Psychosexual Assessment, Intervention and Cognitive Analytic Therapy Treatment

Rose Hughes, 2018. Psychosexual Assessment, Intervention and Cognitive Analytic Therapy Treatment. Reformulation, Winter, pp.5-8.


In this article I describe how a psychosexual intervention within a CAT therapy enabled identification and exploration of sexual withdrawal in the client’s relationship with her partner.

I worked with the female partner for 16 sessions. Her presenting problem was stress in relationships. She felt anxiety, anger and hurt with regard to her parents. This led to exploration of her feelings and behaviours within her relationships and in particular with her partner. There was an avoiding to avoided reciprocal role procedure influenced by her defence against repetition of early hurt, avoidance that was often expressed as a determination to achieve academically.

My work in this instance was informed by CAT but also psychodynamic and psychosexual theories. CAT, like many talking therapies, has not traditionally integrated psychosexual aspects of clients’ problems and so I approached the subject tentatively in the reformulation phase of our work.

The Psychosexual course at the Tavistock equipped me to think with the client about a number of areas of difficulty; the CAT model provided a supportive framework for reflection through reformulation and use of mapping, as well as practical relational solutions through use of Exits. The problem of intimacy seemed to me to be one of low arousal as a consequence of conditional striving and anxious and avoidant relational issues. In their research Basson, Grier and Kaplan suggest that sexual desire is thought about in different ways; there is the belief that’ ‘good sex’ just happens and that sexual arousal is natural rather than relational. Grier talks of the loss of desire as; ‘…disorders of desire may reflect an impenetrable defence operating within the couple to protect the partners from perceived threats to their identity’.

Basson (2003) writes woman’s sexual response is based on motivation for intimacy. Kaplan (2000, 1977, 1987) classified sexual problems into three areas; Desire, Excitement and Orgasm.

Sexual difficulties in these areas, as the product of life experiences and trauma, affect an individual’s well-being. When working with psychosexual issues our CAT reformulation, diagrams and letters may not include the psychosexual themes because there are other priorities in the individual’s case and because of lack of psychosexual understandings and tools within the CAT model. CAT’s Target Problems around sexual themes may also feel shaming and embarrassing for the client and the therapist to enter in to. However, it seems to me that we can speak to these narratives and that CAT has a containing language to hold and think even about sexual abuse.

There were times when I may have helped clients through exploration of their sexual relationship difficulties, for example a woman who presented her eating problems and her obsessive cleaning as her concerns and shared a sense of shame having been groomed as a child by a sex offender and a young man whose girlfriend he discovered had sexually betrayed him. CAT and art psychotherapy interventions helped enough to support improvement, I felt ill equipped at that time to approach the psychosexual consequences of their traumas and wonder what an EXIT in CAT would be beyond grieving successfully for their younger selves and better able to avoid and protect themselves from harm whilst supporting loving attachments?

Case Vignette; Ruby

This case vignette includes descriptions of Precipitating, Predisposing and Maintaining factors of a psychosexual difficulty. The problem was hinted at by omission in the client’s story during the reformulation phase of CAT by the lack of subjective and psychological attention to sexual intimacy.

The Precipitating factors were linked to trans-generational anxiety problems of mother and grandmother, the Predisposing factors were the divorce of her parents and extreme maternal bullying.

In Ruby’s story she described manipulation and control from mother leading to her tendency to social isolation as a defence against unacknowledged fear and deprivation, caused also by her father’s absence.

The Maintaining factors included her avoidance and insecurity around closeness, emotional vigilance around maternal bullying, and an established defence in solitude and healthy motivation backed up by conditional striving to build esteem and safety rather to the exclusion of sexual intimacy.

There was a particularly painful feeling of being unlovable, left out and not securing ‘good enough’ friendships.

The absent male role internalised by the absence of her father contributed to her independent yet anxious attachment style. The relationship with her partner seemed to have slipped in to one of amenable distance, marginalisation to promote professional striving to defend against unarticulated fear of abandonment or destruction and what this may imply to her about her ‘loveableness’. For example her absent father was preserved in her mind as the good parent, but eventually she spoke of his inconsistent care when she longed for reparation through a reliable fatherly presence.

In her partnership she was avoiding disappointment perhaps by distance and resorting to safety in independence.

The sexual problem associated with the above dynamic was of avoidance and low arousal to maintain safety. For her partner, an apparently securely attached and undemanding young man, who in their relationship retained his male friends and ‘blokes’ nights out as a “safe place” whereby he made no demands on his partner during her studies. He strove and defended against conflict by a low arousal style and low demand interpersonal style with Ruby:-

See Reciprocal Role Procedures (RRPs) in the diagram below.

