Assessment

ot.rhis chaprer is ro pro!,de a

lT ryf.:
sexual olslunctrons. In lh,s chapler. \
su,Je ro rhe a.sessmenr or rhe
e a.\ume lhat you are lhe orimarv
lredtmenr provider. rrn Chaprer 8 we proride
intormation r.,
* a ronsuhanr. ) r hereiore. in rh15 chaprer."iir"i.rr"ii
::i:]:: * rhe use or inren iewing. self-repon quesrionnaires.
i,c.l,*". s e pror ide
lllTll*,"
cnophysrologrcat procedures: se also discuss ho$
and p,y.
ro.uppt...nr ,our iri-
rhosocial evatuarion wirh dara Irom a medicate.atril;:'R;];;;;;;;i;
assessment.hould allou vou Lo de5cribe rhe problem.
f"r_rf*., *.r'ti"g
hypothesis.of irr eriology rr e., predtpo,ing. precrprtauns. (9,
dnd mainrainino
lacrors). idenriry $erapeuric
soals. pio,,a. r..aUu.l ,";h.
tablish basetine luncrioning rrom whrch to e.atuate
;lt.;;;#;: m
rr,..rri*.y ir*irn.r.
"i
Interviewing

The lmportance of Listening

In our $ork. we find rhat caretul tisrenrng

in rhe conrerr ol cJinical intervie\{
the comerstone o[ the assessment proce.5.
This vie$ N Dot
unique, ot course. ro the domain ol Lhe se\ual
d)\tun(rions. fna..a. -.r,
rine anictec. chap*rs. and book, have been
\rrii,;;;;,;irfJ
re88:. pope. rqTo: suli\an. rq54. .turlar.
i;i;;l:;;i
11q.:I:;t:-
recommend liar )ou study rhe,e worts for
the g.**t
wi
re8o,,.
inrorlnurion una
insighis the) provide abou( i erviewing tn rhi. Lhaprel. t"***, l"*.
t^.
o!r discussion on.rhe i,sues rhar penain specitrca y
about sexual problems.
a ir"*;.".g.ii.ri,
-"_--?^::1,]:'"
especrarry
i.*n",ce. nor aI heatrh p,ore,sionars (no$
when ir€omes to rhe sexual \phere. We
hoq ro jis(en,
reporr lo us lhat fie) had fiied preriously
h_" hr,t *.""r;;ii;;;
ro drscu\\ ,f,.f, *_r"iprJi"..
wirh their physicians or rtrerapists,
bur weie mer urrh embarasrmenr or lack
 Assessment 67
66 Assesmenl and Treatment

