Cognitive-Behavioral Therapy for Sexual Dysfunction PDF
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Cognitive-Behavioral Therapy for Sexual Dysfunction Cognitive-Behavioral Therapy for Sexual Dysfunction provides clinicians and graduate students with a comprehensive biopsychosocial model of useful, practical, e mpirically- 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 intercourse as an individual perfect performance test. This title reflects the contributions of Mike Metz to the field of couple sex therapy. Michael E. Metz, PhD, was a psychologist and marital and sex therapist, and re- searcher in private practice in Minneapolis/St. Paul, Minnesota. He published over 60 professional articles and 4 books, including Enduring Desire, which received the AASECT 2011 Best Book Award. He was a leading advocate for the integration of couple therapy, sex therapy, and spirituality. He passed away in 2012. This book, Cognitive-Behavioral Therapy for Sexual Dysfunction, is a tribute to his professional legacy. Norman B. Epstein, PhD, is a professor of family science at the University of Maryland, College Park and director of the department’s nationally accredited Couple and Family Therapy clinical training program. He is an author or editor of 4 prior books, has published 62 journal articles and 58 chapters in edited books on aspects of couple and family relationships and therapy, and has presented over 120 research papers and 90 training workshops on couple and family therapy at national and international professional meetings. Barry McCarthy is a professor of psychology at American University, a diplomate in clinical psychology, a diplomate in sex therapy, and a certified couple therapist. He has published over 105 professional articles, 26 book chapters, and 14 books. He has presented over 400 professional workshops nationally and internationally. In 2016, he received the Masters and Johnson award for lifetime contributions to the sex therapy field. Cognitive-Behavioral Therapy for Sexual Dysfunction Michael E. Metz, Norman B. Epstein, and Barry McCarthy First published 2018 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2018 Taylor & Francis The right of Michael E. Metz, Norman B. Epstein, and Barry McCarthy to be identified as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data A catalog record for this book has been requested ISBN: 978-0-415-87407-6 (hbk) ISBN: 978-0-415-87408-3 (pbk) ISBN: 978-0-203-86345-9 (ebk) Typeset in Bembo by codeMantra Contents Preface vii 1 Understanding Sexual Dysfunction and Sex Therapy 1 2 Engaging Clients and Conducting Assessment, Diagnosis, and Treatment Planning 32 3 Overview of CBCST Strategies 61 4 Details of CBCST Treatment Strategies 89 5 Treatment Strategies for Female Sexual Dysfunction 131 6 Treatment for Male Sexual Dysfunction 170 7 Relapse Prevention: Maintaining Gains and Enhancing Intimate Sexuality 206 References 223 Index 237 Preface Cognitive-Behavioral Therapy for Sexual Dysfunction honors the professional legacy of Michael E. Metz, Ph.D. and provides a guide for the practice of sex therapy in a re- lational context, based on sound empirical evidence and the authors’ extensive clin- ical experience. At its core is the comprehensive couple biopsychosocial approach that Mike emphasized for assessment, treatment and relapse prevention with sex- ual dysfunctions through his extensive clinical practice, writings, and professional training workshops. Initially, Mike and Norman Epstein designed the structure and content of the book, and Mike wrote first drafts of the chapters, with input from Norm, especially regarding the cognitive-behavioral and couple dynamic aspects. After Mike passed away in 2012, the book project stalled, but eventually Barry McCarthy, Mike’s longtime co-author on widely disseminated self-help books on male and couple approaches to treatment of sexual problems, joined the project to provide his rich knowledge and experience with Mike’s biopsychosocial approach. Norm and Barry emphasized building on Mike’s foundational work and also up- dating the material based on current research in the field. Staying true to Mike’s thinking and clinical methods was a challenge at times, as there were many instances when we dearly wished we could sit down with Mike and talk through issues in the writing, to share his company and friendship again as well as his expertise. Mike’s unique perspective on the role and meaning of sexuality in people’s lives integrated cognitive-behavioral factors (individuals’ thinking about themselves and their relationships, their emotional responses regarding sex, and their behavioral patterns and skills) with core human needs for intimacy, playfulness and spirituality, the importance of the couple as intimate and erotic allies, and the crucial ability for couples to manage differences and conflicts constructively. Mike emphasized sexuality as a couple relational process in which partners’ subjective desire and sat- isfaction are