In the case of erectile dysfunctions that are based entirely or predominantly on psychological and/or partnership factors, sexual psychotherapy is the treatment method of choice. It represents—in the case of psychogenic erectile dysfunction—one of the few causal therapy options that we have at all in the field of erectile dysfunction. The term sex therapy has come to denote a therapeutic approach and a set of therapeutic techniques based largely on the pioneering work of Masters and Johnson [24], but which have since undergone a number of modifications and additions [2, 12, 13, 27].
With the eclectic formula devised by Masters and Johnson, good success rates were possible for the first time with sexual dysfunctions that until then had been regarded as hardly amenable to psychotherapy. Since neither behavior therapy nor psychoanalysis as mono-procedures are of any noteworthy importance in clinical practice today, in addition to sex therapy, this article will concentrate solely on sex therapy.
By no means every patient with psychogenic erectile dysfunction requires more intensive psychosexual therapy, since less serious causative factors can often be favorably influenced by just a few counseling sessions. On the other hand, experience shows that practically every erectile-disordered man, regardless of the causes of his erectile problems, can benefit from competent sexual counseling. In almost every case, an erectile dysfunction, however caused, reactively leads to considerable intrapsychic and partnership stress, not infrequently even to pathological psychological or physical consequential issues. This interconnection of primary causes and secondary effects, which is so typical for erectile dysfunctions, typically cannot be resolved by somatic treatment alone.
For example, international experience with intracavernosal self-injection therapy shows that the reliable production of erections possible with this method was unable to resolve the secondary issues (but also the underlying conflicts) caused by erectile dysfunction in numerous instances, and treatment was discontinued because the sexual satisfaction and gratification ultimately sought by all patients did not materialize.
There are therefore good reasons to place a high value on sexual counseling in the treatment spectrum of erectile dysfunctions. There is no clear dividing line between sexual counseling and sexual therapy, since in practice the transitions are fluid and depend on the individual circumstances of each patient. It is by no means justified to regard sexual counseling as a more or less value-limited arbitrary form of sexual therapy, as a stopgap for which no special rules and no special competencies are needed. In contrast, Langer has insistently pointed out [17,18] that sexual counseling is a genuine psychotherapeutic activity and has described several prerequisites on the part of the counselor which are still valid today.
In our experience, competent sexual counseling requires a high degree of psychotherapeutic skills, of flexibility and resourcefulness, and of the appropriate sexual medical knowledge. Sexual counseling understood in this way is, as it were, a condensed and very compact form of sexual therapy and, like it, must be learned. Good counseling requires a considerable amount of therapeutic skill, empathy, and communication and persuasion skills in order to establish, in the time available, a trusting relationship that allows the communication of information, the addressing of conflicts and causative factors, and suggested corrective behavioral guidance in a manner that can also be accepted and embraced by the patient or couple. We emphasize these viewpoints here not to discourage interested and committed colleagues from practicing sex counseling, but to correct some distorted views.
Sexual counseling must not be confused with openness to psychosocial aspects of erectile dysfunction and their adequate consideration in (primarily somatically oriented) diagnostics and treatment, the importance of which we have repeatedly emphasized and which, in our opinion, is indispensable in order to find a therapy that does justice to the patient and his or her individual sexual counseling and sexual therapy for erectile dysfunction. Whoever wants to do a more advanced sexual counseling needs this basic attitude, a basic training in psychotherapy/psychosomatics and, if possible, a special sexual medical training (see chapter 3.2).
The practice of sexual counseling essentially consists of a combination of the procedures we described in the chapter on psychological diagnostics—specifically on the design of the initial interview (see under 3.2)—with the principles of sexual therapy, to which we will now turn.
The essential feature of sex therapy is the integration of systematically constructed, therapeutically structured and guided sexual experiences with the psychotherapeutic processing of the intrapsychic and partnership causation dimensions of the sexual disorder. It follows the basic psychotherapeutic principle of change through corrective emotional experiences and uses a proven repertoire of interventions and behavioral guidance for this purpose, in addition to a variable and flexible psychotherapeutic “standard inventory.”