Rub’s ‘TRAP’ was drawn our and discussed in therapy;

see below.

CAT Interpretation

Ruby’s ‘Core Pain’ can be thought about as feeling of loss of affection parentally and a sense of being unlovable and at times detestable. Therefore, achieving success academically and establishing a marriage represented closure to her traumatic childhood experiences. Ruby has internalised fear and rejection.

She tries to attach, to please and acquire internal safety but is anxious such that closeness and developing sexual intimacy is left to one side.

Neuro Psychosexual Approaches

The Psychosexual therapy approach is informed by object relations and neuroscience

In Ruby’s case the ‘fight or flight’ mechanism had been aroused throughout childhood. D Schnarch explores western assumptions about sexuality, anxiety and the cultural progression through the following beliefs about sexuality;

1. low sexual desire

2. sex as a natural function

3. naturalised view that good sex ‘just happens’.

 He describes how this naturalised view may create a cultural and internal pressure to have sexual desire and response, which may set up anxiety about sex, which could lead to a cycle of thinking that:

’ ….worrying about sexual performance seems inappropriate’ Schnarch (1997) p128.

Schnarch sees the psychosexual need to consciously increase sexual knowledge, understanding and intimacy relationally when he wrote that

 ‘…. neocortical desire has to be developed…It also involves creating …; fantasizing and thinking up new things to do’ Schnarch (1997) pp136 -137.

I felt that and her partner were not naming the issue as this may seem inappropriate and so it was unacknowledged. Schnarch notes that the ways some people think about sex can neglect the ‘inherently interpersonal’ and ‘deeply affecting’ aspects of intimacy. D Schnarch (1997) p133.

Our historical assumptions about sexual desire place the sex act within the reptilian and mammalian brain; that it is natural and ‘just happens’. This widely held belief can sabotage the interpersonal human capacity of the neocortex in thinking interpersonally about sex and attachment. In turn this allows society to pay little attention to the sexual education of its young. For example; The healthy need for closeness and distance to maintain identity in couple relationships;

Susie Orbach talked about the development of intimate relationship in her clients when she wrote;

‘What would make it possible for them to create and maintain sufficient distinction from one another in order to be close, in order for there to be an actual other as opposed to a predominately fantasized other (an object relation) that is being related to.’

Orbach (2009) p66.

Schnarch notes that it is through ‘Differentiation’ that healthy intimacy, which is the ability to sooth our own anxieties and emotional immunity from being overwhelmed by others. Schnarch writes that lack of differentiation,

‘….Limits your capacity for intimacy or wanting your partner…’ Schnarch (1997) p136.

Francis Grier spoke of loss of desire based on counter-transference dynamics when she wrote:

‘….disorders of desire may reflect an impenetrable defence operating within the couple relationship to protect the partners from perceived threats to their identity’

As CAT therapists we meet many traumatised people whose over-differentiation or over merged relationships tell us of the deprivation, neglect and abuse endured. A person traumatised routinely and deprived of care, such as in Ruby’s case, may similarly have heightened anxiety and coping behaviours may side track the intimate part of relationships. This was the trajectory I saw in Ruby and her partner.

Ruby’s Story

Ruby’s drive to succeed leads her to spend most evenings alone in the couple’s bedroom studying. There was little expressed conflict and they seem securely attached however qualitatively they were largely just existing. However Ruby is anxious about achieving her aims of a good job and an underlying motivation seems to be to attain good enough esteem, self-sufficiency and security. In therapy we began to identify CAT procedures and target problems and practical home work around finding her voice and to think together about the absence of sexual intimacy. This had become lost to the couple as other life motivations seemed to always take precedence.

Psychosexual Assessment and Intervention;

We began by exploring why sex had become so unimportant to her and how solitude was her safe space to plan, to establish herself, despite the setbacks. My counter-transference indicated to me that Ruby had in part internalised her mother’s pressurising style, not only towards herself, but reciprocally. This was evident in the therapy session by a keenness to follow the CAT model, by taking notes and eagerness for me to produce her reformulation letter but then her own sensitive voice came through in her ‘goodbye letter’ to me at the end of her sessions.

Psychosexual Intervention 1.

Both partners had lived separately and now in their first home they had drifted into spending little shared time alone in the bedroom beyond sleeping. I suggested she may try to arrange to do her admin and organisational tasks in another room and that she and her partner could plan to spend time together in the evening in their bedroom, as an established couple space. She discussed the issues with her partner and he was open to improving the intimacy dynamic.

