1Principles of Cognitive-Behavioral PsychotherapyMagdalena Kitłowska
Contemporary therapeutic methods are based on empirical data, observation, and analysis of facts. Reliance on evidence, the measurability of the observed phenomena, and the possibility of their verification are among the fundamental requirements of modern science. As an evidence-based therapeutic method, cognitive-behavioral psychotherapy (CBT) was developed in parallel with the modern standards of treatment in medicine. Like other therapeutic interventions, CBT is subjected to the rigors of effectiveness, repeatability, and measurability. Moreover, it boasts the largest number of documented studies on its effectiveness [19, 30]. This therapeutic approach has developed in response to the need in psychiatry for effective interventions aimed at the patient's mental state, both during hospitalization as well as afterwards. As in the psychiatric model, the aim of CBT is symptom reduction, improvement of functioning, remission of the disorder, and relapse prevention (or stabilization of functioning and compliance with pharmacotherapy, as is the case with psychotic disorders or bipolar disorder). This close relationship between psychiatry and therapy is visible in the psychotherapeutic diagnosis, which is based on the diagnostic criteria of medical classifications (the DSM-5 or the ICD-10).
Currently, CBT is most commonly used with individuals suffering from mental disorders. However, it is also frequently used as a supportive method in many other areas of medicine aside from psychiatry. These include areas where pharmacological treatment may be hampered by patients' habits or attitudes, for example, in diabetes. CBT is also used to improve the quality of life of patients with chronic pain as well as in pulmonology and sexology. In other words, CBT can be implemented whenever there exists an interrelationship between psychological factors and somatic symptoms. In such situations, elements of motivational interviewing are often used alongside CBT [12, 21, 25, 29, 33]. The aim of including cognitive-behavioral interventions is to restore patients' agency in their treatment, optimize pharmacotherapy or rehabilitation (in situations where the patient avoids or overuses medication due to fears of side effects or pain), as well as improve patient well-being. This form of therapy conforms to contemporary standards of medicine - it should yield measurable effects, be time- and cost-effective, and accessible. Aside from a broad spectrum of applications, CBT has been successfully used with various groups - adults as well as children, individuals with below-norm intelligence (in a more behavior-oriented version), couples, and groups. Cognitive-behavioral psychotherapy can also be used in the form of internet protocols aimed at specific problems [11].
The Specifics of Cognitive-Behavioral Psychotherapy
Numerous publications on specific cognitive-behavioral models describe short-term therapies, usually involving 12-24 sessions. It is worth noting that in research protocols, one of the criteria involves strict patient screening (for comorbid disorders). Typically, they include the implementation of detailed therapeutic programs focused on core mechanisms maintaining the disorder. They are conducted by experienced therapists to eliminate confounding factors from the results. The short-term character of these therapies frequently results both from scientific rigor as well as the economic capabilities of research centers.
Another element that impacts the pace of therapy is homework. Patients carry out therapeutic work between sessions through assignments discussed in-session, which significantly improves the pace of therapeutic change. In clinical practice, the duration of therapy may be longer than in the literature due to the chronicity and intensity of the patient's disorders (including cases of comorbid depression or personality disorders), the therapist's experience and knowledge, access to supervision, the patient's motivation to work between sessions, the therapeutic relationship, comorbid somatic disorders, and other random factors [1].
Cognitive-behavioral psychotherapy maintains a focus on the "here and now" - manifestations of the problem are observed and analyzed as they appear. The patient's history serves as the background that sensitized them to the problem. However, within this approach, understanding the roots of the problem does not translate into more effective coping with it. A useful metaphor here is falling into a ditch. It is good to know how this happened to avoid similar accidents in the future. However, this knowledge will not be helpful in and of itself, as getting out of the ditch requires action. This necessitates between-session homework and a focus on current experiences and manifestations of the problem. This is also beneficial in cases where one of the main mechanisms of problem maintenance involves the avoidance of experiencing emotions or physiological states (e.g., in anxiety disorders or sexual dysfunctions), as gradually building up tolerance for these experiences, normalizing them, and shaping more adaptive reactions to emotions are possible only from the perspective of the "here and now."
The therapeutic relationship comprises three main elements:
1. a bond,
2. tasks,
3. goals.
In the CBT approach, the bond is understood as cooperation between two individuals in an atmosphere of mutual respect and trust. The patient is the "expert" in their experience of the problem. They have many answers and share their thoughts and experiences. The therapist recognizes this expertise and leads the patient toward new interpretations and experiences through structured interventions [15].
Building the therapeutic relationship with the patient starts at the stage of the diagnostic interview and case conceptualization. Examining how the patient experiences the therapeutic contact (i.e., their concerns, embarrassment, fear of criticism, and avoidance) and mindful validation of their experiences by the therapist are key in the therapeutic relationship as well as in the overall therapeutic process, especially in the context of sexual dysfunctions. Here, the patient is an active participant in their therapy and has key influence on its progress. Complicated theoretical concepts are presented in an approachable manner, based on examples from the patient's personal experience.
Another aspect of CBT is its measurability. Both in clinical studies and in practice, tests or questionnaires are regularly used to measure the intensity of a given problem. Currently, there exist measurement scales and methods for every psychiatric disorder treated with CBT as well as for their specific symptoms (e.g., sleep problems, pain intensity, anxiety and depression symptoms, etc.). Measurements are taken at the beginning, end, and throughout therapy. Measurability is also manifested through setting goals in cooperation with the patient. Goals are formulated as specific, realistic, and verifiable. For example, a patient suffering from panic disorder with agoraphobia may set a goal of going to the supermarket on a regular basis (e.g. twice a week), regardless of the risk of long lines at the checkout (potential avoidance).
As mentioned above, homework assignments discussed cooperatively between the therapist and patient are an important aspect of this therapeutic approach. The change process takes place not only during the therapeutic sessions but also during the patient's independent activities. Homework assignments often involve observing the problem and taking notes, gathering new information, or working with cognitive content and carrying out behavioral or exposure experiments. During the therapeutic sessions, the patient's reflections and difficulties in carrying out the assignments are discussed and addressed. Homework assignments increase the patient's engagement and agency in the change process. This is especially the case since many problems do not manifest themselves in the therapist's office, whereas CBT is intended to address the problem here and now.
