Adult Treatment Planner

Objectives and Interventions

• Provide a detailed sexual history that explores current problems and past experiences that have influenced sexual attitudes, feelings, and behavior.
  • Obtain a detailed sexual history that examines the client's current adult sexual functioning as well as his childhood and adolescent sexual experiences; level and sources of sexual knowledge; typical sexual practices and their frequency; medical history; drug and alcohol use; and lifestyle factors.
  • Assess the client's attitudes and fund of knowledge regarding sex, emotional responses to it, and self-talk that may be contributing to the dysfunction.
  • Explore the client's family-of-origin for factors that may be contributing to the dysfunction (e.g., negative attitudes regarding sexuality, feelings of inhibition, low self-esteem, guilt, fear, repulsion; or assign "Factors Influencing Negative Sexual Attitudes" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• Discuss any feelings of and causes for depression.
  • Assess the role of depression in possibly causing the client's sexual dysfunction and treat if depression appears causal (see Depression chapter in this Planner).
• Participate in treatment of depressive feelings that may be causing sexual difficulties.
  • Refer the client for antidepressant medication prescription to alleviate depression.
• Honestly report substance abuse and cooperate with recommendations by the therapist for addressing it.
  • Explore the client's use or abuse of mood-altering substances and their effect on sexual functioning; refer him for focused substance abuse counseling.
• Honestly and openly discuss the quality of the relationship including conflicts, unfulfilled needs, and anger.
  • Assess the quality of the relationship including couple satisfaction, distress, attraction, communication, and sexual repertoire toward making a decision to focus treatment on sexual problems or more broadly on the relationship (or assign "Positive and Negative Contributions to the Relationship" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• Participate in couples therapy as part of addressing sexual problems.
  • If problem issues go beyond sexual dysfunction, conduct sex therapy in the context of couples therapy (see Intimate Relationship Conflicts chapter in this Planner).
• Cooperate with a physician's complete examination; discuss results with therapist.
  • Refer the client to a physician for a complete exam to rule out any organic or medication-related basis for the sexual dysfunction (e.g., vascular, endocrine, medications).
• Cooperate with physician's recommendation for addressing a medical condition or medication that may be causing sexual problems.
  • Encourage the client to follow physician's recommendations regarding treatment of a diagnosed medical condition or use of medication that may be causing the sexual problem.
• Verbalize an understanding of the role that physical disease or medication has on sexual dysfunction.
  • Discuss the contributory role that a diagnosed medical condition or medication use may be having on the client's sexual functioning.
• Take medication for impotence as ordered and report as to effectiveness and side effects.
  • Refer the client to a physician for an evaluation regarding a prescription of medication to overcome impotence (e.g., Viagra).
• Practice directed masturbation and sensate focus exercises alone and with partner and share feelings associated with activity.
  • Assign the client body exploration and awareness exercises that reduce inhibition and desensitize him to sexual aversion.
  • Direct the client in masturbatory exercises designed to maximize arousal; assign the client graduated steps of sexual pleasuring exercises with partner that reduce his performance anxiety and focus on experiencing bodily arousal sensations (or assign "Journaling the Response to Nondemand, Sexual Pleasuring [Sensate Focus]" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• Undergo desensitization (graduated exposure) to sexual exercises that have gradually increasing anxiety attached to them.
  • Direct and assist the client in construction of a hierarchy of anxiety-producing sexual situations associated with performance anxiety.
  • Select initial in vivo or imaginal exposures that have a high likelihood of being a successful experience for the client and instruct him on attentional strategies (e.g., focus on partner, avoid spectatoring); review with the client and/or couple, moving up the hierarchy until associated anxiety has waned (or assign "Gradually Reducing Your Phobic Fear" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• Implement the squeeze technique during sexual intercourse and report on success in slowing premature ejaculation.
  • Instruct the client and partner in use of the squeeze technique to prevent premature ejaculation; use illustrations if needed (e.g., The Illustrated Manual of Sex Therapy by Kaplan); process the procedure and feelings about it, providing corrective feedback toward successful use.
• Participate in sex therapy with a partner or individually if the partner is not available.
  • Encourage couples sex therapy or treat individually if a partner is not available.
• Demonstrate healthy acceptance and accurate knowledge of sexuality by freely learning and discussing accurate information regarding sexual functioning.
  • Disinhibit and educate the couple by encouraging them to talk freely and respectfully regarding his sexual body parts, sexual thoughts, feelings, attitudes, and behaviors.
  • Reinforce the client for talking freely, knowledgeably, and positively regarding his sexual thoughts, feelings, and behavior.
• State an understanding of how family upbringing, including religious training, negatively influenced sexual thoughts, feelings, and behavior.
