You’ve read the books. Maybe you’ve tried scheduling sex, changing your routine, or getting a medical workup. And still the desire doesn’t show up, your body doesn’t cooperate, or you keep doing something you promised yourself you’d stop.
If that sounds familiar, you may have wondered whether something deeper is going on. Often, there is. That’s where depth-oriented, psychodynamic sex therapy comes in.
What Is Depth-Oriented, Psychodynamic Sex Therapy?
It’s sex therapy that looks beneath the symptom to what’s driving it. “Psychodynamic” means we pay attention to feelings and anxiety patterns you may not be fully aware of, and to the automatic ways you’ve learned to protect yourself from feelings that make you uncomfortable. Where relevant, we may also connect people and situations in your present life with ones from your past. “Depth-oriented” means we don’t stop at managing the problem. We work with its root source.
My approach is informed by Intensive Short-Term Dynamic Psychotherapy (ISTDP). It starts from the idea that mixed feelings are normal and healthy: loving your partner and being angry at them, wanting closeness but fearing rejection, feeling attracted to someone and hurt by them. The trouble starts when one or more of those feelings makes you anxious and you push them away without realizing it. You might numb out, get distracted, intellectualize, avoid closeness, turn on yourself with harsh self-criticism and shame, or reach for a quick sexual outlet. The feelings don’t disappear. They get stuck, creating what I call an internal emotional conflict, and sexual difficulties are often where it shows up.
That push-away is called a defense, and it happens outside your awareness, so you’re not doing it on purpose. Defenses protect you from discomfort, but the results of those strategies are generally what bring people to therapy.
How Does This Show Up Sexually and Relationally?
Sex asks you to be open, present in your body, and close to another person all at once, so unresolved issues often surface there. A few examples (composites, not real clients):
Low desire. Someone carries anger toward their partner that they’ve never voiced, or never even noticed. Desire is hard to access toward someone you’re angry at but aren’t dealing with. Or the root is fear of rejection: old experiences of being turned down get placed onto a partner who is actually loving and accepting, and desire shuts down before you’ve had a chance to feel it.
Erection, arousal, or orgasm difficulties. Once medical causes are ruled out, the body may be holding back because of pressure, fear of failure, harsh self-criticism, or fear of the vulnerability that letting go requires.
Sexual behavior that feels out of control. The behavior is often doing a job, like calming loneliness or stress before you’ve felt it, or offering release without the emotional risk of being truly known.
These are just examples, and the roots can be many different things. Part of the work is finding out which ones are at play for you.
Why Thinking Your Way Out Often Isn’t Enough
Many people have tried therapy focused on changing their thoughts and habits, like cognitive behavioral therapy (CBT). These approaches help many people. But when a sexual difficulty is rooted in an avoided feeling, they often fall short. Reframing the thought “I should want sex” doesn’t touch unspoken anger. Anxiety and defenses are often unconscious, automatic forces that diminish our sense of agency. For example, you can know logically that your partner is safe and still feel yourself tense up or go numb. And “just relax” or “try harder” can add pressure that makes things worse.
If you’ve ever said, “I understand it perfectly, I just can’t change it,” this is probably why.
What Does It Look Like in Practice?
In sex therapy, we usually start with the low-hanging fruit: education about how desire and arousal actually work, clearing up myths, communication, and behavioral exercises like sex therapy “homeplay.” For some people, that’s enough to reach their goals. If it isn’t, that tells us something deeper is getting in the way.
At that point, the work becomes more experiential. We don’t only talk about your feelings. I help you actually experience them, at a pace you can handle. I pay attention to what’s happening in your body and emotions as we talk. When you laugh, go vague, or shift into your head, I’ll notice, and with your permission I’ll say so. I ask direct questions, with care, and I watch your anxiety closely so we stay at a level where you can feel without being overwhelmed.
When feelings can be directly experienced instead of pushed away, sexual symptoms often shift. I can’t promise that for everyone, but at the very least, when stuck with— this work can help you develop a more adept, fluid relationship with your sexual challenges.
How the Work Differs for Individuals and Couples
In individual sex therapy, we look at the defenses you use against your own feelings, and against closeness itself. In couples sex therapy, the focus is on the defensive moves that show up between you, the ones that keep you from engaging in an emotionally open, collaborative way with your partner.
I help partners become an “erotic team” in facing their sexual challenges. If a couple can’t talk about a desire discrepancy openly, how can they build a sex life that makes room for their differing feelings and wants? Couples work may include exercises to try at home, but first it’s foundational to learn to engage with each other in ways that build safety. Sometimes individual sessions alongside couples work can accelerate the process.
Why Might You Need Psychodynamic Sex Therapy?
Depth-oriented work may be a good fit if:
You’ve tried exercises, self-help books, or reframing your thoughts, and understood them perfectly well, but you’re still struggling to find a way through your sexual (and relational) issues
Medical causes have been ruled out, or they don’t fully explain what’s happening
You know you want to want sex, but your mind or body doesn’t follow
The problem shows up in some situations but not others
You feel numb, distracted, or “somewhere else” during intimacy
You have mixed feelings you can’t explain, or guilt and shame that seem out of proportion
If this sounds like you, you may be a great candidate for something deeper.
Ready to Get to the Root?
I work with individuals and couples online throughout California and Oregon, and I offer a free 15-minute consultation so you can ask questions and see if we’re a good fit.
Jen Joseph, MA, LMFT, CST is an AASECT Certified Sex Therapist, licensed psychotherapist, PACT, EFT, The Developmental Model, ISTDP-informed Couples Therapy and Transformative Couples Therapy-trained couples therapist, and Certified Discernment Counselor who practices online throughout California and Oregon— including Portland, the San Francisco Bay Area, Los Angeles and beyond.