The following stages are distinguished in the CBT therapeutic process:
1. Establishing the therapeutic relationship, the diagnostic interview and initial measurements, observing the problem, defining therapeutic goals, drawing up and signing the therapeutic contract.
2. Creating a case conceptualization and socializing the patient into the cognitive-behavioral model visually depicting the mechanisms maintaining the patient's problem based on diagnostic interview data and the available literature, introducing the patient into the chief methods and concepts of CBT: working with thoughts and behaviors.
3. Cognitive work (implementing specific techniques which modify negative automatic thoughts or cognitive distortions).
4. Behavioral change stage - exposure or behavioral experiments.
5. Relapse prevention stage, repeated measurements - summarizing therapeutic change on the level of thoughts and behaviors, discussing events which can potentially reactivate old patterns of reacting and the ways to maintain the improvements achieved in therapy.
A clear stage structure together with identifying the mechanisms underlying the patient's problems makes it easy to apply individual therapy protocols in group settings. However, group therapy should additionally consider the factor of learning from other group members. This makes group work especially motivating for participants and increases the available spectrum of behavioral experiments [7].
Basic Principles of Cognitive-Behavioral Techniques
Cognitive-behavioral psychotherapy is a broad group of interventions based on the fundamental assumption that emotional and psychological problems are maintained by cognitive and behavioral factors. The therapy process is founded on cooperatively testing hypotheses about the patient's problem.
The most notable assumption differentiating CBT from other psychotherapies is that during therapeutic work, distorted cognitive content (negative automatic thoughts) resulting from maladaptive beliefs is identified. This cognitive content is susceptible to logical control and change to make the patient's reception of reality more adequate. Changing cognitive content and processes is a central mechanism of change contributing to positive outcomes [9]. Thus, the main goal of CBT is not to answer the question of why the problem emerged but rather to determine which mechanisms are responsible for its maintenance. The notion of secondary gain does not apply here, as it does not explain the complexity and variety of the manifestations of the problem. It also does not contribute to planning therapeutic interventions.
Case conceptualization is a process of synthesizing the client's experience together with adequate theory and empirical findings. It directs the process of therapy and allows for the selection of optimal interventions. Numerous forms of case conceptualizations exist, for example, Judith Beck's historical formulation, which comprises information on the patient's sources of predispositions toward a given disorder, functional analysis adapted from behavioral therapy, or the "vicious flower" formulation. These are various types of visual representations of the problem that are shared with the patient to establish a therapeutic strategy [4, 10, 23] (see Table 1.1).
The answers to the questions of conceptualization depend on the patient's presenting problem. They involve memory processes in post-traumatic disorder (PTSD), worry in generalized anxiety disorder [6], negative thoughts about the self, the world, and the future together with a significant decrease in activity and stimulation in depression [3, 14]. There exists a vast literature dedicated to every disorder and problem. However, in every case, the central mechanisms in specific therapeutic protocols involve cognitive processes and interventions aimed at their modification. The most basic and simultaneously the simplest graphical formulation used in CBT is the cross-sectional or four-factor model, also known as the "hot cross bun" model [28]. In reaction to a triggering event, four systems interconnected in a feedback loop are activated:
1. the cognitive system (automatic thoughts, memories, mental imagery),
2. the emotional system,
3. the physiological system,
4. the behavioral system.
The triggering event can be external (a situation) or internal (e.g., a memory, the patient noticing their physiological state, or the patient anticipating a certain event; see Figure 1.1).
According to cognitive-behavioral theory, changes at the cognitive or behavioral level are the quickest way to facilitate changes in the remaining systems. In turn, thanks to theories of learning, these changes can become habitual and lead to long-term alterations in reaction patterns.
Automatic thoughts present the most accessible level of interpretation of everyday activity. They involve comments about the self, the surrounding world, personal past and future, memories, and mental imagery. The contents appearing in the mind are the sum of knowledge and experience gathered from early childhood onward. Past events, observing family members and their behaviors, education, peer relationships, academic achievement, and childhood illnesses influence the current interpretations of reality. In the area of sexual dysfunctions, an important question in working with patients involves their sources of knowledge on sexual health and appropriate sexual behaviors. In practice, these sources are usually unreliable (e.g., information gained from peers or pornography). Thus, psychoeducation on sexuality becomes one of the most basic elements of therapy.
Table 1.1. Case conceptualization of the patient's problems.
Questions guiding therapy:
What predisposes the problem to continue?
What makes the problem continue (on the level of cognitive content and behaviors)?
What changes to the cognitive interpretation of reality and to behavior will bring about the quickest and the most stable change?
How to prevent the problem from reoccurring?
Figure 1.1. The cross-sectional/four-factor model.
In CBT, deeper cognitive levels that drive automatic thoughts include core beliefs (the most fundamental image of the self, the world, interpersonal relationships, and other people) and maladaptive assumptions (rules for life, strategies of coping with difficulties and threats, strategies of fulfilling basic emotional needs). In standard psychotherapy, work on symptoms of Axis I DSM disorders is limited to automatic thoughts only. Work on the two deeper levels becomes necessary for patients with personality disorders, patients who have difficulties establishing a therapeutic relationship based on cooperation or following the therapeutic contract (e.g., doing homework assignments, taking responsibility for change), as well as patients with instances of relapses and reoccurring symptoms [31, 32].
Behavior is another significant level targeted by many interventions. Behaviors are typically aimed at decreasing the perceived threat or discomfort in a given situation as well as preventing the occurrence of the problem in the future. However, if coping is driven by distorted interpretations (i.e., if intense emotions cause automatic thoughts to become inadequate and maladaptive, or distorted in CBT terminology), it becomes very likely that the behavior will instead reinforce the interpretation and serve as a mechanism maintaining the problem. A classic example of this maintenance mechanism involves (behavioral) avoidance of social situations by individuals suffering from social anxiety disorder. Due to negative thoughts about the self and others' critical attitudes, such individuals frequently avoid social situations to avoid exposure to shame or embarrassment. This way, they protect themselves from unpleasant experiences, but simultaneously, they prevent themselves from having a chance to change their self-view in the social context in the long term. Thus, the behavioral reaction maintains distorted automatic thoughts.
