Cognitive-Behavioral Therapy for Sexual Dysfunction

Michael E. Metz, Norman Epstein, Barry Mccarthy

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781135183769
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Cognitive-Behavioral Therapy for Sexual Dysfunction provides clinicians and graduate students with a comprehensive biopsychosocial model of useful, practical, empirically-based strategies and techniques to address common sexual dysfunctions. It is the most comprehensive volume describing the couple cognitive-behavioral approach to assessment, treatment, and relapse prevention of sexual dysfunction. The focus is on sexual desire and satisfaction with an emphasis on the Good Enough Sex (GES) model of sharing sexual pleasure rather than an individual perfect intercourse performance test. This title reflects the contributions of Mike Metz to the field of couple sex therapy.

Chapter 1

Understanding Sexual Dysfunction and Sex Therapy

Cognitive-Behavioral Therapy for Sexual Dysfunction (CBCST) provides a detailed description of assessment and treatment strategies for sexual dysfunction (SD) for experienced clinicians and graduate students. This book addresses the lack of sex therapy training that is common in psychology, marriage and family therapy, social work, and other mental health programs. Most clinicians receive very little practical training in this crucial area. Our goal is to provide a realistic and authoritative foundation in CBCST concepts, assessment, and interventions that facilitate clinician comfort and confidence.

We focus primarily on CBCST with married and partnered couples, both opposite and same-sex. In the absence of a partner, this approach can be modified for use with individuals. CBCST is a subspecialty of couple therapy. It is grounded in strategies to promote skills for sexual and relationship function and satisfaction, as well as interventions to reduce relational conflict and distress that subvert sexual function and satisfaction. The psychoeducational component of this approach is required because many adults, regardless of intelligence and education level, have limited knowledge and comfort with sexual physiology and psychosexual skills. CBCST interventions focus on the complex interplay among partners’ cognitions, emotional responses, and behavioral interactions that subvert the sexual relationship.

CBCST is an artful blending of sexual science and clinical practice. In behavioral terms, SD involves absent, inhibited, or feeling a lack of control of sexual response. It also involves a variety of non-sexual behaviors (e.g., couple communication) that influence sexual function. The behavioral patterns in a couple’s overall and sexual relationship are important targets for clinical interventions. Cognitive components of SD involve thought processes that interfere with sexual desire, pleasure, eroticism, and satisfaction. Emotional components of SD involve both chronic and transitory emotions (e.g., depression, anxiety, anger, shame) that block sexual satisfaction. CBCST incorporates assessment and intervention with cognitive, behavioral, and affective components within a comprehensive biopsychosocial model. In this book we:

• describe methods for assessing behaviors, cognitions, and emotions within a relationship context;
• detail therapeutic interventions focused on sexual pleasure and function;
• provide clinical “coaching” regarding common processes in sex therapy; and
• offer case vignettes as well as psychosexual skill exercises, handouts, and educational materials.

Roots of SD include characteristics of the two clients (e.g., sexual beliefs they learned in childhood) and their relationship. We emphasize dyadic formulations of SD that take both partners and their interaction patterns into account, incorporating evidence-based procedures and providing guidance for best clinical practices.

Sex Therapy as an Exceptional Clinical Opportunity to Benefit the Relationship

Couples find it difficult to view SD as similar to other challenging relationship issues (e.g., finances, conflicts with relatives, work commitments, parenting) because of the sensitivity of sexual issues. SD invariably is a relationship problem, if not in origin, then in impact. Many couples and therapists wrongly fear that SD signals irreconcilable “incompatibility.” Couples and clinicians overlook the exceptional therapeutic opportunity available for promoting sexual health and couple intimacy by improving the quality of the sexual relationship. Effective sex therapy not only allows the professional to help relieve individual emotional distress and enhance self-worth; it also has great potential to increase emotional closeness. Regardless of a clinician’s primary theoretical orientation (e.g., psychodynamic, humanistic, family systems, feminist) and professional discipline (psychiatry, psychology, social work, marriage and family therapy, pastoral counseling, professional counseling, nursing), CBCST provides a wealth of resources, strategies, and interventions that can be integrated with diverse approaches. Clinicians with a variety of professional backgrounds can use CBCST as a clinical modality that offers exceptional opportunities to reduce distress and enhance an intimate relationship.

Usually individuals and couples do not seek assistance for SD. Often they present concerns associated with medical and mental health conditions (e.g., cancer, generalized anxiety disorder, grief over a parent’s death, parenting problems, depression), which seem unconnected to sexual problems. In other cases, they present global relational issues (e.g., frequent arguments, feeling disconnected from each other) without any specific reference to sexual problems. However, sexual concerns are often in the background of these diverse problems. “I suffer daily anxiety, so I avoid sex.” “Since my father died, I don’t have any interest in sex.” “I’m receiving chemotherapy, so I have no sexual desire.” “We don’t talk much, and rarely show affection.” Sexual concerns are present in a wide variety of clients’ presenting complaints even though they may be hidden or secondary.

Sexuality is personal and sensitive, causing clients and clinicians hesitation and discomfort, so they avoid talking about or even thinking about sexual issues (Risen, 2010). Our objectives are to increase clinicians’ comfort with discussing aspects of sexual functioning, as well as to provide guidelines for sexual history taking, assessment and diagnosis, and CBCST interventions. With increased comfort and confidence, clinicians can help individuals and couples with SD and sexual concerns.

