Cognitive Behavioural Sex Therapy - Marital and Family Therapy and Counselling - Psychology Super-Notes

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By M.S. Ahluwalia
1
Cognitive Behavioural Sex Therapy
Marital and Family
Therapy and Counselling

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Contents
1. Sexual Dysfunctions
2. Cognitive Behaviour Sex Therapy
3. Precautions to be taken in Sex Therapy
4. Case Formulation
Cognitive
Behaviour
Sex
Therapy
Super-Notes
10

Sexual Dysfunctions
11
Sexual
Dysfunctions
Impact of Sexual Dysfunctions
• Sexual functioning is a basic aspect of
human life and any problem in this
area can lead to:
• significant personal distress,
• conflicts in the relationship, and
• emotional problems.
• Sexual functioning also has impact on
one’s self esteem and quality of life
(Chevret et al., 2004; Rosen et al.,
2004).
Multi-factorial and Multi-Disciplinary
• Sexual experience is a synergy of biological,
psychological and social factors.
Therefore, it is important:
• to assess all these areas while taking sexual
history,
• management is multidisciplinary in nature.
• to understand the subjective meaning of
sexuality and partnership within the
intimate relationship.
• to tailor-make the intervention (Rosing et
al., 2009).

Classification of Sexual Dysfunctions
12
Sexual
Dysfunctions
• Sexual dysfunctions are categorized based on the stages of sexual response
cycle. The dysfunctions are thus, related to (Masters and Johnson, 1966):
1
Desire
2
Excitement
3
Plateau
4
Orgasm
5
Resolution
Female Sexual
Disorders
(DSM IV TR)
- Hypoactive
Sexual Desire
Disorder
- Aversion
disorder
Sexual Arousal
Disorder
Female Orgasmic
Disorder
- Vaginismus
- Dyspareunia
Male
Sexual
Dysfunctions
- Hypoactive
Sexual Desire
Disorder
- Sexual
Aversion
Disorder
(16%);
Erectile
Dysfunction
(20%)
Premature
Ejaculation (35%)
- Post-coital
Dysphoria
- Post-coital
Headache (5 -
10%)
(Heiman,
2002)

Psychological Factors that Contribute to Sexual Dysfunctions
13
Sexual
Dysfunctions
1
Predisposing Factors
• restrictive upbringing
• inadequate sexual information
• disturbed family relationships
• traumatic early sexual experiences
which damage the self-concept
• early insecurity in psychosexual
role which may include attitude
towards own body, about sexual
thoughts and urges, maturity etc.
• guilt about earlier sexual
relationships.
2
Precipitating Factors
• Random failure resulting in
anticipatory anxiety
• child birth
• discord in the general relationship
• infidelity
• unreasonable expectations
• dysfunctions in the partner
• reaction to organic factors
• ageing
• depression and anxiety
• traumatic sexual experience
• hesitant sexual experiences.
3
Maintaining Factors
• Performance anxiety and
anticipation of failure resulting in
avoidance and playing spectators’
role in turn can lead to failure.
• Guilt
• loss of attraction between partners
• poor communication between
partners
• discord in relationship
• fear of intimacy
• impaired self-image
• inadequate sexual information
• sexual myths
• restricted foreplay
• psychiatric disorder in any of the
partners
• negative cognitions.

Related Terms
14
Sexual
Dysfunctions
Spectator
Role
Preoccupation with the sexual arousal and need to be good in sexual responsiveness
leading to excessive focusing on each detail of the lovemaking resulting in loss of
arousal.
Performance
Anxiety
Fear of performance is a common sexual problem in which anxiety about engaging
in sexual activity becomes an overriding block to the spontaneous flow of sexual
feelings and thoughts.