Each model addressing a specific mental disorder enumerates the typical maintenance mechanisms. They generally involve behavioral reactions, although sometimes they also list cognitive reactions that serve the same protective function against threat (excessive body scanning, thought control, suppression of memories). Conceptualizing the outcomes of behaviors or reactions in the short- and long-term perspectives, as well as their impact on patients' ability to gain new experiences and modify their interpretations, serves as the basis for behavioral work (see Table 1.2).
Table 1.2. Mechanisms maintaining the problem.
Useful questions:
What does the patient do in a given situation to decrease the perceived threat or to bring relief?
What does the patient do to decrease the risk of the problem occurring in the future?
What does the patient do to avoid consequences/catastrophes resulting from the problem's occurrence?
What are the short-term effects of this reaction?
What are the long-term effects of this reaction?
Cognitive-Behavioral Psychotherapy in Practice
In practice, numerous interventions aimed at restructuring cognitive content exist in CBT. This process begins with recognizing maladaptive automatic thoughts and rating the extent to which the patient believes in them. The next step involves the modification of this content. In this case, therapists can utilize a broad spectrum of techniques, such as the Socratic dialog, work on cognitive distortions, constructing vectors or scales, gathering evidence for and against the thoughts, contrasting, the responsibility pie chart, and many others [27]. The choice of technique depends on the cognitive content itself, the nature of the problem, and the preferences of the therapist and patient (e.g., the Socratic dialog has a much looser structure than work on cognitive distortions). The therapist usually considers the information and facts from the patient's experience which are incongruent with their thoughts and beliefs but which the patient tends to omit. In cases where the patient does not have much varied experience (e.g., due to multiple years of avoidance), the therapist can educate the patient and consider evidence gathering as a homework assignment (e.g., by reading appropriate literature or conducting informal surveys among friends and acquaintances). Aside from working with automatic thoughts, imagery is increasingly frequently recommended as an alternative method of change. Imagery can maintain problems to the same extent as automatic thoughts, but changes in imagery lead to stronger affective changes than in the case of work with thoughts [20].
Imagery is utilized in protocols for PTSD for "rewinding" exercises to generate new experiences (e.g., safety), exposure exercises (especially in cases of cognitive avoidance, where patients avoid focusing on or thinking about the problem), to increase motivation for behavioral experiments, and to practice new behaviors in safe conditions. Imagery is also a basic tool of change when working with patients with personality disorders (i.e., using imagery rescripting in schema therapy [2, 13, 16, 17, 35]). In clinical practice, self-monitoring of thoughts and modifying cognitive content contributes to symptom change even before behavioral change occurs. The aim of this element of therapy is to decrease the patient's belief in negative interpretations and to generate new perspectives. Both of these aims are further reinforced through behavioral change. In CBT, the behavioral aspects are very diverse. However, the aim is always to gain new, more corrective experiences, reinforce adaptive interpretations of reality, and subsequently increase the patient's mental well-being and comfort. The spectrum of behavioral interventions comprises two major groups: exposure exercises and behavioral experiments.
1. Exposure ("exposure and response prevention") is a group of structured interventions based on the concept that when an individual is exposed to an undesirable stimulus without any attempts at avoidance, habituation to that stimulus will eventually occur, and the negative emotional reaction will become muted [26]. These interventions have roots in behavioral therapy, which chiefly focuses on modifying behavior. Exposure exercises are the primary tool in working with simple phobias or obsessive-compulsive disorders, where avoidance of stimuli is the main mechanism of problem maintenance. A specific form of exposure involves exposure to interoceptive stimuli, typically used with health anxiety, panic disorders, or cases of obsessive-compulsive disorder where purely cognitive obsessions occur. This type of exposure also has particular use in sexual dysfunctions, where sexual arousal is interpreted as anxiety-provoking or aversive. Exposure exercises require a particularly strong therapeutic relationship and patient motivation, as well as appropriate socialization to the therapy model and the principles of cognitive work. Exposure exercises are introduced gradually, in cooperation with the patient, who maintains a significant amount of control over this process. The therapist frequently carries out the exposure exercises together with the patient or models adaptive behaviors.
2. Behavioral experiments are much more creative and dynamic than exposure exercises. In each instance, they are individually suited to the therapeutic protocol. The concept of behavioral experiments is founded on Lewin and Kolb's experiential learning cycle [22]. This model involves four significant stages of learning: planning, experiencing (through behavior), observing (facts and events during the experience), and reflecting (relating to previous experiences, interpreting facts, and generalizing). Behavioral experiments have a similar structure. The therapist and patient plan to subject certain cognitive content to a test in real situations (i.e., they establish where, when, and with whom the experiment will take place). The experiment is then carried out, and the therapist and patient observe the results (i.e., facts, not assumptions). They then reflect on these observations and plan another experiment.
3. Bennett-Levy distinguished the following types of behavioral experiments [5]:
- Active experiments that test the patient's cognitive content (negative automatic thoughts or new, adaptive thoughts) in real or simulated situations. These experiments frequently begin in the therapist's office.
- Observational experiments are similar to active experiments, except that the patient is an observer rather than an actor. The aim of this type of experiment is to gather evidence to verify a hypothesis. They are also used when the patient's anxiety associated with participating in an active experiment is too high.
- Modeling involves the patient observing the therapist (or another person, if the patient consents) who models appropriate behavior.
- Surveys may be carried out by both the therapist and the patient. They allow for gathering evidence on other people's perspectives regarding the patient's problem areas. The process of designing the questions and examining the patient's expectations is an important element of survey experiments. An example of a survey question designed by a patient suffering from social anxiety disorder who fears negative evaluation when blushing may be "If you see someone else blushing, what do you think?" Survey questions may serve as a source of alternative interpretations which are often otherwise inaccessible to patients.
- Information gathering from other sources - learning from books, articles, or the internet - is a good self-educational method. However, care should be taken to always verify the patient's sources, as they may not be reliable.
