Couples Therapy for (Older) Beginners

Many of the women I see in my practice have been with the same partner for years. These couples have made homes together, raised children together, weathered hard times and enjoyed happy moments together. And now—just as the pressures of career and family begin to ease up, they find themselves at odds with each other, especially in the bedroom.

The physical and emotional changes that come with aging can play havoc with a couple’s sexual relationship. It can feel as if the rules have changed overnight and finding intimacy with the person who has shared your life is suddenly impossible. This is when a couples therapist can help.

Women who have never been in therapy or participated in marriage counseling before sometimes feel anxious when I propose this idea. To help give them and our readers an idea of how couples therapy works and what they can expect from the experience, I asked Ann McKnight, an experienced social worker and psychotherapist, to answer a few questions.

Q: When couples who have been together for a long time come to you with sexual issues, what’s typically going on?

A: One of the most important things in intimacy is to be present and see clearly this person who is in front of us, and to be ourselves as open and receptive as we can be. That’s what makes great sex. In the beginning stages of a relationship, we have all our walls down—it’s exciting, it’s new, and we feel so open and vulnerable. But then as we move on together in life we start to get those walls built up again. Usually it’s our own fears that keep us from being present, from hearing or being heard by our partners. If our partners are unhappy with our sex life, we start thinking there’s something wrong with me, I’m aging, you’re not attracted to me anymore. But what’s going on for our partners may be something totally different. They likely have their own set of fears that we’ve never guessed at or heard at all because we’ve been so caught up in our own.

Q: So the stereotypical story of the middle-aged couple—she’s putting on weight and he’s looking at skinny 20-year-olds—isn’t one you often encounter?

A: I have to laugh, because in my experience, that is so not the case! Maybe those couples are going to different therapists, but I’m just not seeing them. Actually, as men age, they tend to have a greater desire for intimacy, to value their long-term relationships.

I think there’s just so much cultural downloading that women do, so many judgments about aging and what it means and our values around that. And I’m not entirely sure that that’s laid on us by men. I think that we do plenty of it to ourselves.

I think aging, because of life experience, gives us—women and men—an opportunity to be kinder and more understanding of ourselves. We can integrate more fully all the parts of who we are and all the different roles we play—open our hearts even more fully to each other, to really see our partners and all the change and growth they’ve done.

But in long-term relationships it can be hard for both partners to hold the space they need to express themselves and be seen. That’s when a therapist, a third person who can hold that space, who is trained to see where the communication is getting bogged down, where the stuck places are, can be a great help.

Q: What's the best way to find a good couples therapist?

A: Ask someone you know and trust, whether that’s your physician, a friend, your pastor—and then when you do get a name, use the first time you meet to make sure it feels like a good fit. Does this seem like a person who is understanding each of you and proposing a course of therapy you’re both comfortable with? If not, get another name.

Q: And what if the other half of your couple resists the whole idea?

A: Still go. If there’s something going on in the relationship that’s affecting you, that’s part of your personal experience that you’re ultimately responsible for. And whenever one person starts to make changes in a relationship, things shift and get stirred up in the other person as well.

Q: How should a couple prepare for their first session?

A: As a couple—or individually—think about what you really are hoping will come out of this experience so that you can be open about that with your therapist. Sometimes what we really want is not very realistic—I want you to totally change my spouse’s behavior in every way! Just understanding your own agenda is a big help.

Why Older Men Love Foreplay

We had a flurry of questions about foreplay -- or dealing with the lack of it -- awhile back, which led to a number of conversations within the MiddlesexMD team, but also between team members and their partners. This guest post -- from a man! -- was spurred by one of those conversations. We think it's important -- and reassuring -- to hear that men do like foreplay. If this is a topic you'd like to raise with your partner, perhaps sharing this post is a way to do it. --Dr. Barb

“And the women crazy ’bout me ’cause I take my time.” --Taj Mahal, “Little Red Hen”

I was 12 years old when I first heard about what goes on during foreplay. A mouthy teenage boy from across the street told me about it as he smoked a morning cigarette on his front porch. I really didn’t want to hear it, and when I did I couldn’t understand why anyone -- man or woman -- would want to do such things to each other. I was barely able to fathom what foreplay led to, and this just made the whole thing even more bizarre, at least to a kid living in the Midwest in the late 1950s.