Sex Therapy
15
Sexual
Dysfunctions
• Sex therapy generally refers to the techniques
given by Masters and Johnson (1970).
Common Goals of Sex Therapy
• information and education
• attitude change
• taking mutual responsibility
• eliminating performance anxiety
• improving communication and applying
different sexual techniques
• changing life styles and sex roles
• prescribing changes in behaviour
• Modifications are made depending on the
conditions such as:
• availability of the partner
• kind of the dysfunction
• socio-cultural factors
• presence of co-morbid psychiatric and physical
conditions
• On the part of the therapist willingness to
address the issue with frankness and
authenticity and ability to handle one’s own
sexuality is crucial (Manjula et al., 2003; Rosing
et al., 2009).
• ‘Sensate focus’ is a common component - used
for all kinds of sexual problems in addition to the
specific techniques

c
Contents
4. Case Formulation
Cognitive
Behaviour
Sex
Therapy
Super-Notes
16

Cognitive Behaviour Sex Therapy: Negative Cognitions
17
Cognitive
Behaviour
Sex
Therapy
• Cognitive-behavioural model of sexual
dysfunction deals with the complex
interaction of cognition (thoughts),
behaviour, biology, and interpersonal
functioning central to the understanding of
sexual dysfunction.
• Negative thoughts that adversely affect sexual
function often involve worry about
performance, which can:
• distract from erotic cues
• reduce sexual responding and pleasure and
• increase negative emotions such as anxiety, fear,
despair and can lead to avoidance.
Example Negative Thoughts
- “I should be able to reach orgasm during
every sexual encounter”, may be an
unrealistic expectation by women.
- Attitudes like “women should not enjoy
sex, and if she does, it reflects a bad
character”, “man is responsible for giving
pleasure to woman”, “a man should get
erection at will and should maintain as
long as the partner wishes” etc. can also
contribute to sexual dysfunction.

Cognitive Behaviour Sex Therapy: Treatment Components
18
Cognitive
Behaviour
Sex
Therapy
• Cognitive-behavioural sex therapy consists of several treatment components
focusing on changing maladaptive sexual thoughts and behaviours.
• Treatment is conducted in individual or couple format.
• Treatment plans are individually constructed to meet the specific needs of the
patient.
• Specific methods are used to treat different problems.

Cognitive Behaviour Sex Therapy: Interventions
19
Cognitive
Behaviour
Sex
Therapy
• to correct the common myths and misinformation about sex.
1. Psychoeducation
• planning and making time for intimacy, expanding the sexual
repertoire by increasing interest and changing sexual situations.
2. Sexual Communication
Training
• based treatments including series of specific behavioural strategies
are carried out to reduce anxiety, increase pleasure and intimacy.
3. Desensitization
• to challenge negative thoughts, beliefs and misconceptions
associated with sex.
4. Cognitive Restructuring
• such as exercise and sleep hygiene that may contribute to sexual
response.
5. Lifestyle Interventions
• to resolve interpersonal conflict and enhance intimacy
6. Marital therapy
• to address the individual factors contributing to sexual functioning
such as depression, anxiety, personality traits etc.
7. Individual Therapy

Cognitive Behaviour Sex Therapy
20
Cognitive
Behaviour
Sex
Therapy
1
Sensate Focus
2
CBT for
Premature
Ejaculation
3
CBT for
Vaginismus
Next

Sensate Focus
21
Cognitive
Behaviour
Sex
Therapy
>>
Sensate
Focus
• Sensate Focus is a behavioural
programme by Masters and Johnson
(1970) which involves a couple
completing homework assignments in
the form of structured touching.
• The series of specific exercises for couples
encourage each partner to take turns
paying increased attention to their
own senses.
Sensate Focus
A set of specific sexual exercises for couples or for individuals aimed at
increasing personal and interpersonal awareness of sensory experience.
Basic Goals of Sensate Focus
Exercises
- Improve communication between
the couple
- Reduce performance anxiety
- Know each other’s erogenous zones
- Take mutual responsibility

