A core strategy in sex therapy is the use of semistruc-tured sexual exercises to facilitate changing attitudes, behaviors, and emotions. A critical skill for the therapist is to describe, process, refine, and individualize sexual exercises. Exercises provide a continuous assessment to identify anxieties, inhibitions, and lack of skills. Behavioral exercises help the couple build sexual comfort and skill. Reading, discussing, and processing the exercises helps change cognitions, perceptions, and feelings (McCarthy & McCarthy, 2002).
Therapy sessions are structured, especially at the beginning. The first agenda item is to discuss experiences and exercises of the previous week. The therapist does a fine-grain analysis of the positive and negative attitudes, behaviors, and emotions elicited by the exercises. Initiation patterns, comfort level, receptivity, and responsivity to specific pleasuring techniques, interfering anxieties or inhibitions, and subjective and objective arousal are carefully explored. The model of personal responsibility for sexuality and being an intimate team is reinforced. The therapist is active, especially in the early stages of therapy, serving as a permission giver, sex educator, and advocate for intimate sexuality. As therapy progresses, the couple takes increasing responsibility for processing experiences and feelings, creating their own agenda, moving to individualized and freeform sexual experiences, exploring personal and relational anxieties and vulnerabilities, and acknowledging strengths and valued characteristics. Therapy becomes less sexually focused and more intimacy focused. The meanings of intimacy and sexuality are explored as well as setting positive, realistic expectations for couple sexuality.
An individualized relapse prevention plan is an integral component of sex therapy. Learning to be sexually functional is easier than integrating sexual expression into the couple's life. Researchers have reported high levels of relapse among couples, so it is crucial to have a program to maintain and generalize sexual gains and prevent relapse. Key to maintaining therapeutic gains are positive, realistic (nonperfectionistic) expectations. Partners who accept a variable, flexible sexual style and who realize it is normal to have occasional mediocre, unsatisfying, or dysfunctional experiences will be inoculated against sexual problems associated with physical and relational aging. Common relapse prevention techniques are to keep the session time, but rather than go to therapy session, have an intimacy date at home; to have a pleasuring session with a ban on intercourse (and perhaps a ban on orgasm) every 4 to 8 weeks so you reinforce the importance of sensuality; to develop and play out a new erotic scenario every 6 to 12 months, and, when there is an unsatisfying or dysfunctional encounter, to initiate a sensual or erotic date within 1 to 3 days. If the couple has not had a sexual encounter for 2 weeks, the partner with higher desire initiates a sexual date; if that does not occur, the other partner initiates a pleasuring date during the next week; if that does not occur and the couple has gone a month without a sexual connection, they schedule a "booster" therapy session. The couple is committed to not fall into the cycle of anticipatory anxiety, tense and performance-oriented sex, and avoidance. They maintain a cycle of positive anticipation and feeling they deserve sexuality to enhance their relationship, broad-based, pleasure-oriented sexual experiences, and maintain a regular rhythm of sexual connection.
The two worst mistakes therapists make are diverting the sexual focus and prematurely terminating treatment as soon as sex becomes functional. The therapist and couple may collude in avoidance because sexual dysfunction can be a sensitive and anxiety-provoking area, especially discussing erotic scenarios and techniques. It is crucial to deal with inhibitions and avoidance; for example, the man's fear of the "wax and wane" erection exercise or the woman's intimidation by exercises to guide a partner's hand or mouth to increase eroticism. The therapist stays with the therapeutic strategy and processes and refines the sexual exercises. Unless the clinician is willing and able to structure therapy so that sexual problems are confronted directly and anxieties, inhibitions, and skill deficits are dealt with, the goal of developing a vital, resilient sexual style will not be achieved.
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