Behavioral experiments are often assigned during the session as homework. In the following session, the patient's observations are discussed and related to their initial expectations, which allows for generating or reinforcing new perspectives or for practicing new reactions. At the same time, by independently carrying out experiments between the sessions, the patient is preparing to conclude the therapeutic process, summarize the change achieved within therapy, and create a plan to cope with relapses and reoccurrences of problems.
Currently, CBT interventions go beyond the classical cognitive-behavioral framework to include elements of other schools of psychotherapy. So-called "third-wave" psychotherapists have shifted their focus from behavior to experiencing via mindfulness and acceptance. This led to the emergence of such psychotherapies as Jeffrey Young's schema therapy, dialectical-behavior therapy, and acceptance and commitment therapy [18, 24, 34, 35]. Nevertheless, they also follow the basic foundations of classical CBT, that is, they rely on a strong therapeutic relationship, measurability, effectiveness, and use of homework assignments.
Numerous CBT protocols recommend the most empirically effective interventions for specific problems. However, in practice, patients often present multiple problems which affect several areas of their lives. Thus, it becomes difficult to separate mental health from sexual or somatic health. Moreover, the broader social or cultural context should also be taken into account (see Figure 1.2).
Figure 1.2. The interdependence of somatic, mental, and sexual health and the social context.
Psychiatric problems frequently co-occur with sexual dysfunctions, which in turn affect somatic health, relationship quality, and professional activity. Understanding the co-occurrence of these problems and implementing appropriate interventions is the main goal of our volume. Thus, the authors will analyze interactions from a cognitive-behavioral point of view and suggest interventions which are typical for CBT, basing both on their clinical experience as well as on empirical data.
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2Sex TherapyMarta Rawińska
From the beginning of the 20th century to the 1960s, sexual dysfunctions were treated as an expression of unresolved internal psychic conflicts. Treatment was based on the psychoanalytical approach and focused on early childhood: unresolved difficulties, a lack of or improper attachment to parents, or broadly understood childhood trauma. Symptoms of sexual dysfunction were not treated directly, and psychotherapy was long-term [38].
Between the 1960s and 70s, William Masters and Virginia Johnson contributed to the development of therapy for sexual dysfunctions, treating them as a specific form of psychological difficulty. They created a focused, directive, behavioral form of therapy [17]. Its aim was to understand sexual behaviors in specific, clearly defined conditions (the researchers held 14-day sessions with couples in specially adapted centers), which was intended to lead to both behavioral change as well as changes in feelings during sexual contact. Frequently, the goal of therapy was to replace anxiety in sexual situations with pleasant sensations. The therapeutic methods they used were relatively directive and involved practical exercises, experiments, and training.
The behavioral approach gave rise to the so-called cognitive revolution in which treating sexual dysfunctions refocused on directly observable and recognizable processes of emotional and physiological sensations. The most significant conclusion, which laid the groundwork for later methods, was that sexual dysfunctions result from patients' belief systems, ways of perceiving and experiencing, and prior sexual experiences. They may also have a habitual character. In turn, David Barlow described anxiety reactions as the result of negative thoughts during sexual contact, which directly contribute to the emergence of sexual dysfunctions [2]. This led to the creation of the cognitive approach to sex therapy and, subsequently, the modern model of cognitive-behavioral psychotherapy for sexual dysfunctions.
In the mid-1970s, Helen Kaplan proposed a model of sex therapy that combined psychodynamic, behavioral, and systems conceptualizations of human sexuality. She also described the necessity of pharmacotherapy in situations where it is indispensable for proper treatment [10]. The most important aspect of this approach is the dynamics of the relationship between the partners - the focus is on their interactions (a system of feedback loops), not on individual aspects of functioning or their belief systems.
The systems approach continued to be developed in the 1980s, and it significantly contributed to the understanding of relations between the members of family systems - couples, children, and parents.
Psychotherapy for sexual dysfunctions pertains to many areas of human functioning, which represents its strength as well as its weakness. Therapeutic methods based exclusively on the behavioral model may focus on only one technical aspect of sexual behaviors, which overlooks the emotional aspect, in particular, the sensations and desires experienced by every individual. On the other hand, an exclusive focus on childhood experiences may be excessive; it frequently overlooks the cognitive aspects of functioning, and it does not bring about therapeutic change as quickly as patients may desire. Finally, focusing strictly on the relational aspects may overlook the biological aspects, such as cardiovascular system diseases or hormonal imbalances, which may be direct causes of sexual dysfunctions. Sandra Leiblum compares sex therapy to a unique means of access to the patient's entire "alchemy," juxtaposing it with a cookbook filled with premade recipes [13].
Thus, sex therapy is not only a form of treatment but also a meeting between the therapist and the patient or the couple. Through their cooperation, they touch upon numerous aspects of life, both in the past and in the present, such as health, motivation, cognition, emotions, relationships (also with the therapist), and various situations. For this reason, taking into account all aspects of functioning and accurately diagnosing the patient's problems is crucial.
A good model of sex therapy should combine the psychodynamic (childhood experiences, unconscious elements), systems (interactions and feedback loops), and cognitive-behavioral (beliefs, sensations, and therapeutic techniques) perspectives. Pharmacotherapy is also an important part of treatment. The aim of sex therapy is to restore or create long-term, satisfying sexual contacts. A factorial model based on biological, psychosocial, partner, and sexual elements serves as a good illustration [19] (see Figure 2.1).
Figure 2.1.The interdependence of somatic, mental, and sexual health within the social context.
Areas of Sex Therapy
Sexological diagnosis is a complex process that may continue throughout therapy. Sexological examination, which typically precedes psychotherapy, contains elements of psychological diagnosis as well as assessments of somatic health and medical diagnosis, including laboratory tests [31]. The etiology of sexual dysfunctions is frequently so diverse that it may be difficult to differentiate between psychogenic and somatic factors. The most important aspects of sex therapy include the following four areas:
1. biological,
2. cognitive-behavioral,
3. emotional,
4. relational.