Steps of Sensate Focus
22
Cognitive
Behaviour
Sex
Therapy
>>
Sensate
Focus
1
Non-Genital
Sensate Focus
• Exploring the
pleasure areas of the
partner,
• Communicating likes
and dislikes and
becoming
comfortable with each
other’s body
• Taking responsibility
and pleasure giving.
• During this phase
breast, pelvic area
and genitals are not
to be touched.
2
Genital Sensate
Focus
• Here the pleasuring
exercises include the
breast, pelvic area
and genital area.
3
Vaginal
Containment
• involves insertion
without any
thrusting
movements.
• This enables the male
to become acquainted
with intravaginal
sensations in a non-
demanding
environment.
4
Vaginal
containment
with thrusting
• Until ejaculation

Steps of Sensate Focus
23
Cognitive
Behaviour
Sex
Therapy
>>
Sensate
Focus
• The steps can be done over few days to weeks till the partners are comfortable.
• This basic technique is used in most of the sexual dysfunctions with addition of
specific techniques for the different problems.
• Similarly, the positions are also advised based on the kind of the difficulty.
• Female superior position is suggested in conditions like erectile dysfunction and premature
ejaculation.

Use in Therapy
24
Cognitive
Behaviour
Sex
Therapy
>>
Sensate
Focus
It is useful in:
• enhancing the sensual experiences though focus on pleasurable sensations and
exploration of pleasurable areas.
• defocussing attention from performance;
• improving communication between the couple and
• facilitating mutual responsibility of sexual interaction.

Similar Therapies
25
Cognitive
Behaviour
Sex
Therapy
>>
Sensate
Focus
Helen Kaplan’s (1974) New
sex therapy
• A combination of
behavioural and analytical
strategies addressing the
dysfunction and the
relationship conflicts.
PLISSIT model (Annon, 1976)
• includes tailoring the treatment plan according
to the needs of the patients and the problems.
• One of the most commonly used and effective
models for intervention in sexual problems
• Various levels at which the interventions are
provided can be elaborated as:
• Permission
• Limited Information
• Specific Suggestions
• Intensive Therapy.

26
Cognitive
Behaviour
Sex
Therapy
1
Sensate Focus
2
CBT for
Premature
Ejaculation
3
CBT for
Vaginismus
Next

Premature Ejaculation (PE)
27
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Premature
Ejaculation
Diagnosis
The American Urological Association (2004)
considers that diagnosis of PE should be based
solely upon sexual history and shortened
intravaginal ejaculatory latency time (IELT).
3 key factors necessary for diagnosis of PE
are:
1. Patient reports of reduced control over
ejaculation
2. Patient (and/or partner) reports of reduced
satisfaction with sexual intercourse
3. Patient (and/or partner) distress over the
condition.
Prevalence
- most prevalent male sexual dysfunction
- Estimated to affect 1 in 3 men (20 -30%) in
the age range of 18 -59 years.
However, only 50% report that it bothers
them and only 10% seek help, the reason
being:
- Embarrassment
- Stigma
- Lack of knowledge about treatment
- Lack of reliable treatment options
- Thinking of it as transient problem

PE: Causes
28
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Premature
Ejaculation
Types of PE
- Primary: caused by organic
factors
- Secondary
Causes
1
Organic Causes
• Hypersensitivity of the
penis
• Reduction of ejaculatory
threshold
• Prostatitis
• Urethritis
• Medical conditions like
diabetes and hypertension
2
Psychological Causes
• Performance anxiety
• Stress related disorders
• Depression (14 -58%)
(Kennedy & Rizvi, 2009).
The condition is largely considered as psychological - either a learned behaviour or a response to a
meaningful event/interaction or sexual anxiety.

PE: Other Psychological Factors
29
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Premature
Ejaculation
• Interpersonal conflicts with partner
• sexual guilt
• perfectionism or unrealistic expectations
about sexual performance
• negative cultural conditioning like early
sexual contacts with commercial sex
workers who demand the act to be done
quickly
• situations where there is fear of being
found may cause the individual to become
conditioned to achieve orgasm rapidly
(Palmer & Stuckey, 2008).
• Excessive excitement in earlier
experiences
• sexual abstinence
• new partner
• new settings
• Surroundings
• extremely responsive and assertive
partner
• teenage sex play results in conditioning to
that pattern of sexual functioning (cars,
parking, parks etc.)

