In my last post, I wrote about the fact that relational issues (feelings of distrust, anger, resentment, betrayal) often are the root cause of a couple’s sexual problems.

One way I screen for these deep-seated issues is to have patients fill out a couples’ questionnaire, and then carefully analyze the answers. I pay a lot of attention to how strongly patients agree (on a scoring scale) with the statement, “My partner is my best friend.”

If the score to that question is very low, the unhappy feelings are likely spilling over into the sexual relationship.

Sometimes, these feelings of anger, resentment, or hurt goes back to some discrete time in the couple’s past when there was a significant breach in attachment or empathy. Here are some examples of interactions that might waylaid the relationship but were never discussed again.

• There was a miscarriage, and the spouse was not supportive.

• A spouse lost his/her job, and the partner was not supportive emotionally andwould not cut down their compulsive shopping

• One person fell ill and the other person did not do a good job caring for them.

• A partner felt left out when their partner consistently paid more attention to a new baby or a child from a former marriage

• A partner said something very critical during a sexual interlude.

• A partner’s parent or sibs said something very nasty to the other partner, and he/she was not defended.

These are examples of common incidents in couples’ histories, and they can wreak havoc on a relationship if the wounds are left to fester.

One way therapists work to heal the relationship is to create a “transformative emotional sequence” during a therapy session.

In other words, after the therapist has a good idea of what transpired and what each partner felt bad about, the scene is re-enacted right there. But this time, the therapist is there to interpret the feelings and to coach each partner on how to respond differently, with more empathy and more understanding.

In other words, in the session, the old, walled off, bad feelings are activated (in a safe way, with the therapist there), but then a more adaptive and loving emotional state is created.

The therapist encourages a healing dialogue, essentially in a kind of psychodrama, that helps dismantle of the terrible memory of the feelings from the past, creating a new, happier memory and an enhancement of feelings of safety and trust between the couple.

Several schools of therapy — including AEDP for couples, EMDR, and emotionally focused couple therapy. Sometimes couples are astounded at how quickly episodes that have seemed too dangerous to address can be healed.

And once they can see each other as a best friend and a safe person once again, erotic sex can be slowly integrated back into the relationship.