General Treatment Principles, Strategies, and Techniques

General Treatment Considerations

Assessment and treatment are overlapping processes. The first step is for the therapist to obtain information about the presenting problem, such as onset, duration, change in symptom(s) over time, and couple dynamics around the sexual problem. It is essential to allow time for the couple to explain the presenting problem since this step initiates the therapeutic process and helps them to feel heard and understood. Too much initial history taking, however, may cause the couple to feel frustrated or pessimistic, or to lose interest in treatment. The next step is to begin to proceed with specific treatment strategies for the sexual problem identified by the client(s). The couple must have the impression that the therapist will be able to offer solutions in addition to collecting information. (However, there are many cases where other problems take priority over the sexual problem, which will be discussed later in this chapter.) As the psychotherapy continues, the therapist will obtain new information about the presenting problem as well as different struggles that almost always emerge. In other words, the therapist will search for information about one problem while another issue is being concurrently treated. The key task for the therapist is to flexibly shift back and forth between assessment and treatment.

• • The treatment goal is the overarching concept that drives therapy. It represents the outcome that successful treatment should provide.
• • The treatment strategy is the general method the clinician uses to implement the treatment. The strategy derived from the theoretical understanding of the problem is used to achieve the goals of treatment.
• • The techniques are the specific interventions used to implement treatment strategies.

As sex therapists, we need to address individual, relational, family, contextual, and environmental factors that contribute to a couple’ssexual problems. Then, we need to rely on careful integration of a variety of treatment approaches and theoretical perspectives for treatment. Unlike strictly individually oriented behavioral approaches so common in sex therapy, in systemic treatment the role of the partner is considered in the creation, continuation, and correction of the problem. For example, this perspective is crucial during the homework component of treatment because one aspect of the assignments may have to be shared so that each partner receives some kind of emotional, affectional, sensual, or sexual satisfaction. The systemic viewpoint further considers how each partner feels about the problem, their opinions about the impact the problem has had on their relationship, coexisting nonsexual problems in each partner, overt and covert sexual problems in the partner not presenting for help, how to work together to solve the issues eventually uncovered, and so on.

Beginning Treatment

This guide is useful for those therapists who are inexperienced in how to begin the process of working with a couple. As soon as you have a particular impression about the problem you will be treating, you should follow up by gaining more information using the guidelines listed later in this chapter. You should also become familiar with the overview chapter in our companion volume, Systemic Sex Therapy, 3rd edition (2020), on each sexual problem in question so that you are prepared to conduct a complete initial assessment, then offer the couple some understanding about the nature of the problem and initiate an effective treatment plan. Finding a starting point is not always easy, especially when giving homework. Thus, the therapist can discuss the goal that is to be achieved but may want to caution the couple that their ability to do the assignment and feedback about the assignment may change or refine what the couple works on first in a series of treatment steps they begin.

Initial Contact

Typically, the initial phone call is the clinician’s first contact with the client(s). Sometimes, Internet websites or email requests are used to inquire about treatment. The therapist should respond as quickly as possible in a phone conversation. During this interaction, the reason for seeking treatment is stated, often accompanied by client distress when describing it. Sometimes clients will say that they have tried to solve the issue on their own or have worked with other clinicians without successful resolution. The therapist must demonstrate understanding and acknowledge their concerns in this first contact. Some preliminary information, such as scheduling and fee structure, can also be discussed at this time. Not returning phone calls, calling days later, or rushing the conversation are all recipes for losing the client. We have found these basic steps to work well:

• • Ask the client if they have the time and privacy to speak for a few minutes. If not, schedule a follow-up phone call. Control the time limit of the first phone contact. Some individuals will want to spend too much time discussing the reason for the referral, especially if distressed. The therapist must be sensitive yet mindful of time boundaries.
• • Inquire about how the client heard about you, for this information can reveal what is expected from treatment.
• • Request a brief description about the nature of their problem, stating that you want to make sure they are beginning with the right therapist.
• • Ask if they have seen a physician within the past year for this or any other problems. Request that they bring a list of medications and dosages to the first meeting.
• • Question the relationship status. Are they married or partnered? Explain that sex therapy works best when both partners come to the sessions. Ask if the partner is willing to come. If not, then say you will discuss it in the first session.
• • Discuss your hours, fees, location, and other details.
• • Make an appointment if they are ready. If not, ask if there is any way you can help them.
• • Ask if they have any questions.

