Psychotherapy aims to restore a man's potency to the optimal level possible within the limits of his physical well being and life circumstances. The goal is to surmount the psychological and relational barriers that preclude mutual sexual satisfaction. Psychodynamically oriented therapists view the dysfunction as a metaphor in which the man/couple are trying simultaneously to conceal and express conflictual aspects of themselves or their relationship. In symbolic terms the dysfunction contains a compromised solution to one of life's dilemmas.(42) Alternatively, behaviour therapists understand the dysfunction as a maladaptive response to interpersonal or environmental situations, or past experiences.
To date, no treatment interventions based on the recent theoretical formulations of Barlow(39) (about the role of anxiety and cognitive processing in arousal disorders) and of Bancroft(40> (about the coexistence of mental excitation and inhibition of sexual arousal) have been reported. But as these notions are further elaborated, they may be translated into innovative treatment concepts.
Sex therapy today involves integrating medical and psychotherapeutic interventions. The conventional role of the mental health clinician in the treatment of erectile dysfunction had been to treat those with psychogenic erectile problems. Now with the advent of efficacious, reversible, and safe medical therapies the role of the clinician has expanded to include helping men/couples, regardless of the aetiology of the dysfunction, make use of these new interventions. Thus, the clinician provides assistance in overcoming the resistances to utilizing medical treatments that may help patients and partners develop a satisfying sexual relationship. (43> Sometimes attitudinal or psychological resistances need to be worked through prior to beginning a medical intervention. If not overcome, these forces can render the best-intentioned treatment efforts ineffectual. The therapist can also help the couple to cultivate a romantic ambience and engage in conversations that will physically and psychologically prepare them to become lovers again. Frequently the therapist can also assist the couple in accepting the changes that may have occurred in their lives, for example menopause, disability, illness, or other life stresses.
Many men with erectile dysfunction can achieve a significant recovery in sex therapy; those with acquired disorders typically fare better than those with lifelong problems. In an excellent review of the treatment studies for erectile dysfunction, Mohr and Beutler(44) wrote that the 'component parts of these treatments typically include behavioural, cognitive, systemic and interpersonal communications interventions. Averaging across studies, it appears that approximately two-thirds of the men suffering from erectile failure will be satisfied with their improvement at follow-up ranging from six weeks to six years.'
All studies with long-term follow-up note a tendency for men to suffer temporary relapses. Hawton et al.'(29) reported that 75 per cent of couples experienced 'recurrence of, or continuing difficulty with the presenting sexual problem'; but that this caused little or no concern for 34 per cent of these couples. Patients indicated that they now discussed the difficulty with the partner, practised the techniques learned during therapy, accepted that difficulties were likely to recur, and read books about sexuality. These techniques proved to be effective coping strategies. Hawton et al.(45) suggest that a positive treatment outcome is associated with better pretreatment communication, general sexual adjustment (especially when the female partner is interested in and enjoys sex and has no psychiatric history), and with the couple's willingness to complete treatment homework.
Interventions for relapse prevention are seldom reported but should be considered. Routinely requesting patients/couples to return for 'booster sessions' may help to maintain the initial positive gains. Also helping couples understand that a temporary relapse is likely and providing them with coping strategies may enable them to regain their sexual confidence.
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