PE: Maintaining Factors
30
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Premature
Ejaculation
1
Stress
2
Depression
3
Marital Disharmony
and hostility
towards partner
4
‘Don’t touch’
approach to
genitalia
5
Avoidance of sexual
intercourse
6
Nagging by female
partner
Once PE develops in a stressful situation, there is performance anxiety in the next encounters which
can result in playing spectator’s role and losing confidence, and one can develop secondary
erectile dysfunction.

PE: Related Issues
31
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Premature
Ejaculation
• In an episode of PE, the intimacy shared with a partner suddenly comes to a quick end.
• The partner may be upset with the rapid emotional change, or the outcome of the
sexual encounter.
• One might feel angry, ashamed, guilty and frustrated and turn away from the partner.
It impacts the relationship and the interactions between the couple.
• The female usually feels disregarded, used and not loved.
• Persons with PE usually do not come within a year of the marriage, consultation
commonly happens 5-20 years after the marriage.
• Problem increases after all the children are born and reached some level of
independence (Laumann et al., 2005; Metz et al., 1997).

PE: Treatment
32
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Premature
Ejaculation
• Common components that are found to be effective in treatment of PE are:
• Communication skills,
• Sexual skills,
• Lowering Performance Anxiety and Sexual Anxiety (McCabe, 2001).
• Distraction procedures like thinking about non-sexual material, work, family
budget, counting backwards, biting lips, contracting rectal sphincter, pinching self,
pulling hair, alcohol use, sedatives, anaesthetic ointments, masturbating 1-4 hrs
before coitus reduce sensate input during coital process but are not successful
in learning to tolerate the sensations and delay the ejaculation (Masters &
Johnson, 1970; Porst et al., 2007).

PE: Treatment Techniques
33
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Premature
Ejaculation
There are a number of techniques that are used in combination and isolation to treat PE:
• In 1956, Semans described the basic procedure for the stop-start technique.
• In this method, a man is repeatedly brought to high levels of arousal and
then stimulation is stopped just before ejaculatory phase begins
(ejaculatory inevitability), repeated for 3-4 times before allowing to ejaculate.
1. Stop-Start Technique
• Masters and Johnson (1970) adapted this technique to a start-stop-squeeze
sequence in which the penis is squeezed proximal to the frenulum, by the
man or his partner for 15-20 seconds, immediately upon stopping of
stimulation.
• After applying squeeze for 3-4 times the man is allowed to ejaculate.
2. Squeeze Technique
3. Pulling down on the scrotum
Both these techniques are
usually employed in a
graduated fashion:
- starting with partner
manual stimulation
- vaginal containment
without thrusting, and
- ultimately, active
thrusting intercourse.

PE: Treatment – Adjunctions
34
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Premature
Ejaculation
• Other areas of the individual are also addressed to facilitate sexual functioning such as behaviour,
affect, genital sensation, imagery, cognition, interpersonal relationship, and use of drugs.
• Use of pelvic-floor muscle rehabilitation with exercise training, electro stimulation, and
biofeedback to help patients gain control of ejaculatory latency has also been advocated (Kaplan,
1994; La Pera & Nicastro, 1996).
• Combined use of psychosexual-behavioural therapy and pharmacological agents has been
advocated for the difficult-to-treat cases in some studies.
• Drug therapy followed by behaviour therapy is found to help in maintaining the improvement for longer
periods and also help in improvement in the couple’s sexual relationship and renewal of intimacy
(Steggall et al. 2008).
• With behavioural therapy of about 12-18 sessions the improvements were seen in latency period,
satisfaction, decreased anxiety and difficulty in retarding ejaculation (Chen et al., 2009).

