A very delicate matter: More couples are seeking sex therapy. But is satisfaction guaranteed? Angela Neustatter reports

SEX therapy is booming. When passion dims or the mechanics fail, couples who might once have contented themselves with a cuddle and a chat now consider that they have a problem to be addressed. Counselling organisations providing approved sex therapies, in particular Relate, report that demand for their services now far outstrips supply.

Later this month Relate will consider the results of a survey of 600 couples aged 20-50 who have completed their sex therapy programme. Nine out of 10 couples say their sexual relationship improved. Happiness, it would seem, is 'sensate focus' - sex therapy based on several weeks of intimacy without intercourse.

SENSATE focus therapy was pioneered in the early Seventies by American sex researchers Masters and Johnson. Before its arrival, much of the advice on how to revive a flagging sexual relationship was offered through the agony columns of women's magazines. Then, says the problem columnist Deidre Sanders: 'It was absolutely seen as the woman's place to seduce the man, and her fault if things were not all right.' Slipping into black lace negligees, buying Chanel No 5 out of the housekeeping and serving up candlelit dinners were recommended.

Masters and Johnson's big idea was that sexual dysfunction was a couple's problem, not just one partner's fault. It offered another way of tackling the intimate anguish. When Relate adapted the method and started to set up its own sex clinics, explains Sanders, it became a much more publicly accepted path to take. Relate now has 100 clinics, trains the largest number of people in sensate focus and sees 3,000 clients a year.

The basic principle of sensate focus is a kind of return to innocence, where couples are forbidden to have sex for weeks or even months.

At the end of the sessions with a counsellor, in which problems which may be blocking desire are discussed (and, if necessary - and surprisingly often it is - sex education is given) the pair are given 'homework'. For this they are told to make 'special time' for each other, perhaps a couple of times a week, during which they are encouraged to explore each other's bodies using massage with oil, caressing, stroking, and (it is hoped) experiencing delicious frustration.

For the first part of the programme, which lasts an average of 13 sessions (for which Relate charges up to pounds 25 a time), genital touching is forbidden. The idea is that there should be arousal and desire which create an urgency for sex. But the taboo remains until the counsellor is convinced there won't be a sudden wilt or freezing of lust at the idea of the real thing. After this familiarisation, according to Marj Thorburn, head of sex therapy at Relate, 'the pressures so many couples feel should have gone. Once they know they cannot have sex they can enjoy being sensual and then, when the programme is ending, we can discuss finding a pattern of love-making which suits them both. The important point is that we are not saying they must reach a 'normal' target or a particular number of times per week, but that whatever feels good for them is fine.'

It is not a miracle cure, however. In spite of Relate's own research, evidence exists that sensate focus therapy may be less effective than it believes, and might even sometimes aggravate rather than solve problems for some.

Most of the women who seek help do so because of lack of desire and not getting orgasms - either they have never enjoyed sex, or they have stopped wanting it. For most men, it is failure to achieve or maintain an erection which sends them for advice. Some sex therapy professionals, such as Dr Alan Riley, editor of the Journal of Sexual Health, point out that these common problems are the ones on which sensate focus has most little effect. According to other research, only about 30 per cent of erectile problems, and a relatively small number of women with lack of sexual interest are helped by the sensate focus method, and he adds: 'We don't have any definitive findings saying one kind of sex therapy is right.' While Keith Hawton, a consultant psychiatrist and author of Sex Therapy - a Practical Guide (OUP), says: 'Sex therapy is not a panacea. There are many with sex problems for whom it is unhelpful and at present it is not possible to draw a clear distinction between those who benefit and those who do not.'

More significantly, can it do any harm? Marj Thorburn acknowledges that not everyone stays the Relate course. She also admits that, in fact, sex therapy can be very destructive to a relationship which has outlived its shelf-life. 'The intimate contact required in the homework is something people cannot tolerate if they are profoundly angry with their partner, feel very hurt, or if in whatever way they no longer feel committed to the relationship. These relationships will be blown apart by sex therapy.' Relate therapists try to spot these situations in the assessment, and a fragile but still-breathing relationship may improve.

The eminent psychologist Dorothy Rowe also sees potential for damage to self-esteem in an approach which, although Relate is at pains to direct it at both partners equally, may well be reinforcing the hidden agenda for so many women - that the onus is on them to get the sensual work right. She says: 'We live in a culture where women are constantly given the idea that they must please men, and I am sure many carry this attitude into sex therapy. If it does not work, or work to the satisfaction of the man, there is a very real risk the woman may feel she is to blame.' And she wonders whether an approach so focused on the sex act can really answer sexual problems in the long run. 'I don't believe any problem is just about sex, and I think if the block is serious some fairly deep analytic work would probably be necessary.'