Assessnrent should always begir wiih an appropriate inlroduction for lhe

of interesti as a result, lhe clients did not Pursue their concerns' For example, clientG). During this time the assessDrenl struct[re and conlent should be
a 70 vear-old female clientrecenllv lold us that sh€ tried 1o discuss her
vaginal
outlined. We prefer to do lhis while both panners are present. For illuslrative
drvne.' problem qrrh her thy'rcian I nlonunarel! lur our clienr' rhe physi- purposes, let us consi.ler a fictitious couple, Mary and Bob. We might begin
. ian aroiaea runner .li*t,riior
^l
Ihi' proDrem. and onl) later relened ro ir as
and did not by saying:
her "olher problem." She sensed his discomfort with the subjecl,
raise rhe pioblem again. She laler told us, "You know, my doctor was too ''Today in lhis firsi inierview I *!uld like to obtain some back8rornd inlonna_
e'nbarrassed to even say the word 'sex,' so he made me feel weird
for aski'g
tion. Then I would like lo get dn trnderstanding otwhal issues broughr you here loday.
I'd like ro spend thrce meelings Batherins inlordarion My p,evious experience
Sinrilarly, a 60-year'old gentleman, who had been widowed in the past sugsests lhat it is most helplul if I inlenie$ each ol you, separately, ior one sesion
vear. mentioned to his physician ihat he was wo ied about bis sexual each. So, to begin loday by interviewinS you, ltlary. While I do tbis, I d like lo
I'd lile
iunciioning; ttris concem was especiallv relevanl now that he had slartod ask Bob locomplete sooe quesliornaires lhal ny secrelary has loryou. JNole:The use
to the
dating again. The physician's response was io shift the conversation of sell repot measures is discu$ed lalcr in lhis chapter.l Next weel vhen we meet,
man'i tiooa pressure ana to avoid the sexual issue' The clieni told us that he l'd like to inrer!iew Bob alone, and ask Mary lo conrplete the questiondaires. Then, ai
dropped lhe subjecr and thought that he m sl have been inappropriate
for
" ourrbid session, t'd like ro sce bolh olyou togethcr Attheendolrhedindscssion,l
asking: 'l felr dumb and embarrassed for bringing up th€ subject will bc able to provide you with my clinical impressioD and outline a thcEpy program
Such repofis from clienls are unfbduna{ely all too common, even
in this
for you, il rhis is i,tdicatcd."
supposedly ;nlighiened era. It has been our exPerience that many health
*.i-"""ar er; 'rrll un$illing. lndor roo uncomlondblc ro dddre" a As fie therapist, you should also menlion your credenlials and lel the
",** ' *^*r c.rcern'. f.r 'hose 'r !otr rphy'i(ian' coun'elot' JnJ couple know tbat you are comfonable dealing wirh sexual problems. You
it.r,p'.,,,*ro.,,. dble ro Jddre" ronLcrn\' wc nroriJe Ine lollowin8
'Jrh should conley to the couple thal overcoming sexual difficullies requires ihe
suidelines. cooperative efiorts of bolh patners. This is necessary ro address because such
a couple oiten believes that (l) one person is to blame for lhe problems, and
(2) it is ihe role of Ihe therapisl to idenlity and cure" the "guiltyhick" one.
Step'by Step Details ol lnterviewinB Afrer you have said lhis, however, it is impo(anl to inieNiew each person
separately following the inlroduction, to galher accurate information that is
ComDrehen5ive Jn,] accLrdre d*es'menr r,.nrcidl r" lormuldring " helplul
unencumbered by a panner's presence. Time can be wasted it' the paaners are
redrnent prog'am. Ho$e!er. "brdinrng mealinglrl inrormarion rr a skrll rhar always seen logether. Many individusls have hidden srories (e.9 , affairs,
can be
invofves far irore than just asking the right questions' Assessment homosexual interests) that would never be revealed in the presence of their
e\.eJiall\ challenr.inc, becau'e mo'r people are uncomio'rable drsctrssing partners; ye1 this information is vital for developing a case formulation and
,r,i''."r,r s.t,.i.". Our '0 and o0 )ear old clierr' menriuned rbove $ere planning ihe $erapy program.
both flervous about discLrssing their sexual concems; they needed relaxed' After lhe inlrodnclory remarks, lhe partoers should be invited io ask any
individuals
encouraging responses lrom rheir phvsicians' Futlhermore, manv questions they mighl have. The remainder of the iirst session is (hen spent
*^ *r. ns U.ti.''.huul $har 'e\udl conducl I' ar'cplJl'lc or una'cepl
''r, ( interviewing one ofthe partners alone. 'the nex( session is sed to intervie\'i
able. and rh.l nrar be ofrende,l ,l a'herdpFl \re$'do nol agtee
wirh their
the olher partner alone.
The lhird session can be used io assess lhe inreraction of the couple.
We begin by proposing that an interview will best serve lh€ needs ofthe During ihis session, you can observe lhe partners communicate and interact
ctienr rc.iobrarn rmnonanl rnlolndlion in a \en\ili\e and etlicienl manner' wilh each other. Problems and strcngths in communication readily emerge at
'lo$drd lhr' end, $E belicre rIbr Ihe c uLiai componenrs ol an eltrcrive
this time for example, you can assess how caring, hostile, honest, and so
ctinicat lnter.,lew include (l) making assumptions (hvpotheses) before
the
(3) process through- on, ihe couple appeaN lo be. I{ is also imponant io deternrine how much trust
interview;(2) setting goals for the interview: attending to
each partner has in the other: we try b do this by comparing lhe amount of
nur ana lll fotlowing a specific structure and conrent du'ing the
'.lnieivl.wr self disclosure that occurs during the couple session with lhal in lhe earlier

