Topics covered: Ellen's story, four categories of sexual presenting problems, PROBE (Problem, Response, Onset and Universality, Biology, Etiology) Assessment. Length: 36:14
Ellen Gigliotti, M.A., LMFT, is the owner of Sanctuary Christian Counseling, Shippenspurg, PA. She is in the process of completing both her sex therapy and Gottman certifications. Ellen specializes in couple and sex therapy.
Tip: Before you begin viewing this masterclass, pull up or print Ellen’s assessment.
Sex therapy disclaimer: The couple must be stable enough for sex therapy, and therapists should have couples therapy experience before "doing" sex therapy. The couple dyad must be “emotionally close enough to enter sex therapy.”
Sex Therapy is CBT based--easy to learn and easy to practice.
“Sex is super glue for a marriage”
It's important to assess for and treat trauma before beginning sex therapy, including family of origin or sexual trauma. It’s not always best to start with sex therapy.
Therapy progression: Woman with history of child abuse, including sexual abuse attended individual therapy for years to work on childhood trauma. Then, the husband joined her for couple therapy. Lastly, they participated in sex therapy.
Ellen's process for "stepping down" therapy clients:
"I like to see couples once/week for at least one month, then they decrease to every other week, and then to whatever interval seems appropriate to them."
Get comfortable with the language.
Case example: Ellen had a female client that had been raped by her husband. It took her over a year for her to say the word “vagina.”
Give clinical words to sexual terms and physiology. Practice.
If the client uses general phrases to describe the problem, ask questions and incorporate clinical terms in order to:
Make clear that you are comfortable with terms
Ask for clarity, in order to assess properly
Invite clients to use correct terminology
Four areas where sexual problems can arise
Desire: A person’s desire to be sexual with their mate. Not only to be aggressive, or assertive, but also receptive. The desire to engage in any kind of sex play.
Arousal: The normal, physiological things that designate arousal for men and women. For men, the primary sign of arousal is an erection. For women, it’s lubrication.
Orgasm: Capability of orgasm, desire for orgasm
Pain: When a client is presenting with pain, a medical professional must be consulted. Pain can be physiological, a result of medications, related to physical trauma, emotional pain, etc.
Request a good assessment from a urologist, gynecologist, or other relevant specialists, at the beginning of therapy, in order to incorporate or rule out physiological health..
PROBE Sexual Intake
Oftentimes, if there is an issue in one of the four categories, there will be one in at least one other category.
A note on diagnosing
In your state, are you considered a diagnostician (based on your license)? Ellen does not assess based on DSM V diagnostic categories. If necessary, tweak the PROBE assessment to allow for diagnosing.
General assessment questions
How’s the sexual part of your life?
What’s a typical sexual encounter?
How is this a problem for you?
What kind of problem is it (to each partner)?
Case example: The couple was sexual with each other once per year, but it was not a problem for them.
What’s the response of each partner to the problem?
What happens when the problem happens? What does each partner do/say? What’s the script? What do you think is the message?
How have you tried to solve the problem? What has been helpful/not helpful?
Help foster dialogue about the scripts around the problem.
Look at the response to the problem in all its different forms.
How many times in the last 3 months have you had a sexual encounter (whatever the sexual goal)?
What would be your preferred frequency?
In general, what would you like [in your sexual relationship]?
Is this a problem that has been in your life since you became sexual? If yes, there is probably a physiological problem.
Primary onset: It’s been around for a long time; something deep-seated.
Secondary onset: It's a new problem, and easier to discover
Is the problem present under certain circumstances, or do you always have this problem? For example, with erectile dysfunction: Is it an issue no matter what you’re doing/who you're with (when you’re masturbating, with your partner, etc.), or only under certain circumstances?
General health can be a big determining factor in sexual problems, including conditions such as diabetes, high blood pressure, and cardiac events. They can cause sexual dysfunction or impact physiology related to the sexual response cycle.
During this stage, assess medication use, hormonal function, pornography use, masturbation, gender and sexual identity, pregnancies, miscarriages, still births, abortions, infertility, birth control.
Birth control: If a couple has always relied on the pill, and they’ve recently switched to using condoms (a barrier method), it could have implications for their sexual functioning.
Masturbation: A man who was masturbating 10 times/day. His wife believed he had erectile dysfunction, but the mastrubation could have been affecting is sexual response.
What do you think is the issue? How do you feel about it?
Do you masturbate now?
What kind of fantasies to you have? Any together? Are they/are they not attached to pornography?
Do you engage in oral sex? Do you engage in anal sex? Is that consensual?
Assess for BDSM (Bondage, Dominance, Sadism, Masochism): Is it consensual? Is it a problem for one or both partners?
Etiology (What is the cause?)
In this section, assess for abuse and trauma, including unwanted sexual behaviors and unwanted sexual touch.
Did you ever experience touch that made you uncomfortable?
Were you ever touched in a place that you didn’t think you should be touched.
Were you ever touched in a way that made you feel "creepy?"
Were you ever touched in your bathing suit area by someone who didn’t have the right to do that?
Were you ever exposed to anyone else in a way that made you uncomfortable?
Did you ever see, hear, smell, taste anything that was uncomfortable to you?
Assess for the dynamic of faith (e.g., sexual “purity”).
"Weird" family of origin messages
"Weird" sex messages from their faith
Esther Perel has a podcast episode relevant to this type of issue and its dynamics in a marriage. It's titled, Talk to Me in French (free download)
Family of Origin/Intergenerational dynamics
loyalties and legacies
Sexual development (gender realization, masturbation, first kiss, teenage years, dating, first sexual experience, exploratory play, dating relationships, consent, etc.).
How did your family talk/not talk about sex? Opinions? Personality issues? Moral messages? Sex myths?
What kind of meaning does each partner give to the causes of this?
Last thoughts/General advice from Ellen
Overall, the purpose of sex therapy is: "Let’s talk about what sex means to you."
"People are trusting you with a very private and personal part of their lives. Tread lightly, be honoring and respectful. Just be with them in this. This is painful."