The fact that you take 5-10 minutes to talk with them on the phone indicates your interest in working with the client(s). Clients immediately appreciate the attention or service they receive from the initial contact. It is one of the common factors that helps create an alliance with the couple and improves outcome (Weeks & Fife, 2014).

The Initial Session

The initial session is one of relationship building and discovery. In sex therapy cases, most clients are ashamed, embarrassed, uncomfortable, or have some difficulty talking openly. Additionally, they can feel pessimistic due to previously failed attempts to resolve the problem. The therapist can open the session with a statement acknowledging the couple is attempting to improve their sexual life and that getting started is difficult for most clients. The therapist can ask the couple (assuming the couple is the unit of treatment) how they feel about coming to therapy for help with a sexual problem. The therapist can normalize the feelings, if appropriate, and work to help the couple become more comfortable. Explain that in most cases the couple needs to be seen together; however, if there is a need for some individual sessions or work and everyone agrees to the plan, the therapist may see one or usually both individually for a limited number of sessions. If the therapist chooses to later conduct some individual sessions, the rules of how to do so and the rules of confidentiality have been carefully described by Weeks and Fife (2014).

The initial session is also a time to follow up with questions about medical and psychiatric histories, focusing on medications and organic conditions that can affect psychological or physical functioning. Once the couple appears ready to proceed with an assessment of the problem, the therapy can begin. It is advisable to ask permission to proceed with more sensitive assessment questions, explaining that you will need very specific information in order to help them. They can also be told that if a question is too awkward or anxiety-provoking, they should tell the therapist in order to talk about how to proceed. For example, information they think may be hurtful might be reserved for an individual session. We have noted that in cases of lack of desire partners often do not want to state the full extent of their lack of desire for their partner.

The Triage Tree

The treatment of each of the presenting issues described in the next sections involves making complex decisions about the proper selection of techniques in handling specific sexual difficulties; thus, it is essential for the therapist to know the sequence in which the problems are treated. We have found that presence of a single sexual dysfunction is rare. In fact, multiple sexual problems often exist within the individual and the couple. In our practices, it is quite common to see more than one coexisting sexual difficulty (such as preference for different times, sexual positions, how sex is initiated, etc.) and officially designated disorders as well as relational issues, even though the couple may present with an awareness or focus on just one sexual issue. Accordingly, the clinician must make decisions about which problems to treat first and how to work with problems concurrently. We have generally found that the decision-making principles presented in the Treatment algorithm work to ensure effective treatment by providing the logic of when to begin treating a specific dysfunction and how to triage comorbidity within an individual and within the couple system.

Of course, not every couple will present with the same constellation of problems, so the therapist needs to understand the underlying logic of some difficulties being foundational to the solution of other problems more than the specific ordering listed below. In general, we suggest the following treatment algorithm:

• • Treating presenting problems first versus other problems that warrant clinical attention.
• • Treating a comorbid problem first. Comorbidity reflects the effect of all of the client’s illnesses, not just the presenting problem. For example, untreated depression and other psychiatric disorders and relational conflict usually take precedence over the treatment of sexual problems.
• • Treating multiple sexual dysfunctions in the couple in a logical and sequenced way rather than being pressured to work on a specific problem the couple thinks should be solved first. The couple needs to understand the rationale for the sequencing of treating multiple problems.

The triage tree should be seen as a heuristic or “hands on” device rather than a fixed set of rules about which issue(s) to treat first.