35
Cognitive
Behaviour
Sex
Therapy
1
Sensate Focus
2
CBT for
Premature
Ejaculation
3
CBT for
Vaginismus
Next

Vaginismus and its Types
36
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
Vaginismus is a sexual pain disorder: there is involuntary spasm of
the muscles around the lower one third of the vagina causing pain on
any attempts of penetration.
• The severity of pain can be mild to severe.
• Women with severe vaginismus avoid all kinds of sexual touching or
intimacy and often do not cooperate for gynaecological examination.
Prevalence
12-17% of the women who
report to sex therapy
clinics complain of
vaginismus
(Spector & Carey, 1990)
Types
- Primary vaginismus is diagnosed in women who have never experienced vaginal penetration.
- Secondary vaginismus indicates prior successful vaginal penetration.
- Generalised Type: vaginal tightening occurs in all situations of attempted vaginal penetration.

Vaginismus: Contributing Factors
37
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
The three most common contributing
factors to vaginismus are:
• Fear of painful sex
• Belief that sex is wrong or shameful
(often the case with patients who had a
strict religious upbringing)
• Traumatic early childhood
experiences.
Other causes may be:
• sexual abuse
• frightening childhood medical
procedures
• painful first intercourse
• relationship problems
• sexual inhibition
• fear of pregnancy

CBT for Vaginismus
38
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
Cognitive behaviour therapy in Vaginismus includes various components:
1
Sex Education
2
Self-Exploration of
Sexual Autonomy
3
Desensitization
4
Graduated
Insertion Under
Relaxation
5
Insertion of Penis
with Woman in
Control
6
Transferring
Control of Penis
Insertion to Partner
The success of the therapy ranges from 60-90% for a maximum of 1 year follow-up
(Van Lankveld et al., 2006; Jeng et al., 2006).

1. Sex Education
39
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
• This can be done using the relevant
scientific literature on:
• the anatomy,
• physiology of the vagina,
• the functioning and
• mechanism of sexual activity.
• Depending on the requirement, the clients
can be suggested to read selected literature,
watch relevant material.
Components of Psychoeducation
- nature of the problem
- factors maintaining the problem
- clarification of their misconceptions
- information on the anatomy and
physiology of the sexual functioning.

2. Self-Exploration of Sexual Anatomy
40
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
• This can be done using a hand mirror and exploring the organ by one’s own
fingers.
• This method would help in:
• understanding the anatomy and also
• exploring the pleasure associated with the same.

3. Desensitization
41
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
• When a woman exhibits fear of sexual intimacy and intercourse, she’s exposed to
situations that create a mild sense of psychological discomfort or anxiety.
• Once these situations are conquered, the patient is exposed to sexual situations
that they find more threatening, until coitus is eventually achieved without
difficulty.
Desensitization
A type of behavioural therapy based on the principle of reciprocal inhibition
wherein the individual is trained to approach the feared stimuli gradually in a
state of relaxation.

4. Graduated Insertion Under Relaxation
42
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
• It is aimed at decreasing avoidance behaviour and penetration fear.
1. Relaxation
• First, client is
trained with
relaxation
techniques such as
Jacobson’s
Progressive
Muscular
Relaxation
2. Insert Tip of
Finger/Cotton
Bud
• Once she is able to
relax commence
with the tip of a
cotton bud, or the
tip of the patient’s
little finger
3. Insert Two
or More
Fingers
• Gradually insert
two or more
fingers, internal
sanitary pads,
various lubricated
cylinders, etc.
4. Insert Penis
• Eventually,
gradually insert
the penis.

5. Insertion of Penis with the Woman in Control
43
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
• This is done in female superior position, so that the woman can have control over:
• the insertion and
• the movements culminating with vigorous coital movement.

6. Transferring Control of Insertion of Penis to Partner
44
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
• The final step in the treatment is to allow the partner to insert without anxiety
and avoidance on the part of the woman (Butcher, 1999).