I learned too many things about sex from other, usually older, boys. My parents stayed away from the subject, figuring, I guess, that I’d learn from other boys. So, much of what I learned was from their raging-hormone perspectives. The focus was always on them and their pleasures, their “conquests,” imaginary or not. I can’t remember hearing guys talk about sex (much less intimacy) from the girl’s point of view -- sex was more, as we say now, all about them. I saw this attitude flourish in college in the late 60s, when guys practically competed for sexual supremacy, which you couldn’t achieve with just one partner. “Wham, bam, thank you, ma’am” relationships were fine and dandy. Numbers mattered.

Which brings me back to foreplay. It’s hard to say that it’s a lost art if it was never discovered in the first place. Or maybe, like so many things in relationships, it’s been allowed to languish, to become an afterthought in a hurry-up world, especially as we grow older. There are all kinds of reasons why foreplay might get shortchanged or forgotten. And it’s not as if it can just be wished back into existence. Mutually exciting foreplay depends on couples being willing to take an unhurried approach to their lovemaking, to find out what makes each person feel sexually energized and ready for more. In our haste to get to home base, we men tend to want to bypass first, second, and third. Women, seeing our haste, assume that that’s just the way it is -- that men prefer sex with no prologue.

I’ve learned that if you miss the prologue, the play’s not nearly as good; you can’t drive a woman wild by rushing into the final act. But you can heighten her lust for you, and yours for her, if you learn to let the present moment linger for a while and enjoy it to its fullest. You’ll both know when it’s time to move on, and you’ll both be ready for it.

I think that words are a key part of foreplay. Words that precede any touch. Words that express your appreciation of her, your attraction to her. Words that ask her what she’d like you to do. Words that continue during foreplay and beyond, not a lot of them but occasional affirmations, expressions of desire, words that keep you connected both physically and, well, orally.

Everybody is happier and more satisfied when foreplay is part of the experience. It’s something that makes both men and women want to have more of where that came from. Who can argue against such self-perpetuating pleasure?

Want Better Sex? Mark Your Calendar.

It’s interesting to me how many patients who come to me with concerns about diminishing libido are there because of their husbands or long-time partners. These lucky women have a great relationship with a great person, and they don’t want anything, including their own lack of sexual desire, to jeopardize it.

I respect that. I think that the desire to keep a long and satisfying relationship intact is a good reason to want to want to have sex.

I also believe that a lot of women in this situation sell themselves short. They think that because their partners want to have sex more often than they do themselves, there is something “wrong” that they need to “fix.” Often, it’s just a matter of timing.

Being “in the mood” for sex comes more easily to men. A man who is physically healthy and capable of an erection is almost always in the mood. Men are wired to go from zero to sixty on nothing more than a flash of leg or a lingering kiss. Women, on the other hand, tend to rely more on emotional or intellectual stimuli to reach a state of physical desire. And that takes time.

My advice? Get out your trusty planner and schedule a date for sex. Think of it as extended foreplay. If you schedule a week in advance, you’ll have days to think about your date night--what you’ll wear, what he might say about what you’ll wear, how he will want to take whatever you’ll wear off you. You’ll have time to buy some candles, choose a new aromatic massage oil.

Most importantly, because you’ll have to synch your calendar with your lover’s, you’ll have time to anticipate and talk about sex with each other, to make the crucial emotional and intellectual connection that helps both of you get in the mood for physical intimacy.

Some people dismiss scheduled sex as unromantic or think that deep physical attraction has to be “spontaneous.” I think it’s important to distinguish between sex that happens spontaneously (which can be very nice!) and sex that includes creativity and spontaneity in the act of making love (also very nice!). Think of scheduling sex as a way of insuring that you and your partner have a space and time where spontaneous acts of love and erotic play can occur.

Connection: The Second Component of Great Sex

We’ve talked about how crucial mindfulness--being mentally and emotionally present in the moment--is to enjoying great sex, sex that is “better than good,” as reported in a study recently published in The Canadian Journal of Human Sexuality.