TIIIIIITTI ITIIIIIIII
 68 Assessmeot and Trealm€nl
69

individual sessions. This rhird session is also designared to presenr an initial clienrcoupt. Cerminly, it eirher pr(ner is .letressed and/or overly anxious,
.case fornrrlation and provide an outliDe of the therapy plan. or ifthere is a grear denl of inger or even hatred berween a couple,
then ir i;
more appropriate r!) address oonsexnat issUes lirst. Io some ;ases.
sexuat
Jitficullic, nr \ t.e rsrg.r. cd in trB ot nrtrer FUnhern,^re,
Trohtcrn.
5l5.lO\ I eff€ctive assessnrent nnd thorrly requirc a co rboraiivc att;trrde atu)ng
Uoth
tr ner- and rLe rherJfi.r $r,il, i. .,,rrrlron,i.ed.rr rIe pre,ence
Assumptians. Assumplioos are the hyporh€ses rhat a clinician makes in hosrilirr. Si "isr.h
rl,.,r r.,r, ,\ Jer, .t\.,,.r rinnal.omrr.unit,,ri,,n berueen
'rldr,y.
order to gather the most accurate informalion without wasri'rg time and eflort. a couple, which nnrsl be addressed before scxuat issues can be
effeclivetv
AssDmptions rellect the preferred direcrion of error. Thus, for example, il is
better at the beginning to assrne a low level of verbal understanding on the
pa oi a client and thus !o direct language to the client ir a clear and concrete Prr.r'rr "Process" is rbe ternr rhrr describes lhe inleraction berween a
manner. Obviously, as a clinician learns more about a client, these assump- client and a lherapisli rhis rnterd.liur can eilher facititate or irhibir
rhe
tions are adjusted. assessmeni. When we use rhe term ,.process," we also ear
to inclu{te lhe
Olber examples ol nselul assumptions includ€ the followins: plrysicil scttiog lis ir privare? protessiooat?), the lherapisl,s appearance (in-
telligenr,.ompetent, lrusrwonhy)), anrt lhe lhcrapist,s persorr:, i p*se,,rarion
. ClieDrs will be embarrassed and have diificully discussing sexual (calm, liiendly, accefrins't), rs welt as rh. n)ore connxm
meanings oi rhe
te.m'proccss." lr is cteln' lhar m!ny clinicians feel un.onrtorlabte i; deatino
. uirh .e\Ual t{^bl. r.. P. n,,n..t ectr,6. . r .t,.. k
Clients will no1 understand medically conect temrinology -nJ er,,hJrr",,,,renr *rii
. Clients will be misinformed about sexual fuoctioning. ollen sl,4N rlu.n,tl, ,, (n,tlj tn ,F tn.rjJ Jn,t .r !el,r I
) d. \l.rr:.n"g(rnenr
. Clients will be in crisis and may be sricidal. Il,e5e negali\c teelir't..,,.rt.t t-i dr,,.r\e:.rrt .re"r. r torr,er ..,-erre.ri.e ^r
lr)4
. Clients have noi been open with each other and do nol freely discnss the.apy. li a rherafisl's tcelings cannot be nuraged atproprialely,
lhen he or 5(
sexual matters. rl,e \l,ouhl n^r ,,r,,cd,.,ts..,rt .crrra. p,nr,t<ir.. i,r.rir. re",tirl ,1,.,<rn
cmoarra(rn,ent .,r rr1ir,frr.n.F .,. {.,n0 ,.r.t ?n}eJr-rt,r .lrrnr.
n.Fn.
tioned ea ier (li(I.
Go.rlr. Goals are the desired oulcomes eslablislred before each session lo
Additional exan+les ol process fachrs lhat can saborare assessmenr
give th€ assessment procedure a focus. At times, the goals have to be adjusted (dnLl !rh,eq,ren. rt,. r,,t .
as information is leamed, to accommodale the needs of the cliEnt. Uowever,
$et.. jn ,.r.t. . rrrrrence, hrrueen rtri rtrcrrpis a d
clienls in lenns oi gc, gender, an(i/o elhnicityi and erotic arrrac;ions
adhering closely to the goals will help make rhc therapy more eflicieol by or
inteQersonal repulsiur, l)crween rherrpisr and ct;nr, or crient arrrr
helping to ninimize sidetucking. rrrerapisi.
Examples of the goals you rnight sei for the firsl sessioo incbde lhe ,,Sn1rcrur.,
followingl
Stru(hn.tlCo te t !n(t ,,conrenf, reier to rhe oftle.iD8 of
qtresiions to bc r!ked, rn(t rhc rrcrs ro bc covcrcd,
respecrivcty. ln g"ne,;t, ir
. Esiablishing rapporr.
is to the clicnt's beDetir lar l rhcmlie l0 gel lo the hexn ot. lt; clienl,s
concerDs. Ihus, speniting sevcrrl sc$sions ,breakins lhe ice,,or..esrrbtlshinp
. Obrainnlg a general description ol sexual problenrs. a relationship" is not warrrnted in nr)sr cases r ltowever,
. Obtaining a rhorough psychosocial history.
u is usctLrt ro ger
generdlrrrL ,,t r1,....., ,,t . Lr.l,{\ e.t.....rjt\ .r, r( r.t.rr(\ r.. tr.,.r
i
. her ,;,rut
Obtaining a descriplion ol oth€r life corce0s, curent slressors, aDd adtusrmenr
dre like, to deleonine whether sEx th€rapy is appropriale for lhe We donotailvisc to owiog un in!arianl order oiqllesrions
client/couple at ihis lime. -Instead, tora clienrs
lhe srtrrcnn.e in.i conl.nr ot lhe inlerview sho kirefldcr lhe needs ol
the client. l'here are ticquenlty crisir issues thal musl l)c
a(en(led lo betbre
Witb regard to lhe last mentioned goal, tlrere are oo specific guidelines r\Lr:J mrlrr) .,'n I . d.t.tr..\at | ,r ir rjJ\ ... L r.,
.",r..,nr -rt,,{ ., ctr, nr In
for Daking this deteminarion. Thus, a therapis( should deterrine, on a drgre,. l,e\orhl rl.i , .r.., ,ln.r. J. L,, .i.r.
I rt,. trEr..,r.i. , ..nl . rn ,
case by-case basis, wherher or not working on a sexual problem will benefit a ulllnalr'y t^ d l,eI(r ,..,.trr.r1,r.r,nE ..t .,n. .,r.r L,. r,,.. .1.. nr . tr.,r,tcr,

