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Treatment begins with a thorough evaluation, which has two purposes: to determine whether the patients are suitable candidates for sex therapy and to formulate the erotic sexual tasks appropriate to that couple. The evaluation interview includes a medical and psychiatric history of the patients and a thorough sexual history. The initial aim of the therapist is to obtain as clear a picture as possible of the “target” sexual dysfunction or dysfunctions and of the current sexual relationship of the couple. The patients are asked to describe their latest sexual experience together “as a video picture”; only when the therapist understands both the symptom and the context in which it appears will the next area be explored. An attempt is made to formulate both the immediate and the remote causes of the patient’s problem. To this end the experiential description of the sexual interaction, the “video picture,” is supplemented with a description of the history of the dysfunction, including the patient’s childhood experiences. The relationships among parents and siblings are explored, and the sexual functioning of each partner in childhood, adolescence, and premarital adulthood is ascertained. The etiology is completed with a discussion of the couple’s marital history.
During the initial evaluation interview, if profound intrapsychic or interpersonal difficulties are revealed which might preclude successful sexual therapy, the patients are referred to the appropriate individual or to conjoint therapy and are not accepted at that time for sex therapy. They are, however, encouraged to return, should they still need sex therapy after the resolution of their other conflicts. Contraindications to sex therapy lie in the intrapsychic and interpersonal domains. According to Kaplan, “Sex therapy is indicated only if . . . earlier problems are not insuperable nor screens for psychotic processes. With severely disturbed individuals or couples, sex therapy is usually not indicated”. Contraindications include significant medical illness, use of narcotics, or alcoholism, and major active psycho-pathologies (“florid schizoid reactions, blatant paranoia, and significant depression in either partner”). However, if these are remedied, successful treatment is still possible, “providing the therapist is sensitive to and careful not to tamper with the crucial defense against the emergence of open illness”. Interpersonal contraindications are a lack of caring and cooperation necessary to perform the sexual tasks together.
For patients who are marginally suited for sex therapy, the next few sessions are devoted to exploratory exercises intended to clarify their status. The “sensate-focus” exercise (Masters and Johnson) is frequently used as a “probe”; sometimes the couple is merely instructed to shower together, washing and drying each other (Witkin). Usually within three sessions, but sometimes requiring as many as four or five sessions, the prognosis is much clearer, and the patients will either continue in sex therapy or be referred to another treatment modality.
Once therapy proper begins, the average course of treatment lasts between six and sixteen weeks. In almost every case, persistence of the symptom beyond twenty weeks is considered an indication that this particular problem is not amenable to rapid sex therapy and calls for other forms of therapy.
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