Psychosexual Intervention 2.

Aim. Improving low arousal;

I described to Ruby that low arousal can be part of the experience of not creating a space to build intimacy. Ruby and her partner were happy but lack of closeness at times affected her deeply, feelings such as abandonment and dissociation were intimated at.

I described the use of graduated clothed touching. Massaging hands and arms and working towards unclothed body touch and from there creating increasing sexual intimacy. I felt it important to contextualise how their intimacy difficulties are part of human relating and to avoid pathologising this young couple.

Psychosexual Intervention 3

At the subsequent session Ruby wanted me to remind her what the task was!

I wondered if this was to recruit me as the ‘expert’ to create a conditional-to-striving environment with me as the conditional judge! I observed that this may therefore place herself emotionally at a distance from her partner by placing the educational striving into this gentle and deeply personal and intimate relational work.

Psychosexual Intervention 4.

Ruby seemed happier and reported that the couple were both creating some focus in their relationship for sex. At one level I was glad that just in the naming, the distance and isolation that the anxiety and fears of being unlovable seemed to recede.


Ruby and her partner benefitted from this brief psychosexual intervention within CAT psychotherapy in that a problem of arousal and avoidance may have set their life together on a path of lack of intimacy. To conclude, sexual problems bridge what Daines and Perrett call the artificial division between physical and psychological problems.

‘This is a result of the way that sexual functioning and the personality as a whole interrelate and the fact that sexual functioning is impinged upon by both internal and external factors. In the face of this complexity it is not surprising that the therapeutic approaches that have been developed to deal with sexual difficulties vary greatly in their focus’

(Daines and Perret, 2000, p6).

It therefore seems important that psychosexual assessment and intervention be integrated into my CAT practice and I hope this article will be of professional value to other CAT therapists.

Rose Hughes CAT Psychotherapist and supervisor, an Art Psychotherapist. Psychosexual Cert. Tavistock London.


Basson Rosemary (2003). Sexual and relationship therapy. Biopsychsocial models of women’s sexual response. Published by Brunner and Routledge Taylor and Francis Health Sciences. Vol 18, No 1.

Clulow, C. (Ed) at al (2009) Sex, Attachment and Couple Psychotherapy. Psychoanalytic Perspectives. Karnac Books, The library of Couple and Family Psychoanalysis. (2009.) Page XXX, Page XXX1V and page 54- 66

Diagnostic and Statistical Manual of Mental Disorder. DSM V. Anxiety Disorders, p 1890-214. American Psychiatric Publishing. (2013)

Daines, B. and Perrett, A (2000) Psychodynamic Approaches to Sexual Problems.Open University Press. p 6

Freud, S (1940) An Outline of psychoanalysis S.E.23. Fairbairn and the Origin of Object Relations. Edited by James S. Grotstein and Donald B. Rinsley. Page 90. The Guilford Press New York and London. (1994).

Grier, F (2009) Chapter 3; Lively and Deathly Intercourse in Clulow, Cled et al (2009) Sex Attachment and Couple Psychotherapy Psychoanalytic Perspectives. Page 45-61 Karnac

Kaplan. H Psychodynamic Approaches to Sexual Problems . Open University Press 2000

Kaplan. H ; Disorders of sexual desire New York, (1977):Brunner ad Mazel and Sexual Aversion, Sexual Phobias, and Panic Disorders. New York ;Brunner and Mazel (1987.)

Norton Seymour, J , (1997) Assessing the sexual relationship. In Ed D.E. Scharff and J.Savege Scharff

Susie Orbach. page 66 Chapter 4. 2009 Chapter 4, Separated attachment and sexual aliveness; In Clulow,C., ed (2009) Sex , Attachment and Couple Psychotherapy.Psychoanalytic Perspectives. London .Karnac

Ryle,A .(1990) Cognitive Analytic Therapy: Active Participation in Change.

Schnarch,D., (1997); Sexual Desire; who wants what in a Passionate Marriage, New York; Norton , p128,p136

Schnarch,D. (2009) Passionate Marriage; Sex, Love and Intimacy in Emotionally Committed Relationships. Sex, Attachment and Couple Psychotherapy. Psychoanalytic Perspectives. pages 133-135

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Rose Hughes, 2018. Psychosexual Assessment, Intervention and Cognitive Analytic Therapy Treatment. Reformulation, Winter, pp.5-8.

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