I like to think of “connection,“ the study’s second ingredient of optimal sex, as “mindfulness times two.” Connection is what happens when both partners are present together: in bed, in the moment, in each other. As one study participant describes it: “Inside my body I’m the other person’s body and we’re just all one together at that moment.”

This sense of merging, of “two becoming one,” was regularly cited as part of the experience of great sex, which has to involve “at least one moment,” as one woman said, “where I can’t tell where I stop and they start.”

I believe that this kind of intense sexual alignment is something that becomes more accessible to us as we get older. Part of our maturity is greater acceptance of self and others, which leaves us more open to making a deep physical and spiritual connection with another person. To experience the joy of merging, of temporarily letting go of the sense of any boundary between the self and the other, a person has to know herself well--and feel safe and respected by her partner.

Which brings me to two great impediments to sexual connection: unsafe relationships and sexual trauma. If you have reasons for not feeling completely safe with a particular partner, or if you have a history that leads you to feel unsafe whenever you are in a sexual situation, you’ll need to address these issues before you can experience intense connections in intimate relationships. There are resources that can help.

But for two self-aware people who respect and desire each other and who are capable of being completely present with each other in the moment, a deeply satisfying sexual connection can happen even without penetration or orgasm. The study’s authors report that great sex is often more about the level of energy between partners than about the actual physical act itself. (Check out our website’s alternatives to intercourse for imaginative techniques for increasing sexual energy and connection.)

Have you experienced these moments of sexual oneness? What were the circumstances? We’d love to hear your stories!

Sexual Satisfaction: All in Our Heads?

I saw a headline that irked me in’s Broadsheet a week or two ago. I couldn’t quite put my finger on why it bothered me until I wrote a post about the cancelation of the flibanserin project last week.

The headline was “Forget the pink pill, try a placebo.” The article opened by saying that “Researchers are desperate to discover ‘female Viagra,’ but Cindy Meston says sugar pills might hold the key.”

Meston, a clinical psychology professor at the University of Texas at Austin, co-authored a study, published in the Journal of Sexual Medicine. Reviewing data from an earlier clinical trial of a drug treatment for low sexual arousal, she noted that about one-third of the test subjects who were given a placebo instead of the actual drug reported they had more “satisfying sexual encounters” during their “treatment.”

The Broadsheet reporter takes these findings as “a reminder that in the rush to ‘treat’ female desire, there is one organ researchers can’t forget: the brain.”

That’s a conclusion I certainly agree with: Mindfulness influences our sexual behavior. More simply, when we think about sex, we have more sex.

So let me get back to what bothered me about that headline: Yes, the brain is a critical and often under-estimated part of women’s sexual response. But it doesn’t function alone. It requires and interacts with hormones, which trigger physical responses that depend on our circulatory systems and tissue health. And the brain functions within the context of our histories and cultures and relationships.

Suggesting that a placebo is the answer for every woman’s sexuality oversimplifies and trivializes the issue. (In most clinical studies, by the way, placebos get about the same 30-percent response rate, so this study isn’t remarkable by that measure.)

Meston herself isn’t proposing that placebos are the answer: “Expecting to get better and trying to find a solution to a sexual problem by participating in a study seems to make couples feel closer, communicate more, and even act differently towards each other during sexual encounters.”

That’s definitely the first step—to be intentional about taking control of and improving our own sexual experience, involving our partners when we can. Any pattern at all that helps to focus our attention will help—whether it’s a before-bed routine with a partner, a sensual lotion that’s part of our self-care, or even taking a sugar pill.

But if that’s not enough, it’s because while it’s in our heads, it’s also not in our heads.

Being There: The Number One Component of Great Sex

In an earlier blog post we reported on a study published last year in The Canadian Journal of Human Sexuality called “The Components of Optimal Sexuality: A Portrait of ‘Great Sex.’” Analyzing interviews with 20 sex therapists and 44 people who reported having experienced “great sex,” the researchers identified eight major components of “optimal sexuality”sex that is “beyond functional, beyond positive and satisfactory, beyond good.”

