Sexual dysfunctions and cognitive-behavioral psychotherapy - ebook

CONTRIBUTORS

This volume is unique because it was written by specialist practitioners who work with mental disorders and sexual dysfunctions in their daily clinical practice. All authors possess expert knowledge in their respective fields, continue their scientific development, and constantly improve their ability by participating in training sessions, workshops, and international conferences. Above all, together, they form an impressive team of specialist psychotherapists, sexologists, physicians, psychologists, and physiotherapists. They are united by one basic principle – a humanistic approach that centers around understanding the person – and thus rational thinking and care for their needs, dignity, and development. In turn, cooperation allows for complex treatment, and the goal of the patient’s health can be achieved more quickly and effectively.CONTRIBUTORS

Marta Rawińska, PhD

University of Economics and Human Sciences in Warsaw

Private practice, Warsaw

http://martarawinska.pl

* * *

Dorota Baran, PhD

SWPS University, Warsaw

Private pratice, Warsaw

Aleksandra Bilejczyk, Msc

Private practice, Warsaw

https://centrumkontakt.pl/

Arkadiusz Bilejczyk, Msc

SWPS University, Warsaw

Private practice, Warsaw

https://centrumkontakt.pl/

Daniel Cysarz, PhD

SWPS University, Warsaw

Private practice, Warsaw

https://seksuolog-psychoterapia.pl/

Wiesław Czernikiewicz, M.D., PhD

SWPS University, Warsaw

Sławomir Jakima, M.D., PhD

Private medical practice, Warsaw

Magdalena Kitłowska, Msc

Private practice, Warsaw

Pracownia Terapeutyczna Pratera, Warsaw

Jędrzej Kosewski, Msc

Private practice, Warsaw

https://strefazmian.com

Łukasz Müldner-Nieckowski, M.D., PhD

Sexology Lab

Department of Psychiatry

Jagiellonian University Medical College

Centrum Terapii "Synteza", Cracow

Patrycja Piasecka-Sulej, Msc

Centrum Terapii Lew-Starowicz, Warsaw

Małgorzata Pogorzelska, Msc

Private practice, Warsaw

https://www.seksuolog-pogorzelska.pl/

Magdalena Smaś-Myszczyszyn, Msc

Private practice, Warsaw

Warszawski Instytut Seksuologii i Psychoterapii

Małgorzata Starzec-Proserpio, PhD, MD, MSc in Health Sciences

Department of Obstetrics

Centrum Medyczne Kształcenia Podyplomowego, Warsaw

Centrum Medyczne "Żelazna"

Centrum Terapii Lew-Starowicz, Warsaw

Maja Świetlicka, M.D., Msc

Private medical practice, Warsaw

Piotr Paweł Świniarski, M.D., PhD, FEBU, FECSM, FEAA

Clinical Department of Urology and Urological Oncology

Nicolaus Copernicus University in Toruń

Ludwik Rydygier Collegium Medicum in Bydgoszcz

MENVITA Andrology and Sexual Health Clinic, Warsaw

Izabela Tomaszewska, PhD

Poradnia Psychologiczna “Nasza Strefa”, Warsaw

Jagoda Zajączkowska, Msc

Pracownia Terapeutyczna Pratera, Warsaw

Helena Zakliczyńska, M.D., PhD

Private medical practice, Gliwice

Poradnia Seksuologiczna i Patologii Współżycia

Samodzielny Wojewódzki Zespół Publicznych Zakładów Psychiatrycznej Opieki Zdrowotnej w WarszawieFOREWORD

Dear Readers!

Sexual dysfunctions are relatively frequent, especially if they are defined as co-occurring with other psychological disorders such as, for example, anxiety, restlessness, or depression. The relationship between sexual dysfunctions and other psychological disorders is presented on a descriptive-epidemiological level. It may be expected that successful treatment of the primary comorbid disorder will be accompanied by improvement, and even remission, of the sexual dysfunction. Thus far, cognitive-behavioral techniques have proven to be the most effective in treating sexual dysfunctions. There is evidence that cognitive-behavioral psychotherapy focused on the primary disorder also attenuates the symptoms of comorbid disorders despite not being directly aimed at their treatment. This phenomenon has been described quite well in the international literature, especially in relation to anxiety disorders.

However, thus far, no works on the topic of sexology and cognitive-behavioral psychotherapy have been published on the Polish market. This volume is intended for psychotherapists, physicians, psychologists, students and graduates of humanities and medical studies, and other specialists working with psychogenic disorders, as well as all individuals wishing to expand their knowledge of human sexuality. This volume is divided into four parts. The first discusses issues related to the principles of cognitive-behavioral psychotherapy, sex therapy, and pharmacotherapy. The second part is a review of therapeutic models of various disorders and their application to treating sexual dysfunctions. Next, issues related to treating sexual dysfunctions and the most frequent treatment methods are discussed. The fourth part is devoted to specific difficulties and issues within the broad sphere of human sexuality. This volume presents scientific knowledge, backed by results of both Polish and international studies. All authors are specialists in their fields, practitioners and scientists who actively practice cognitive-behavioral psychotherapy and therapy of sexual dysfunctions.

We hope that this volume will allow you to develop your clinical competences and broaden your perspective on various mental disorders to include sexuality, which is a vital aspect of life.

Scientific editor, Marta Rawińska PhD1
Principles of Cognitive-Behavioral Psychotherapy
Magdalena 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 . 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 . 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 .

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 .

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 .

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 .

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 . 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 (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 , negative thoughts about the self, the world, and the future together with a significant decrease in activity and stimulation in depression . 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 . 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 .

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 . 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 .

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 ). 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 . 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 . 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 :

• 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 . 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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