Sexual Dysfunction as a Relationship Problem

Sexual problems have multiple causes, dimensions, and effects on the individual, the partner, and their relationship. Effective treatment integrates medical, pharmacological, psychological, and relational components (e.g., Althof, Rosen, Rubio-Aurioles, Earle, & Chevret-Measson, 2006; Binik & Hall, 2014; Metz & Pryor, 2000). SD can have a profound detrimental effect on the overall quality of a couple’s relationship (Levine, Risen, & Althof, 2016). Difficulties with SD become relational problems when they are sources of embarrassment, conflict, dissatisfaction, or avoidance.

The Interplay of Sexual Dysfunction, Individual Psychological Function, and Relationship Problems

SD is a source of significant psychological distress and relationship problems. It commonly results in couple conflict, confusion, alienation, and dissatisfaction. SDs are classified as individual psychiatric disorders in the Diagnostic and Statistical Manual 5 (DSM-5; American Psychiatric Association, 2014), even though they are expressed in relationships and are influenced by interpersonal processes. Individual pre-existing health and mental health problems and couple relationship conflicts can contribute to the development of SD (Metz & Epstein, 2002). Thus, SD offers an exceptional opportunity for the helping professional to provide support and enhance the quality of life of the individual and couple, promoting personal and relationship health and satisfaction.

Core Sex Therapy Competencies

In addition to general clinical proficiencies that all therapists need (e.g., excellent listening skills and empathy), there are three core proficiencies in sex therapy: (1) accurate, evidence-based biopsychosocial information about sexual behavior and function; (2) comfort with discussing sexual details and addressing sexual difficulties; and (3) knowledge of strategies for the assessment, formulation, and treatment of SD. Equipped with specialized knowledge, personal and professional comfort, and practical skills for assessment and intervention, a clinician can feel confident providing CBCST.

Our aim is to provide clinicians with best practices for assessment and treatment based on the findings of clinical research on SDs and couple relationship factors that influence them.

Relevance for Heterosexual and Same-Sex Couples

The vast majority of knowledge about SD has been gathered from research and clinical practice with heterosexual married couples. However, these concepts and methods are highly applicable with same-sex couples. Characteristics of individuals that contribute to SD (e.g., performance anxiety, sexual trauma, depression) operate similarly regardless of sexual orientation. Although there are important factors in the lives of same-sex couples that differ from those in heterosexual couples (e.g., discrimination, gaps between partners in their stages of coming out), dyadic aspects of SD (e.g., power struggles and avoidance) are similar. Where sex researchers and therapists have found differences by sexual orientation—for example, dyspareunia among heterosexual couples occurs with vaginal intercourse whereas among gay men it occurs with anal intercourse; low sexual desire occurs more often among lesbian couples than either gay male or heterosexual couples—it is important to address factors unique to sexual orientation (Nichols, 2014). Otherwise, sex therapy competencies are applicable across sexual orientation.

Sexual Dysfunction and Sexual Health

The Diagnostic and Statistical Manual (DSM-5) is a primary source for classifying SD.

The DSM-5 Sexual Dysfunctions are:

• Hypoactive Sexual Desire Disorder—males.
• Sexual Interest/Arousal Disorder—females.
• Inhibited Arousal—difficulty with sexual arousal.
• Inhibited Orgasm—delay or absence of orgasm.
• Premature Ejaculation—rapid ejaculation.
• Genito-Pelvic Pain/Penetration Disorder—persistent genital pain or spasms of the vagina that interferes with intercourse.

However, the DSM-5 classification system views sexual problems from an individual perspective, ignoring relationship dynamics that influence each partner’s sexual cognitions, emotions, and behaviors. Aubin and Heiman (2004) and Weeks and Gambescia (2015) examine SD from a relationship perspective, which we strongly support. Clients often present difficulties such as couple conflict regarding frequency of sex and preferred behaviors (e.g., oral sex, anal intercourse). These relational aspects of sexual problems can cause significant individual and relationship distress.

Descriptions of SD include three components: (a) a condition that is chronic or persistent (in contrast to occasional difficulties with sexual desire, arousal, or orgasm that are normal); (b) the sexual condition causes personal distress, and (c) it causes relational problems. The latter two components are crucial for understanding the impact of SD and the need for treatment.

Sexual problems may be comorbid with other psychological issues (Rosen, Miner, & Wincze, 2014). SD commonly occurs with mood disorders, generalized anxiety disorder, obsessive-compulsive disorder, and sleep disorders. Common interpersonal causes of sexual problems include relationship distress and alienation, psychologically and/or physically abusive behavior, and attachment injuries and broken trust (Johnson, 2008). These problems need to be addressed either before or concomitant with CBCST.

CBCST seeks to promote sexual health for individuals and couples. The United Nations World Health Organization described sexual health from an integrative biopsychosocial perspective:

Sexual Health may be defined as a dynamic and harmonious state involving erotic and reproductive experiences and fulfillment, within a broader physical, emotional, interpersonal, social, and spiritual sense of well-being, in a culturally-informed, freely and responsibly chosen, and ethical framework; not merely the absence of sexual disorders.

(World Health Organization, 1975)

Thus, the goal is not only to reduce distress, but also to enhance positive experiences.

There is no set definition of a “normal” sex life. Individuals and couples vary widely in terms of how often they engage sexually and what behaviors are involved. For some couples, once a week, twice a month, or even a few times a year may be acceptable. A couple’s sexual behaviors may vary considerably from one encounter to another (e.g., a heterosexual couple may not always have penile-vaginal intercourse, and partners do not have an orgasm every time). Satisfaction depends on the expectations and meanings that the individuals attach to their sexual experiences, and the degree to which there is a good match between partners’ goals and personal standards. Individuals experience variations in their level of sexual interest, degree of physical responsiveness, sexual satisfaction, and the degree to which they accept these variations as normal influences their satisfaction.

Table 1.1 Sexual Difficulties Involving Dis...