Biological Areas of Sex Therapy
Biological causes of sexual dysfunctions include prenatal and genetic factors, developmental disorders, lifestyle factors (overloading of the nervous system due to chronic stress or substance use), childhood history of illnesses, surgical procedures, and overall health. In this area, sex therapy focuses on medical treatment of the primary diagnosis (hypertension, diabetes, prostate hyperplasia, hormonal changes, etc.).
Cognitive Areas of Sex Therapy
Cognitive areas of sex therapy involve the assumption that various thoughts emerge in sexual situations, as in every other situation. These thoughts are frequently automatic in nature, meaning that they appear relatively mechanically, without detailed reflection on the situation. This mechanism develops in various situations throughout the lifespan. Recent studies have shown a certain regularity to the appearance of specific automatic thoughts and beliefs in individuals diagnosed with sexual dysfunctions. These thoughts are directly related to negative emotions during sex and they involve self-judgment as a sexual partner [25].
Cognitive work is performed in stages. The first stage involves naming the automatic thoughts or beliefs that significantly impact the patient's emotions before, during, or after a sexual situation. Their validity and usefulness in a given situation are examined, and evidence "for" and "against" a given thought is gathered (other techniques are also used, e.g., the Socratic dialog or the downward arrow technique). The last stage involves modifying the negative thoughts or beliefs to make them more adequate and useful for the patient. The patient is encouraged to practice through homework assignments between sessions. Cognitive work is always accompanied by behavioral techniques. This is because the assumptions of the cognitive-behavioral approach involve a close relationship between the three areas of action, beliefs (which are frequently strongly related to emotions), and cognition (the ABC model).
Behavioral Areas of Sex Therapy
Modern behavioral models take into account the principles of social learning and emphasize cognitive aspects and the individual capacity for self-regulation [29]. The basic assumption of behavioral interventions is that negative emotional reactions result from specific behaviors. To decrease negative affect in a given situation, the behavior must be changed. Behaviors generating positive emotions and rewards must be repeated, while behaviors generating negative affect must be extinguished. For example, if sexual arousal is associated with negative emotions such as guilt, anxiety, or shame, the patient may avoid or inhibit it. However, it must be noted that behavioral techniques are a part of a comprehensive process of psychotherapy. Used exclusively, they will not serve their function and may even lead to frustration and disappointment over a lack of effects.
The technique of designing behavioral experiments together with the patient is less directive. Its main assumption is to define "what am I doing that makes me or my partner feel this negative emotion in a sexual situation?" The partners are asked to imagine alternative scenarios and behaviors and implement them as part of an experiment to replace undesirable behaviors with desirable ones.
Therapeutic interventions are most frequently based on structured tasks that the patient carries out on their own or with their partner between the sessions (never in the presence of the therapist). They may also involve behavioral experiments aimed at identifying, analyzing, and modifying the patient's or the couple's behaviors. The most frequently used structured tasks include the following:
- Sensate focus
This method is recommended in situations where the partner's anxiety is the primary problem. It is frequently used to treat psychogenic sexual arousal disorders, both in women and in men. It is no longer implemented according to William Masters and Virginia Johnson's guidelines (2-3 weeks of laboratory treatment) due to time restrictions. Rather, it is used in homework assignments (e.g., an hour per day for several weeks [17]). It usually comprises four stages:
1. The therapist asks the couple to refrain from sexual activity for a period of time. The partners engage in exercises involving touching one another. They are instructed to focus on gentle and pleasurable sensations. However, they should avoid touching genital or highly erogenous zones (which should be discussed with the patients, as erogenous zones may differ in intensity between individuals). Touching exercises should be conducted in intimate, safe conditions.
2. Expanding the touching exercises by including touching genital areas, taking care to maintain an atmosphere of safety and intimacy.
3. Creating a positive, intimate atmosphere during physical contact allows for direct genital contact at this stage. The therapist encourages patients to focus primarily on positive, pleasurable sensations, avoiding a strict focus on achieving orgasm.
4. This stage combines the first three stages, also allowing for achieving an orgasm. The main goal is to have the partners focus on pleasurable sensations of closeness and various forms of touch for as long as it is mutually pleasurable.
- The squeeze method and the start-stop method
The main goal of these methods is to teach the patient to control the moment of ejaculation, which, in practice, involves an accurate assessment of arousal level. They are recommended especially for men suffering from premature ejaculation. They involve teaching the patient to identify their arousal level - from the initial increase during foreplay, through a stronger or weaker erection, to the so-called point of no return. When arousal is rated by the patient as very high, they should interrupt the sexual activity (this may mean either interrupting genital contact or merely stopping movement and waiting). An example of an arousal control technique is functional training, which is described in greater detail in the chapter on treating premature ejaculation.
- Stimulation and self-stimulation techniques
These methods are recommended for exploring the patient's or partner's so-called body map. They are useful for treating such sexual dysfunctions as hypoactive sexual desire disorder, orgasm disorder, delayed ejaculation, or erectile dysfunction. Stimulation methods are frequently indicated for treating delayed ejaculation. Experimenting with methods of stimulation that are discussed in the session is intended to draw attention away from excessive control and to increase the desire for further stimulation to achieve orgasm.
- Relaxation training
The basis of this technique is the relationship between muscular tension, the autonomic nervous system, and the subjective mental state. Relaxing the muscles leads to vagotonia, lowering anxiety and tension. In turn, this leads to a more positive reception of sexual stimuli. Relaxation exercises focus on breathing and heart rate, individual body parts, the sensations coming from the limbs and experiencing a sensation of relief. The goal of the training is to achieve a state of relaxation, slow down the body's activity, and regenerate the organism, leading to increased duration of the sexual reaction, among other effects. Jacobson's training, Schultz's autogenic training, or training protocols specifically modified by the therapist [15] are used in sexology.
- Systematic desensitization
This method was designed in the 1960s by Joseph Wolpe [40]. Its goal is to reduce anxiety and tension through relaxation and to connect this state with stimuli that are antagonistic toward anxiety. In the first stage, the patient is taught relaxation techniques. These involve directive training led by the therapist, or autogenic training, where the patient records and listens to themselves, bringing about a state of relaxation. In the second stage, a hierarchy of unpleasant and pleasant stimuli is established (e.g., the patient's difficulties in contact with women and difficulties in specific stages of sexual contact). The patient ranks the stimuli from the least to the most threatening. A similar hierarchy is created for pleasant stimuli, from the least to most intensely pleasurable. In the next stage, desensitization proper is implemented. This method is particularly useful for treating sexual dysfunctions related to anxiety reactions, high tension, and stress.