influenced by biological, psychological and interpersonal factors. The integrative biopsychosocial model described in this book represents the maturation of the sex therapy field, the history of which we summarize. Although the book emphasizes cognitive-behavioral concepts and clinical methods, the strategies and techniques are relevant for therapists using a variety of theoretical models. We focus on psychological processes and couple dynamics, but bio-medical factors are rec- ognized throughout as crucial for understanding sexual function and dysfunction. Social and relational factors, as well as partners’ cognitions and emotional responses, certainly have been addressed in the sex therapy literature, but they often have been downplayed. From Mike’s perspective those are crucial for understanding human sexual response. Sexuality is not only about physical function, as physical viii Preface responses and subjective satisfaction are influenced strongly by the meanings that partners attach to their sexual and overall relational interactions, as well as the couple’s emotional responses and behavioral patterns. Consequently, the assessment methods described in this book pay a great deal of attention to individuals’ cog- nitions, emotional responses, and behavioral skills (for communication, problem solving and eroticism/sexual pleasuring). We also emphasize systematic assessment of couple interactions, such as demand-withdraw patterns, that may develop in re- sponse to a sexual problem or that may cause and maintain a dysfunction. Likewise, the treatment approaches described in this book emphasize conjoint interventions that target reduction of couple interaction patterns contributing to sexual dysfunc- tion and enhance eroticism and sexual pleasure. Thus, cognitive-behavioral couple sex therapy is a consistent integration of approaches to individual functioning and couple dynamics. It calls for knowledge and skills for both individual and couple therapy, reducing both individually-based and relationally-based barriers to joyful sexual relationships. Mike Metz was a well-respected clinician, researcher, and educator who cared deeply about assisting couples to develop satisfying sexual and overall relationships. He believed that the concepts and methods of cognitive-behavioral couple sex therapy have great potential to empower diverse couples, in terms of sexual orien- tation, race, ethnicity and partner status, to experience healthy and fulfilling intimate sexual relationships. It is a strengths-based approach that encourages and guides couples to collaborate as a team to enhance their relationships. Although couples typically enter therapy focused on problems and emotional distress regarding sex- ual dysfunction, the clinician’s optimistic and straightforward approach helps instill hope and positive motivation. The therapist plays an active educational role but collaborates consistently with the couple to achieve their personal goals for their relationship. Mike’s therapeutic style was empathic and respectful of individual, couple, cultural and value differences. We have attempted to weave those qualities that we share as well throughout this finished version of Mike’s labor of love. This book adds to the major contributions that Mike Metz made as a professional model for the study of human sexuality and the sensitive treatment of sexual dysfunction. Sexual problems offer unique opportunities for psychological, relational and sexual growth, as couples’ initial focus on physical function is broadened and satisfying emotionally intimate sexuality becomes a cornerstone of their personal bond. The dyadic focus of cognitive-behavioral couple sex therapy simultaneously produces benefits for individual mental health and relationship quality. We hope that this book will motivate seasoned clinicians and academicians, as well as new professionals, to integrate sex therapy into the mainstream of the mental health field. Sexual function problems are among the most common and distressing concerns facing the general population, whether they are a primary complaint pre- sented by clients or surface through a clinician’s assessment. This book honors Mike Metz’s legacy by presenting the theoretical approach and clinical methods that he played a central role in developing and championing. Norman B. Epstein and Barry W. McCarthy Chapter 1 Understanding Sexual Dysfunction and Sex Therapy Cognitive-Behavioral Therapy for Sexual Dysfunction (CBCST) provides a detailed de- scription 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 foun- dation in CBCST concepts, assessment, and interventions that facilitate clinician comfort and confidence. We focus primarily on CBCST with married and partnered couples, both op- posite 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 com- ponents 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 sex- ual 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.
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