Nor does Rowe believe sensate focus addresses the power struggle in relationships, which so often affects sex, where one partner puts the other down. 'I can see this simply being extended into the therapy. You would get one partner telling the other they aren't doing things right, they aren't trying hard enough, or there could be damning with faint praise, as men so often do when teaching women to drive: 'You're doing very well dear, it'll soon be much better . . .' '

In more extreme circumstances, there may be even more serious worries. Susan Dyas runs a telephone help-line for abused and battered women. She says she sees the harm done by sensate-focus therapy. 'I have had many calls from women who have been for Relate sex therapy and who have found that the forbidden sex element makes things worse. They say their partners have become angry and sometimes violent when they have refused sex after the prolonged touching. It's not Relate's fault. They are not trained to spot controlling, aggressive men, but nevertheless it's harmful to the women.'

Relate is not alone in offering sex therapy. A number of teaching hospitals have sex clinics, using a variety of different methods. Dr Michael Crowe, consultant psychiatrist at the Maudsley Hospital in London, takes a behavioural approach designed to change behaviour which may be sabotaging sex. Other practitioners use hypnotherapy. There is also the medical approach, where hormones and drug injections are used to stimulate erections in men, and testosterone may be given to women to increase desire.

However, as a spokesperson at the UK Standing Conference of Psychotherapy, which is compiling a list of ethical practitioners, points out: 'Anyone who wishes can call themself a sex therapist and you certainly get people suggesting all sorts of unorthodox practices.'

It is in the fringe area that actual abuses are most likely. All the practitioners interviewed here would condemn any therapist who has sex with clients as a way of 'breaking down barriers'. But what of the controversial work carried out by the well-respected therapist Martin Cole, who uses surrogate partners (professionals hired for the job) as a way of helping people who absolutely cannot manage sex with their partners? Cole believes that this is very different from therapists becoming surrogates because: 'I maintain a professional relationship with clients. They understand that the surrogate is there for a purpose and there is no question of emotions being involved. There is not the scope for blurring of boundaries as there is if a therapist has sex with a client.'

YET finally, no matter how right the conditions or how skilled or inventive the therapist, doesn't sexual success or failure depend on whether some basic desire remains - or whether the sexual attraction between a couple has simply died? 'It's not easy to bring back attraction if it really has gone, and we would help a couple to accept that if we could. Sex therapy would probably not be particularly useful to them,' says Zelda West-Meads, director of Relate. Oliver James, a psychologist with a particular interest in sexual matters, agrees. 'Take a situation where the man is much older than his partner and, given that male potency drops steadily with age, he becomes increasingly less satisfying for her. That man would feel worse if he tries sensate focus and it does no good. Or take the case of the couple of the same age where the woman who has had children and perhaps aged less well than her partner. They may be very fond of each other but that does not mean he will be aroused by her. Going through sensual exercises and finding they did not help would make her feel terrible.'

Viewing the human distress they see caused by sexual dysfunction, practitioners talk of the need for better funding and an NHS policy supporting their work. It is clear that sex therapy does work for some people and that it can make a huge difference to their happiness. Relate's surveyed couples reported, along with greater sexual satisfaction, increased general contentment in their relationship. But while no-one should begrudge such couples this help, many might tend to share the view of agony aunt Claire Rayner. 'Isn't it time for us to become less focused on sex for all our satisfactions? A lot of people have very contented lives without sex. Maybe if people stopped feeling that little or no sex was a problem, it wouldn't be.'

Four clients tell their stories (Real names have not been used in these interviews)

Barbara, company director, age 31

Saw Harley Street sex therapist

Paid 100 pounds per session

MY partner Bob and I had a very good sex life until I got endometriosis, which meant making love was immensely painful. My doctor suggested we should stop having intercourse for six to nine months. Ironically it was when I was better and we could have sex again that things seemed to get worse. I was very scared, I think, and assumed it would be painful. Also the feelings of loathing I had for my body - I was very large as a teenager and I still feel I am far too fat - had surfaced and were making me very uncomfortable about sex.

I realised that we needed help and I think Bob was relieved. We made an appointment with a male doctor in Harley Street, who was recommended. He had a large desk and we sat opposite him a bit like naughty children. He chatted for a while then asked me what turned me on.

I didn't feel comfortable enough with him to say, so I was non-committal. Then he asked Bob if he could get an erection and he said yes. At which point the doctor said 'What's the problem, then?' I started telling him about my past and he just interrupted me and said that was stuff for long-term analysis. I felt so small and humiliated. The second session he tore Bob off a strip because he doesn't live with me (there are complicated reasons for this). I felt he alienated Bob. He then wanted us to watch videos of couples making love, but I felt so uncomfortable with him that I just couldn't. I asked if we could watch them in private and he snapped back that it wasn't a library and he just wanted us to learn some techniques. Then he sent us away, saying we needed to do a lot of talking. We felt he hadn't helped at all.

I would think sex therapy a very bad idea if I hadn't then been recommended to an excellent woman therapist. I've been going to her for a while and she's helping me work through the issues which, I can see, have been blocking my sexual feelings. I feel very optimistic and so does Bob.