- Masturbation training
This multistage method was designed to treat primary anorgasmia in women [16]. In the first stage, the woman explores her naked body and its reactivity to touch, including in the genital area. The next stage involves Kegel muscle exercises and stimulation of the genital area using hands or sex toys to achieve orgasm. The final stage involves teaching the partner, communicating the knowledge gained in the previous stages, and directing them toward providing appropriate stimulation.
Masturbation training is also used with patients suffering from premature ejaculation. However, it should be noted that it has specific limitations. If implemented incorrectly, it may lead to the development of sexual egocentrism, excessive conditioning to autoerotic stimuli, or reliance on pornography for stimulation.
- Mindfulness training
These methods may be used with various sexual dysfunctions, especially desire and arousal dysfunctions. Mindfulness training allows the patient to become aware of all sensations from the body and the mind, including physical sensations and emotions. Patients frequently deny unwanted emotions and thoughts or seek to combat them. Mindfulness allows for full acceptance of what goes on in the body and the mind by observing it in a conscious, nonjudgmental manner. Thus, it increases self-awareness and the focus on one's own emotional states, leading to greater self-acceptance, together with all the variability and change inherent in human nature. Empirical results indicate that regular mindfulness training (including meditation) not only leads to increased ability to focus attention but also causes permanent changes at the neurological level [35].
Numerous behavioral methods used in sex therapy are described in the literature: the forbidden fruit method, the honeymoon method, the intercrural sex method, squeezing the penis at the base, the exhaustion method, slow sex, pelvic floor muscle exercises, combining digital and vaginal sex (by having the woman place her hand near her vagina to further stimulate the partner during penetration) and lateral movements of the pelvis [15].
Emotional Areas of Sex Therapy
The emotional areas of therapeutic work mainly center around the patient's individual experiences. They are closely related to childhood experiences and family conditions (physical or emotional absence of a parent, the parent's failed marriage, disturbances in psychosexual development). Psychosexual development may also become impaired by, for example, punishments for instances of childhood sexual curiosity, sexual abuse, guilt and fear related to masturbation, rejection and humiliation in first intimate relationships, or lack of success in sexual encounters and the resulting frequent changes of partners or withdrawal from contacts altogether.
Anxiety plays a central role in the etiology of sexual dysfunctions. It can either accompany sexual dysfunctions, be a causal factor, or be an effect thereof. It can have an intrapsychic source (related to complexes, lowered self-esteem, distorted beliefs about sex and sexuality, or traumatic childhood experiences), or it may stem from dyadic factors, for example, the partner's reaction to the patient's behavior.
At each stage of therapeutic work, the emotional complexity of each patient should be accounted for since the importance of emotional factors manifests itself on various levels of functioning: lack of identification or a distorted identification with a sexual role, disgust at human sexuality, unfulfilled childhood needs of safety and acceptance, or generalization of early childhood or adolescence experiences to later interpersonal contacts.
Relational Areas of Sex Therapy
Relational factors may involve only one relationship or a certain person, but they may also manifest themselves in contacts with multiple partners in multiple relationships. They are frequently unconscious but visible in many reactions and situations. They may also emerge in specific phases of a relationship (e.g., the birth of a child, sexual infidelity, etc.). Observing these dyadic factors requires extensive experience and diagnostic skills, since they are frequently influenced by the individual experiences of each partner (beliefs, attitudes, emotional difficulties, etc.). The most frequent relational factors include communication issues, the partner being perceived as less attractive than before, excessive routine in sexual interactions, rejection by the partner, lack of trust and safety in the relationship, treating sex as an area of the relationship where the patient has to "prove themselves," relationship conflicts (e.g., overdominance in specific areas of life), excessive self-control and self-monitoring in sexual situations, infidelity, and generalizing prior experiences to the current relationship (both in the context of childhood experiences as well as experiences of previous relationships, e.g., comparing partners).
In sum, appropriate sex therapy should be suited to the patient's personality, their current situation, and the specific etiology of their sexual dysfunction. It should not be implemented separately from the context of the patient's other mental and behavioral disorders. Behavioral and cognitive concepts seem to best meet the needs of sex therapy since they conceptualize disorders in terms of inappropriate habits shaped by learning processes. Thus, therapy focuses on behaviors, emotions, and replacing dysfunctional habits with more adaptive ones [6].
Effectiveness of Sex Therapy
Evaluating the effectiveness of therapy for sexual dysfunctions is undoubtedly challenging, and it differs from empirically verifying the effects of psychotherapy [18]. In the cognitive-behavioral approach, the effectiveness of the psychotherapy process is determined by a broad range of outcomes, such as an increase in the frequency of sexual contacts, an increase in the duration of the sexual encounter, and so forth. Sex therapy involves a range of factors that are difficult to verify empirically since they involve the patient's subjective experiences - improving the quality of sexual contact, deriving more physical and/or emotional satisfaction from sex, increasing the sense of intimacy with the partner, improving relationship quality, increasing motivation, and so forth. The effectiveness of the change process in the area of sexuality is largely determined by improving the quality, and thus the pleasurability, of sex in the patient's experience.
There is a lack of studies on the effectiveness of sex therapy. William Masters and Virginia Johnson [17] described the treatment they conducted in their center as very effective. However, thus fair, their studies have not been replicated in the same form. There are no equivocal data on the effectiveness of the methods utilized in sex therapy. Studies on this topic are frequently financed by pharmaceutical companies and thus largely focus on testing the effects of a given medication. Many studies have also focused on treating erectile dysfunction or premature ejaculation where a broad array of medications is useful [14]. The few existing studies on sex therapy (often in conjunction with pharmacotherapy) allow to examine methods that are effective in treating specific sexual dysfunctions [4, 22].