It didn’t surprise me at all to read that the number-one component, the one that was brought up most frequently by both experts and “practitioners,” was “being present.”

We’re not talking, of course, about being literally, physically present (although that’s fairly essential), but about being mentally and emotionally there in your body, in the moment. Here’s how one woman who was interviewed for the study put it:

“The difference is when I can really just let go and completely focus and be in the moment and not have that, you know, running commentary going through my head about anything else.”

For women our age, that running commentary is likely to include not only the long to-do lists of our everyday lives (what am I going to fix for dinner? how can I convince Mom that she really does need that hearing aid? I hope Sally’s midterms aren’t stressing her out too much), but the new and nagging concerns that come with middle-age sex (does my face look more wrinkly when I’m on top? is he going to be able to keep his erection this time? I’ve really got to get back into a regular routine at the gym).

There’s plenty of evidence that the practice of mindfulnessnon-judgmental, present-moment awarenesshelps people manage things like stress and depression. It only makes sense that intensely focused attention, the ability to be fully aware of sensations experienced moment by moment, would be a central feature of sex at its best.

If you feel sometimes that you are not totally “there” during sex, that you’re distracted or just going through the motions, consider learning more about meditation and mindfulness. Being more present in all aspects of your life will help you more fully experience the pleasures and sensations your body is designed to feel.

Watch for more “components of great sex” in future posts, and let us know what you think. We’d love to hear what makes it “better than good” for you!

Sagging Libido? Tone It Up with Yoga

There are many “natural” reasons women our age begin to lose interest in sex. Hormonal changes, diminished energy, lowered self-esteem as we mourn the loss of our youthful bodies -- a complicated mix of physical, psychological, and social influences conspire to make us feel less sexy and less sexual.

When patients ask me about “natural” ways to increase levels of arousal and desire, my prescription almost always includes a combination of mindfulness and exercise. Awareness techniques like meditation help us focus on the moment and block out the stress and distractions of our everyday lives. Exercise increases blood flow, releases endorphins, tones our muscles and our perceptions of ourselves as strong and attractive.

I wasn’t surprised then, to read in a recent issue of the Journal of Sexual Medicine that yoga, a practice that combines both of these libido-enhancing elements, “improves several aspects of sexual functioning, including desire, arousal, orgasm, and overall satisfaction” -- particularly among women over age 45.

This study, which surveyed healthy, sexually active women before and after a 12-week program of daily yoga practice, found significant improvements in all of the areas measured: desire, arousal, lubrication, orgasm, pain, and overall satisfaction. Nearly 75 percent of the women who participated in the study “said that they were more satisfied with their sexual life following the yoga training.”

Other research has found that yoga increases body awareness and can be used to direct blood flow to the pelvis to enhance arousal and lubrication. The mindfulness that yoga teaches and requires helps a woman be more aware of her body and its needs. “When you’re present, you know what you need to feel fulfilled by your partner,” explains one expert. “You can then translate and communicate this deeper understanding to your partner during sex.“

And of course the increased flexibility and improved muscle tone that come with regular yoga practice help a woman feel more confident and attractive -- in bed and out.

If you’re looking for a natural way to tone up your libido, find a yoga class. And let us know how it works for you!

Make Time Stand Still -- the Body Scan

I’m busy exploring the boundaries of a new phase of my life, brought on by an illness I’m managing. As illnesses will, it’s grabbed me by the collar, given me a big shake, and forced me to order my priorities. Also, it’s made me take a good look at Time.

Not in the Time-is-Limited sort of way, but in the nature of time. How fast it goes when we’re not paying attention, or when we are multitasking, when we’re playing our To Do lists in an endless loop in our minds. And how it’s actually possible to slow it down when we are paying careful attention to what we are doing.

I first noticed this in a not-so-pleasant way, as a young girl, in bed with horrible headaches. These headaches made me seek out darkness and quiet, and there was very little that medications could do to reduce the pain. I would lie for hours in bed in an eyemask, and the hours felt like days. I could think of very little else besides the pain, and time stood still.

