Tell us about your practice. How did you end up counseling couples?

I never actually intended to be a couples therapist. Several years ago when I went back to school to study counseling (with the intention of working in alternative medicine) I was blown away when I learned in my first family therapy class that maybe some of what I was experiencing in my marriage was not indicative of my failings as a human and in fact, perhaps it was normal stuff! I was absolutely floored and I was hooked. I dove headfirst into learning about relationships and switched my focus to couples. Along the way, I learned A TON about myself and my marriage and it changed the entire way I viewed the world.

Let's jump right in: Many women with pelvic pain find sex uncomfortable, and they're fearful that their partners will leave them if they're unable to have sex. How can a couple's therapist help both partners feel heard and reassured in these tough situations?

Sex can be a wonderful part of a relationship, and it can also be an extremely overwhelming and vulnerable experience. My first job as a couples therapist is to normalize the struggles that either or both members of the couple are having. We live in a culture that doesn’t discuss sex in a healthy or useful way so many of us end up not talking about it at all or keeping our difficulties hidden away. The truth of the matter is that SO MANY people have issues around sex! From the very beginning, I reframe this as a normal relationship issue that they can face together rather than one person’s “problem” to be solved. Couples need to hear this so they know they are not alone.

From there, I work to get a deep understanding of what living with pelvic pain has been like for the woman and how it has impacted her and her partner. As part of the normalizing process, I usually offer some education around sexual health in general and assess each person’s sexual histories. I then guide the couple through a process that helps them share their experiences with their partner, and teach the partner to really listen with empathy.

Many women struggle to discuss their pelvic health and sexual needs -- whether with their providers, partners, or friends. How do you help women feel more comfortable discussing sensitive issues when they come into your office?

My focus is always on the needs and priorities of the person. My approach varies based on our relationship and their comfort level, but as a general rule, I use a research-based tool called the EX-PLISSIT Model. It was designed to create a more sensitive and open experience for clients to discuss sexuality.

Each of the letters stands for the steps:

1) Explicit Permission. This is the most important step. People often just need to be given “permission” to discuss an issue related to their sexuality and sometimes, in doing so, they get what they need and don’t need or want to move further. I explicitly offer this permission to clients as well as ask for it to discuss these topics. I also check in after our discussion to see how the client is feeling and to ask about ways in which I can shift my approach to make them more comfortable.
2) Limited Information: If appropriate, we move on to the second step where I offer information to the client that is relevant and specific to the issues they have raised during step one. I am careful not to “pile on” or overwhelm client with more information than they need.
3) Specific Instructions: If a client is interested, I will offer specific therapeutic suggestion for addressing the issues they raised or offer resources and referrals to other providers.
4) Intensive Therapy: If, after our initial discussion, the client wants to pursue further treatment of the issues they raised we will discuss a plan for therapy. I again seek out explicit permission from a client to do so and then we collaborate to develop a treatment plan. Throughout this process I remind clients that what they are going through is extremely normal…because it is!!!

Women with pelvic or sexual pain disorders are often told that their problems are psychiatric, not physical. Even when they receive a physical diagnosis, secondary traumas inflicted by their experiences in the medical system can linger for years. Can a couple's therapist also help address the impact of individual traumas on the couple's relationship?

YES! The impact of this type of gaslighting that women with pelvic pain experience is very real. It absolutely can and should be addressed by a couples therapist. Again, the first order of business is to normalize and validate these experiences and their impact, as well as offer psychoeducation about how our bodies and minds respond to trauma. Too often we are told to just “get over” things and move on, but with trauma that is easier said than done.

“The impact of gaslighting that women with pelvic pain experience is very real. It absolutely can and should be addressed by a therapist.”

The specific way in which I work with clients to address these issues depends on the person and the couple. Because I use a trauma-informed approach in all of my work, I take things slow and focus on avoiding re-traumatization. Sometimes I will recommend that the woman who has suffered with pelvic or sexual pain get individual, adjunct treatment from another therapist. This is important to offer the support they might need if they find they are constantly triggered during couples sessions. The couples work is still really important to healing, but it can be activating, especially around issues of sex, so I always want people to have the additional support they need.

Most often in this type of work, I help couples to articulate the narrative of the trauma on relationship by helping them to answer the questions of, what happened? How did we make sense of it? What did it do to us as people and as a couple? How did it change the way we engage with each other? What’s the meaning of it all? From there, we work to create a new story, one in which both members of the couple, particularly the woman, get to decide the direction and outcome of their lives rather than being directed by others.

We often say at Inspire Sante that females are strong as hell. How have you seen this exemplified in your work with women?

They are!! I see this and am inspired by it every day! I have had the honor of bearing witness to women leaving abusive relationships; advocating for themselves and their families against big, scary systems; rebuilding their lives from scratch after things have fallen apart; taking huge risks and recreating themselves personally and professionally; and bravely sharing their most vulnerable stories to help others. The place I see the most incredible strength in women is when they lift and hold each other up when they most need it.