These widely popularized sexual therapeutic homework or exercises serve as a catalyst of corrective emotional experiences and also fulfill a variety of therapeutic functions. For example, they are intended to open up for the patient(s) new access to a pleasurably tender approach to physicality and sexuality, freed from performance pressure, tension, and fear of failure, and are of eminent importance for the diagnostic and therapeutic process because they almost always reveal the decisive dynamics of the sexual disorder and make them accessible for therapeutic processing. Through direct physical experience, the sexual problematic with its inner-emotional and couple-related dimensions often becomes much clearer and more immediately available for therapy than through any anamnesis or verbal intervention, no matter how thorough.
However, it is important not to equate these exercises, which are performed by the patient (couple) at home between therapy sessions, with sex therapy already, as has frequently been advocated in the lay press and in self-help manuals, but sometimes also by sex therapists themselves. The practical use of behavioral guidance for erectile dysfunction is presented in more detail below.
The basic approach of sex therapy is experience-oriented, goal-directed, and time-limited. In accordance with Kaplan's concept [12, 13], after a thorough diagnosis and functional analysis of conditions (see section 3.2), the factors that lead directly to the manifestation of the sexual disorder during the sexual response process are first worked on therapeutically. Almost always, fear of failure, negative expectations, pressure to perform, distracting thoughts, introspection, unfavorable situational conditions and destructive couple interactions are decisively involved. By the way, direct does not mean slight or superficial, but only indicates the fact that these factors have a direct pathogenetic effect, as final links of a chain of causes of different lengths. Only if it is possible to influence the directly acting factors favorably, the sexual problem can be improved. To what extent this is possible depends on the intrapsychic and/or couple dynamic conflicts underlying the sexual disorder, and—often even more so—on the functional significance of the symptom for the patient himself and the partnership.
An old guiding principle of sex therapy states that not every sexual dysfunction is based on such deeper factors, but that there are sexual dysfunctions that are actually caused more “superficially” – when, for example, after a one-time alcohol-, stress- or disease-related decline in erection, self-reinforcement and chronification occurs through the mechanisms listed above.
Clinical experience shows, however, that most men cope with such an experience more or less easily, so that the development of a dysfunction occurs only if certain basic conditions exist which allow the development of a dysfunction.
Although this simple consideration relativizes the assumption of a “superficial” causation of sexual disorders, it remains to be noted that there is indeed a considerable range with regard to the rootedness or the “depth” of the causative factors. It is a great advantage of the sexual therapeutic treatment format to be able to adapt flexibly to this circumstance.
This flexible adaptability to the individual circumstances of the disorder is expressed in another guiding principle of sex therapy, which states that, in principle, the directly effective pathogenetic factors are always addressed. Only when the appropriate interventions and treatment steps are not sufficient or encounter resistance and obstacles that stand in the way of symptom improvement, must more “in-depth” work be done. The extent to which this will become necessary often cannot be estimated at the beginning of a treatment, a circumstance that requires an alert eye and far-reaching psychotherapeutic competencies on the part of the therapist in order to be able to deal with the therapy process, which often develops dynamically – especially in the couple-therapeutic setting.
The basic procedure of sex therapy in its combination of behavioral and revealing, conflict-working elements can be schematically represented in this way: The specification of a behavioral instruction appropriate to the individual problem and its practical implementation is followed by the analysis of the couple's or patient's experience, in which the obstacles and immediate causes of the disorder should be focused. The crucial psychotherapeutic step then consists in helping to modify or reduce these obstacles before the next behavioral instruction can be given. Numerous side paths branch off from this main path, which may require specific interventions.
In practice, sex therapy encompasses some effective factors, including behavior-modifying components, which are applied primarily in the “exercises,” a targeted influence on communication structures, cognitive, educational (“enlightening” and providing information), couple-therapeutic, and psychodynamic elements. However, sex therapy lege artis is anything but a “mix of techniques”, but uses these components in a targeted and considered way within the framework of an overall psychotherapeutic strategy.
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