  • Explore the role of the client's family of origin in teaching his negative attitudes regarding sexuality; process toward the goal of change.
  • Explore the role of the client's religious training in reinforcing his feelings of guilt and shame surrounding his sexual behavior and thoughts; process toward the goal of change.
  • Assist the client in developing insight into the role of unhealthy sexual attitudes and experiences of childhood in the development of current adult dysfunction; press for a commitment to try to put negative attitudes and experiences in the past while making a behavioral effort to become free from those influences.
• Verbalize a resolution of feelings regarding sexual trauma or abuse experiences.
  • Probe the client's history for experiences of sexual trauma or abuse.
  • Process the client's emotions surrounding an emotional trauma in the sexual arena (see Sexual Abuse chapter in this Planner).
• Verbalize an understanding of the influence of childhood sex role models.
  • Explore sex role models the client has experienced in childhood or adolescence and how they have influenced the client's attitudes and behaviors.
• Verbalize connection between previously failed intimate relationships and current fear.
  • Explore the client's fears surrounding intimate relationships and whether there is evidence of repeated failure in this area.
• Discuss feelings surrounding a secret affair and make a termination decision regarding one of the relationships.
  • Explore for any secret sexual affairs that may account for the client's sexual dysfunction with his partner.
  • Process a decision regarding the termination of one of the relationships that is leading to internal conflict over the dishonesty and disloyalty to a partner.
• Openly acknowledge and discuss, if present, homosexual attraction.
  • Explore for a homosexual interest that accounts for the client's heterosexual disinterest (or assign "Journal of Sexual Thoughts, Fantasies, Conflicts" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• State a willingness to explore new ways to approach sexual relations.
  • Direct conjoint sessions with the client and his partner that focus on conflict resolution, expression of feelings, and sex education.
  • Assign books (e.g., Sexual Awareness by McCarthy and McCarthy; The Gift of Sex by Penner and Penner; The New Male Sexuality by Zilbergeld) that provide the client with accurate sexual information and/or outline sexual exercises that disinhibit and reinforce sexual sensate focus.
• List conditions and factors that positively affect sexual arousal, such as setting, time of day, atmosphere.
  • Assign the couple to list conditions and factors that positively affect their sexual arousal; process the list toward creating an environment conducive to sexual arousal.
• Identify and replace negative cognitive messages that trigger negative emotional reactions during sexual activity.
  • Probe automatic thoughts that trigger the client's negative emotions such as fear, shame, anger, or grief before, during, and after sexual activity.
  • Train the client in healthy alternative thoughts that will mediate pleasure, relaxation, and disinhibition.
• Discuss low self-esteem issues that impede sexual functioning and verbalize positive self-image.
  • Explore the client's fears of inadequacy as a sexual partner that led to sexual avoidance.
• Communicate feelings of threat to partner that are based on perception of partner being too sexually aggressive or too critical.
  • Explore the client's feelings of threat brought on by the perception of his partner as too sexually aggressive.
• Verbalize a positive body image.
  • Assign the client to list assets of his body; confront unrealistic distortions and critical comments.
  • Explore the client's feelings regarding his body image, focusing on causes for negativism.
• Implement new coital positions and settings for sexual activity that enhance pleasure and satisfaction.
  • Assign books (e.g., Sexual Awareness by McCarthy and McCarthy; The Gift of Sex by Penner and Penner; The New Male Sexuality by Zilbergeld) that provide the client with accurate sexual information and/or outline sexual exercises that disinhibit and reinforce sexual sensate focus.
  • Suggest experimentation with coital positions and settings for sexual play that may increase the client's feelings of security, arousal, and satisfaction.
• Engage in more assertive behaviors that allow for sharing sexual needs, feelings, and desires, behaving more sensuously and expressing pleasure.
  • Give the client permission for less inhibited, less constricted sexual behavior by assigning body-pleasuring exercises with partner.
  • Encourage the client to gradually explore the role of being more sexually assertive, sensuously provocative, and freely uninhibited in sexual play with partner.
• Resolve conflicts or develop coping strategies that reduce stress interfering with sexual interest or performance.
  • Probe stress in areas such as work, extended family, and social relationships that distract the client from sexual desire or performance (see Anxiety, Family Conflict, and Vocational Stress chapters in this Planner).
• Verbalize increasing desire for and pleasure with sexual activity.
  • Suggest experimentation with coital positions and settings for sexual play that may increase the client's feelings of security, arousal, and satisfaction.
  • Encourage the client to gradually explore the role of being more sexually assertive, sensuously provocative, and freely uninhibited in sexual play with partner.
  • Reinforce the client's expressions of desire for and pleasure with sexual activity.