It wasn’t until I tried meditation for the first time that I had the experience again -- meditation made time stand still. This was in the 70s, and through the PBS television series, Lilas Yoga and You. Remember lovely Lilas? She ended most classes with Savasana. It was through her suggestions during savasana that I first learned to do a “body scan,” a way of getting in touch with my body through guided meditation.

In Body Scan meditation, you begin in a relaxed state, then use your mind to ‘visit’ every part of your body, noting how it feels, acknowledging pain or stiffness or itchiness, lightness or heaviness. It’s a way of checking in with your body, to connect with it. It sounds simple, but it does take practice. You can use body scan to help you relax. You can use it to help manage pain.

That work, inadvertently, taught me to manage the pain of my headaches from a very early age. I learned to separate the pain I experienced in my head from the rest of my body. I learned to relax into the pain, and keep it sequestered from the rest of my body. I thought I'd discovered some secret power, until I came upon the work of Jon Kabat-Zinn. What I’d stumbled upon through Yoga, he’d been teaching for years through his Stress Reduction Clinic at the University of Massachusetts Medical Center.

By now you must be asking yourself how any of this ties into midlife sex. Well, my secret power, savasana and body scan meditations, also taught me to relax and enjoy sex. I’ve always been a woman who wished for a body different from the one I had, so early experiments with sex were always fraught with efforts to conceal from my lover the parts of my body I didn’t like. That kind of distraction is a real barrier to intimacy.

Later, mindfulness techniques helped me to turn off the chattering brain brought on by an overstuffed life, at least during lovemaking.

Now, meditation helps me to stop the clock during lovemaking. It helps me keep the pain in my body contained so that it can’t overwhelm the experience of lovemaking. And it helps me to fully appreciate my one and only body. The only one I'll ever have. Might as well love it.

If meditation can make time stand still, can stop the clock, might as well try it, right? If you've never tried meditation, you should know it's not that hard to learn, and not that easy to master. It's one of those things that just gets better with practice. And I know of no better or less intimidating guide than Kabat-Zinn, especially through his Mindfulness for Beginners program.

Q: Am I stuck with an unfulfilling sex life?

No!  It’s great that you recognize the value of remaining sexually active, despite your decreasing libido.

As we get older, we have to learn some new techniques to continue to enjoy sex. You can use the MiddlesexMD website to have a discussion with your husband:  Take him to the site.  It will help him understand what you're experiencing, and that it's not "about him."  Review together the bonding behaviors and alternatives to intercourse.

You may find a role for erotica, like DVDs or books. Just this week a woman told me that she keeps a book of erotica nearby. It works really well for her to read from it in anticipation of sex (although her husband isn’t aware she has it for this purpose).

If you're comfortable with the idea, incorporating a vibrator may help; after menopause we do require more stimulation for arousal and orgasm. Healthy relationships require intimacy -- it's worth the effort.

A Little Conversation About Mindfulness

Since launching MiddlesexMD, I have to say, my dinners have gotten a lot more spicy.

You know how it is when dining with buddies. It’s polite—required—for them to ask what you’ve been up to lately.

When I tell them about MiddlesexMD, you would think it might stop the conversation cold, but I’ve found just the opposite is true.

My friends do want to talk about this. It’s not surprising when men are there that they are a bit more quiet, but they are engaged, too. We all appreciate our partners’ attention to these discussions—because we’re not always alone with these changes. They affect our sexual partners, of course.

I had dinner the other night with an old friend. The subject of our conversation turned to the idea of how important it is, especially for long-partnered people, to keep their sexuality top-of-mind if they want to keep their sex life going. I talked about how older women, particularly, need extra stimuli (both physical and emotional) as they get older.

We need more opportunities to think about sex, consider it, fantasize about it, and more emotional intimacy throughout the day to find or sustain the mood.  Sex is like any pursuit, if you want to get better at it, it requires your attention. Some call this "work" Awareness or Mindfulness. And I think this dimension of a relationship is valuable enough to “do the work.” (Smile.)

It was a simple conversation. I didn’t think it had any sort of profound effect at the time. But I ran into that friend a few weeks later. She pulled me aside, and whispered, “Hey Barb! Thinking about sex more? It WORKS.”

I wasn’t surprised, if it works for me, it should for you too!

Gee, I love my job.