Cognitive-behavioral techniques, sensate focus, behavioral experiments, and mindfulness training are the most effective for treating sexual desire and arousal disorders in women. Masturbation training combined with cognitive-behavioral techniques is effective for treating orgasm disorders. In turn, sexual pain disorders are most effectively treated by systematic desensitization, cognitive-behavioral techniques, and relaxation training.
Treatment of erectile dysfunction in men increases in effectiveness when behavioral techniques, that is, sensate focus and masturbation training, are used together with psychodynamic or cognitive-behavioral psychotherapy. For treating premature ejaculation, cognitive-behavioral techniques and the start-stop method appear to be the most effective. On the other hand, there is no equivocal evidence for the effectiveness of treating delayed ejaculation. This may be because this sexual dysfunction is often related to psychological factors (beliefs, experiences, etc.). Additionally, hypoactive sexual desire in men (excluding somatic causes) remains an understudied phenomenon.
It should be noted that all of the above techniques can be used in conjunction with couples psychotherapy and/or pharmacotherapy. For both men and women, the most important factor is the broadly understood relationship between the partners.
Cognitive-Behavioral Psychotherapy in the Treatment of Sexual Dysfunctions
Cognitive-behavioral psychotherapy is considered to be the most effective form of treatment for many disorders with a mental etiology [5, 34, 39]. Treatment of sexual dysfunctions in the cognitive-behavioral approach conforms with the strategies used for other clinical disorders. Individuals who present with sexual difficulties (typically erectile dysfunction or premature ejaculation) are most frequently diagnosed with anxiety disorders. In some cases, individuals seek therapy for sexual dysfunction without connecting the fear of a failed sexual encounter with generalized anxiety or social anxiety [9]. The same mechanism frequently occurs during sexual situations. Another example of the effectiveness of cognitive-behavioral psychotherapy is the treatment of bipolar disorder. An increasing number of studies shows that psychotherapy in conjunction with pharmacotherapy can modify the course of this disorder [20, 28, 37]. Not long ago, it was commonly held that psychotherapy for bipolar disorder is limited to improving social functioning, while pharmacotherapy should be the main form of treatment. This is because bipolar disorder has a strong biological etiology [20]. However, recent studies have shown that structured psychotherapy improves patients' quality of life and that treatment effectiveness is much higher. Although some studies indicate greater effectiveness of CBT for depressive episodes than for manic episodes, strategies for mitigating and preventing affective and behavioral symptoms decrease both the psychosocial and interpersonal consequences of bipolar disorder [12, 21]. The strategies used in cognitive-behavioral therapy are aimed at the following:
1. educating the patient and their family about treatment and the typical issues associated with the disorder,
2. teaching the patient to control the symptoms of depression or mania (mood charts, controlling daily cycles, social skills training),
3. aiding pharmacological treatment (psychoeducation and examining the patient's thoughts and beliefs about medication),
4. teaching the patient effective methods for coping with stress, including a discussion of factors that may inhibit treatment,
5. decreasing the trauma and stigma associated with a bipolar disorder diagnosis [3].
Studies on the effectiveness of cognitive-behavioral strategies indicate that treatment of sexual dysfunctions should chiefly consider personality and emotional factors, beliefs about the self and others, beliefs about sexuality and sex in general, cognitive schema, and automatic thoughts [1, 7, 24-27].
Personality and Emotional Factors
Individual predispositions toward the emergence of sexual dysfunctions are considered to be the most important personality factor. Numerous authors note that higher levels of neuroticism are one such factor [2, 3, 15, 20, 25, 26].
One of the first studies on the role of partners' personality factors in their sexuality and marriage was carried out by Lewis Terman [36]. He distinguished between two groups of marriages - happy and unhappy ones. His results showed that husbands in happy marriages were characterized by emotional stability, higher extraversion, readiness to take initiative, greater responsibility, and greater ego strength, understood as greater self-confidence. Husbands in unhappy marriages exhibited numerous neurotic traits, that is, more frequent states of anxious arousal, mood changes, and tension, as well as more frequent marital conflicts. Wives in happy marriages were characterized by a sense of safety, lower levels of anxiety, politeness and agreeableness, and a strong ego. Wives in unhappy marriages exhibited high emotional tension, susceptibility to irritation, and frequent mood changes. Studies also show that the probability of a successful relationship increases in couples for whom marital fit is highly correlated with sexual fit. Studies on the importance of personality traits for attitudes toward sex show that high extraversion is related to lower anxiety in sexual situations, more frequent desire for sex, and greater willingness for sexual experimentation [8]. High neuroticism in women suggests greater guilt due to their own sexual needs and lower sexual satisfaction. On the other hand, high neuroticism in men is related to higher sexual satisfaction. Sexual satisfaction also increases together with agreeableness. Elements related to emotional stability, low neuroticism, high extraversion, and openness to experience are positively correlated with low fear of sex. High openness to experience is related to a greater need to consume pornography and a greater willingness for sexual experimentation and sensation seeking.
Other factors that may influence sexuality include higher anxiety, disorders in arousal-inhibition mechanisms, and personality disorders.
Negative Beliefs and Dysfunctional Assumptions Related to Sex
Negative beliefs about sex lead to unrealistic expectations or demands placed on the self or the partner. They are often based on "ideal models" presented on the internet, which are also treated as valid and appropriate. Many distorted beliefs involve a sense of personal unattractiveness if certain conditions are not met (e.g., pertaining to bodily appearance, sexual performance, or lack of orgasm). Stronger negative beliefs and beliefs in myths regarding sexuality were reported by patients with sexual dysfunctions [7, 24]. They are related to misguided views on the sexual needs and preferences of the opposite sex, the necessity of the woman achieving orgasm to consider sex satisfying and positive, the belief that men should have erections "on demand," belief in sexual stereotypes, sexual fads, and so forth. Negative beliefs typically take the form of conditionals: "if not ... then," or obligations: "must," "should." Unsurprisingly, if a man with the belief that "if I am not 100% erect in an intimate situation, then I am worthless" does not achieve an erection in a sexual situation, his reaction will be more negative (both on the emotional level, with fear, anxiety, and shame, as well as on the behavioral level, with a lack of erection despite attempts to that effect). In the long term, this may affect his self-esteem and deepen his frustration and difficulties. Negative beliefs in women frequently focus on physical unattractiveness - "If I do not meet certain standards of beauty, then I cannot be desirable" or "He is not aroused by me if he does not get an erection." Dysfunctional beliefs serve as a kind of magnifying glass in psychotherapy and as such facilitate access to the patient's individual experiences and self-beliefs. Simultaneously, they sensitize patients to developing sexual difficulties, while negative experiences further reinforce dysfunctional beliefs.
