratives, like shadows in the bedroom, shape how we show up, or fail to, in the dance of intimacy.
Ed and Sheena were about to have sex for the first time after their third miscarriage six weeks before. Sheena had recently felt Ed being distant towards her. This made her wonder if Ed's disappointment about their most recent loss was turning into anger. Did Ed silently blame her for their losses? After all, her body had failed to carry through the pregnancies. She hoped that the two of them getting intimate with one another that night would bring them closer together.
As a couples therapist, I often work with people who say things like, "My partner is so avoidant," or "I think she might be a narcissist," or whatever the latest psychological buzzword happens to be. These days, diagnostic language from psychology and social media has seeped into our everyday conversations. In earlier decades, people came into therapy saying, "He's selfish," or "She's too controlling." The words have changed, but the impulse is timeless: When someone hurts us, we want an explanation.
A previous post summarized the many myths about desire differences and the sex- therapy approach to resolving them-using either self-help or professional therapy. The sex-therapy program helps many couples-but not all. Recently, Canadian researchers reported an effective new approach, eight weeks of group therapy that produced significant benefits. It's based on reimagining lovemaking to facilitate sex worth wanting. What if Low Desire Is a Reasonable Response to Lackluster Sex?
In my sex therapy practice, I see a respectable number of couples in heterosexual relationships where the presenting issue is that the male partner has been engaging in sexual behavior with other men and has kept this secret from his girlfriend or wife...until it was no longer secret. Needless to say, by the time these couples come to see me, their relationship is in deep crisis. I would like to address a few of the common issues that these couples face.
When we first met, 12 years ago, my husband and I didn't waste any time in starting the sexual part of our relationship. He warned me he was a sex addict, and I am enthusiastic about sex. On our first night together I was aware of some erectile dysfunction he wasn't entirely hard and benefited from holding himself when penetrating me though this didn't stop us reaching climax. We joked about how many times I would orgasm and neither of us seemed inhibited.
Neutrality in couples therapy means the therapist stays balanced and impartial toward both partners. It's about not taking sides, but instead validating each person's feelings and perspectives. Rather than focusing on blame, the goal is to improve the relationship dynamics so the couple can improve their skills and move forward together in a healthier way. Neutrality can sometimes cause more harm than good However, in some cases, neutrality in couples therapy can be damaging, especially when therapists work with clients who are experiencing high conflict, having trauma, or experiencing a power imbalance.