Simon, teacher, age 29

Saw Relate sex therapist

Paid pounds 25 per session

WE got married shortly after my wife Hannah left university. We felt very happy to have found each other and our relationship had the solid foundation of a wonderful friendship. I knew Hannah was a bit more sexually experienced than I was but this didn't worry me and she seemed happy with our lovemaking. But as time went on I sensed that her enjoyment wasn't real, and although she assured me she had orgasms I became convinced she was faking it for my sake. I was inhibited about saying anything but I felt a terrible failure; I loved Hannah such a lot and no matter how passionate I was she never seemed truly overwhelmed as I was and we didn't have sex very often.

It was when we began to talk about having a baby that I felt I must say something. I was afraid that the sex problem might damage our relationship, and it wouldn't be right to have a child if that were a real risk. So one night after we had made love I confronted Hannah, saying I knew it wasn't good for her. At first she insisted it was fine, then she admitted she had never had an orgasm with me or anyone else, although she could have one with masturbation.

We decided to go for help, and during the talking time Hannah mentioned all sorts of things she'd never told me before: a promiscuous mother and a stepfather who had made inappropriate advances, both of which had upset her and made her try to shut down her sexuality. And other things came out to do with seeing sex as dirty, which had been conveyed to Hannah when she was very young. So the early sensual sessions when we just touched and caressed were very valuable. I could feel Hannah relaxing and when we moved on to genital touching she started to show me how she liked to be touched. It gave me a lot of confidence to feel I was at last pleasing her. When we had full sex Hannah had an orgasm, and things went on getting better and better. Earlier this summer we had our baby.

Jenny, interior designer, age 41

Saw private sex therapist

Paid pounds 35 per session

MY husband Larry had stopped being able to make love to me and, although it didn't seem to worry him so much, I felt terribly rejected and unhappy. He had a medical check-up and there was nothing wrong so I suggested we go to therapy. His doctor suggested he see a well-known woman therapist who had been practising for more than 20 years. He liked her, which pleased me, although he never told me what happened in the sessions. But, in fact, rather than improving things between us, they got worse. I then decided I should go too, and the therapist agreed to this but said she would not see us together. Then Larry began cancelling a lot of his appointments. I asked her why she did nothing about this, to which she replied that she wouldn't challenge or 'bully' him because he had been brought up by a strong woman and was married to another one who dominated him. In fact a lot of time was spent in my sessions discussing the way I 'handled' my man and I felt I was being told I should be a passive little woman concerned only with trying to make Larry feel good.

I felt the therapist was absolutely on the side of Larry and quite enamoured of him. Even the secretary seemed to be part of a fan club. She would say things to me like: 'We saw your handsome husband today - what a hunk.' I had no sense that my feelings or unhappiness were of importance. I might have accepted all this if things had got better between me and Larry, but they didn't, and in the end we decided to go for couple counselling. I wrote to the therapist to say this and got a letter back saying she didn't think it would work because I would always be feeling I was dragging my man, and he would always feel he was being dragged. I was shattered by that and utterly undermined. I felt she had told me there was no hope, and the next feeling was white-hot fury. Neither helped my situation with Larry, which had got worse if anything over our nine months of therapy. I just wish we had never gone to this woman.

Gordon, bank manager, age 33

Saw Relate sex therapist

Paid pounds 10 per session

WE'VE been married 12 years and in the early days we had fantastic sex, although even when we were courting I sometimes had difficulty getting or maintaining an erection. Because the problem came and went I didn't do anything about it, but I was aware of it more often after we were married. I began to worry, and the more I worried the worse it became. It was making us very unhappy. Jane, my wife, used to initiate sex a lot of the time in the early days and I really like that, but she lost all her self-

confidence and stopped approaching me altogether. She felt she wasn't turning me on and some nights she would be in tears. Other times we ended up rowing.

Then one day when Jane was going to the doctor about something of her own I found myself saying: 'Ask if he can help with my problem'. The next thing that happened was we were offered sex therapy at a Relate centre. We were seen together by a therapist who took a very thorough history of our backgrounds, our marriage and she really listened to what we said about each other. She said we clearly didn't need marriage counselling because we obviously loved each other. She then offered us the sex therapy programme. Almost as soon as we started things improved and a lot of that was because the therapist got us to talk about our feelings, something we weren't doing before. I hadn't realised Jane thought it was her fault, and she hadn't known how anxious I felt because I didn't think I could satisfy her. Understanding each other brought us closer and it was a relief being told not to have sex. Neither of us had seen what a pressure the whole situation was and we really enjoyed the business of massaging each other and cuddling. I got an erection easily and it stayed. It was the same with genital touching, and then when we came to making love it was fantastic. We completed the programme in half the time expected. Getting help was certainly the best thing we have done.

TO FIND HELP

THE following organisations can give help in finding an accredited sex therapist:

Relate, Herbert Gray College, Little Church Street, Rugby, Warwickshire CV21 3AP. Tel: 0788 573241

Institute of Psychosexual Medicine, 11 Chandos Street, Cavendish Square, London W1M 9DE. Tel: 071-580 0631

Association of Sexual and Marital Therapists, PO Box 62, Sheffield S1O 3TS. Send SAE for list of sexual therapists.