CBT for Vaginismus: Adjunct Techniques
45
Cognitive
Behaviour
Sex
Therapy
>>
CBT
for
Vaginismus
Other techniques that are used along with CBT are:
• Cognitive Therapy: aiming at correction of faulty attitudes and irrational beliefs
• Sensate Focus: to
• increase the pleasure of sexual intercourse
• defocus from the performance.

c
Contents
4. Case Formulation
Cognitive
Behaviour
Sex
Therapy
Super-Notes
46

Precautions to be taken in Sex Therapy
47
Precautions
to
be
taken
in
Sex
Therapy
• Cultural Factors: take the cultural factors into consideration while doing sex therapy such as advising
nudity when it is not acceptable to either of the partners.
• Language: The language therapist uses should be in agreement with that of the client, colloquial language
which may not communicate what one wants to communicate and may also cause discomfort either in
patient or therapist should be avoided.
• Don’t Challenge Gender Issues: Very deeply ingrained gender issues which may result in negative
feelings in the patient need not be challenged.
• Don’t Hurry: Not to hurry the therapy when the previous step in the therapy is not achieved.
• Relationship First: When there are relationship problems between the couple severe enough to account
for sexual problems, the relationship problem needs to be addressed first.
• Ensure Feasibility: Ensure the feasibility of sex therapy in terms of space, time, privacy, work pressure,
interference by other family members etc.
• Take Elaborate Sexual History: Make sure that elaborate sexual history is taken from both the partners
separately covering the predisposing, precipitating and maintaining factors.

c
Contents
4. Case Formulation
Cognitive
Behaviour
Sex
Therapy
Super-Notes
48

Assessment of Sexual Dysfunctions
49
CBST
Case
Formulation
• Assessment in sexual dysfunctions is
done using various methods.
• One important among them is the case
history
• In addition to the history, measures
can be used to assess:
• Depression
• Anxiety
• Sexual knowledge and misconceptions
• Dysfunctions
• Attitude towards sexual practices
• Info. about Attitude and Expectations:
• Attitude towards the problem
• Expectations from the treatment
• Responsibility partners are willing to
take
• Reason for seeking treatment now
• Information about sexual
development and attitudes towards
sexuality is needed to understand:
• each partner’s background
• causes of the problem

Taking Case History
50
CBST
Case
Formulation
• History is often taken from both:
• The couple together
• As well as individually
• Aim of taking a detailed history is to
identify the precise nature and
development of the problem.
Aspects of Nature and Development of Problem
• Nature
• Frequency
• Severity
• Distress
• Duration
• Factors contribute to improving or worsening
• Cognitions
• Method of coping
• Beliefs
• Attempts to treat.

General Guidelines for Taking History
51
CBST
Case
Formulation
• Begin with relatively non embarrassing questions before going into sexually
explicit questions
• Start with open ended questions and then proceed to closed ended questions,
• Do not use colloquial terms - it can be imprecise and uncomfortable and it is better
to use the common vocabulary after discussing with the clients.

Assessment of Sexual Dysfunctions: Areas
52
CBST
Case
Formulation
• Specific questions have to be asked for each kind of the disorder
• Certain general areas have to be assessed in all patients:
1
Details of the
presenting
problems
2
Relationship quality
3
Personal history of
sexual development
and experiences
4
Family environment
5
Early childhood
experiences
6
Body image and self-
esteem
7
Present relationship
with the partner
8
Current practices
and preferences
9
Fantasy

Formulation of the Case
53
CBST
Case
Formulation
• After getting information from all the sources (history, assessments, physical
and medical examinations) the case is formulated for therapy.
• The formulation provides understanding of the difficulties and a rational basis
for the treatment approach.
• The formulation is generally based on three main categories of information:
• Predisposing Factors
• Precipitating factors
• Maintaining factors

Determining Suitability of Sex Therapy
54
CBST
Case
Formulation
• The suitability for sex therapy is determined by:
• the nature of sexual problem - primary /secondary,
• medical /psychological factors.
• If the problem is secondary and psychological in nature, it is amenable for
therapy.
• Treatment progress is better if:
• partners are motivated to get treated and willing to cooperate
• there are no major problems in the general relationship
• there is absence of physical or psychiatric illness.
• During pregnancy usually sex therapy is not recommended.

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