Cognitive Schema: Negative Beliefs About the Self
The few available studies on sexual schema indicate that both men and women with sexual difficulties (compared to a control group) are more likely to interpret unpredictable events in terms of failure and own incompetence: "I am worthless," "I am weak and hopeless," "I cannot do anything" [26, 27]. Negative schemas become activated in situations that patients interpret as threatening and that are closely related to the type and content of the dysfunctional belief. In patients with numerous negative beliefs about sexuality, the reaction pattern and resulting lower self-esteem are activated in specific situations. The sexual situation itself may be predictive of negative self-belief (typically incompetence beliefs) activation, with dysfunctional beliefs and assumptions maintaining and reinforcing this schema.
Negative Automatic Thoughts
Negative automatic thoughts occurring during sexual activity result from the activation of a specific cognitive schema. They play a significant role in the maintenance of sexual difficulties. Studies indicate that men more frequently experience negative thoughts of a goal-oriented nature - a lack of erection, failure, inadequate sexual performance - as well as thoughts related to a conservative attitude toward sex (stereotypical perception of gender roles). Women's automatic thoughts more often involve a low sense of attractiveness, body shame, sexual abuse, lack of emotional engagement on the partner's side, or a strong desire to control the situation and their own reactions [26]. Patients with sexual difficulties more frequently experience sadness and disappointment. On the other hand, they experience pleasure and sexual satisfaction less often. Thus, it can be inferred that lower mood during sexual activity is closely related to the activation of negative schema pertaining to incompetence, which leads to a specific sexual reaction (or lack thereof). This way, low mood becomes a significant factor in maintaining sexual difficulties.
The available knowledge on cognitive-behavior psychotherapy for sexual dysfunctions allows for proposing a conceptualization of sexual difficulties [2, 23]. Pharmacotherapy can be included in the model below at every stage depending on the specific diagnosis (see Figure 2.2).
Figure 2.2. Conceptualization of the emotional-cognitive development of sexual dysfunctions (source: own work).
Psychotherapy Model for Sexual Dysfunction
Cognitive-behavioral psychotherapy for sexual dysfunctions is largely based on the strategies used to treat other clinical disorders. Appropriate adaptation and modification allow for effective treatment of sexual dysfunctions while simultaneously taking into account patients' other difficulties. The psychotherapy process involves identifying negative schemas in cooperation with patients and then modifying them through appropriately selected techniques. It bears noting that, similar to any appropriately conducted psychotherapy, regardless of the theoretical approach, the therapeutic relationship is key. A therapeutic relationship based on trust, understanding, and mutual sympathy often helps patients resolve their problems more quickly and effectively. In some cases, it constitutes a necessary part of effective treatment. If the patient's primary diagnosis is different and sexual dysfunctions are treated as secondary, then the psychotherapy process is based on models proposed for the specific diagnosis, while the treatment of sexual dysfunctions takes place simultaneously, not exclusively.
The cognitive-behavioral psychotherapy process can be divided into the following stages:
- Establishing contact with the patient (interviewing, beginning the therapeutic relationship).
- Identifying problems (both sexual difficulties and other problems experienced by the patient). This is an important stage in diagnosing primary and secondary problems.
- Creating a case conceptualization (measuring, creating scales, additional diagnostic procedures).
- Setting therapy goals.
- Socializing the patient into the model of their problem; education and psychoeducation.
- Behavioral experiments involving cooperatively designed exercises and homework assignments (couples exercises, between-session training).
- Summarizing the change process (repeated measuring, discussion with the patient).
- Designing a strategy for maintaining the gained benefits and coping with relapses.
- Concluding psychotherapy (directing the patient toward "living without therapy," proposing a monitoring period of, for example, three additional sessions after psychotherapy is concluded).
Figure 2.3 shows a model of the psychotherapy process in sexual dysfunctions.
Figure 2.3. Model of a therapeutic process for sexual dysfunction.
Despite the constant influx of literature on the treatment of sexual dysfunctions, there is a lack of studies that would consider all crucial aspects of diagnosis and treatment. Most data exclusively concern the effectiveness of pharmacotherapy, where the relational aspect is seldom included, and the psychotherapeutic aspect is outright ignored. Psychological and contextual factors deserve inclusion in studies, especially since the few available studies on this topic show excellent effectiveness [11, 25, 26]. Cognitive-behavioral therapy is notable because both men and women suffering from sexual dysfunctions report a lack of erotic thoughts during sexual activity. Their negative automatic thoughts focus on disappointment, failure, and negative consequences of sex, including judgment by the partner, and so forth [9, 25-27, 30]. Studies underscore the importance of the cognitive aspects of functioning, especially the thoughts and emotions accompanying sexual activity. The relationship between automatic thoughts, emotions, and sexual reactions as well as their connections with core cognitive schema and beliefs about sexuality suggest the existence of a cognitive-emotional vulnerability to sexual dysfunctions [9, 27, 33]. These conclusions may have significant clinical implications. Individuals suffering from sexual dysfunctions typically exhibit different cognitive schema during sexual activity than healthy individuals. These differences point to the potential benefits of using cognitive techniques in the treatment of sexual dysfunctions. In conclusion, it bears noting that the cultural aspect has not been studied extensively thus far. It undoubtedly influences study directions as well as treatment options and therapeutic strategies. The cultural aspects of sexual dysfunction treatment have been examined in sociological and anthropological articles [32]. In medical and psychological databases, the significance of the cultural factor in treating sexual dysfunctions has been virtually ignored. Nevertheless, understanding the cultural context could provide further clues to the etiology - and, in turn, treatment methods - in the area of both pharmacological and cognitive-behavioral interventions.
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