}-IIITII
 7(l A$e$nreDl and Ireal'renl Asessnretrt 71

With rhis rccosniliol ol lhe need lo indi!khralize lhe inteNiew structure scribed medicatioBl ls clienl cunenlly being trerted lor anv rtredical
and content 1o erch clienl. \!e cair rc!erthel.ss suSgest atr or.ler that nright be problems? For wonren: lrrquire about nreDslrual dilliculties and, il
a useful beginning or 'llcl.nll slruclure lor your Lrsc.'z al,trulri te. a.k r\.ur rle flreri.tiu.p.
l. wirh non{hrc!(cnin-p dcnxr-ura])hics (r.9.. rgc. nrarital status,
Sla11 5. Be sensitive (o polential covert issres. Ask whelhcr there.re any
who lircs in houtchold. ctlncrt crirpk,]nrcllt, cdLlc{tiurnl backgrourd ad- issues thal the client.loes oot wrnl discussed in lront ol his or her partrer.
dress, lelefhone nunrirer,.lc ) What signilicani conllicl exisls (inrpressions of oDe s parher or hidden
2. Conlirue wirh lhe open cn(le(l qucsti(nl "Wh.tt brings you here to experiences)? We bdiew st'-onlll ilt creati g on ntle'l'ier ?ntiktnne t it
(l yl" Norice how lrcclJ nnd co.rlorlabl\ thc clie,'l discusses sexual uratters thitll eoch parhtet L?l be asstrcd of @tlfile tidlit\'. wi(hout scParale
ir geneirl, xrd his or hcr t,arriculd difliculty. Llsc Irot,es fird dneclive .onfi.lential inlerriess, crrcial infolllration may reur.\in hid.len. For exanrple,
co.rn.rls lo kccl) rLe clie|l's rc|o11 on llngcl (hcc you reach a general consider tlre case ol N4,. and Mrs. L:
inrprcssion conccming ihe scol)e ol llic sexuxl problcnr. lher) orove oI to the
dc!.iled chronolosical history. Mr rld lvl,s. L. xged 45 rnd 42. rcspcclilcl). hrd L,ccn nranied l0 tcnrsi thev
3. Olnain a ])syclx)sexuxl dn(l fs\chon)cial history. had one son, aSed 8 Uolh hrd so.re coltegc cdu.dlion xnd we.e successlullv em
ahildltoo.l. Ask rbout llre larnilt nruc(ure and experiences wheo tloted in nrnkllc-lclel niAnasenrenl posiriots. When they wcrc Ioselle. al rhe onset of
^. client was a chil(l Also ask rh(trrr so.i^l sr rus. abrse or neglect,r firsl rhe tirsi inlcrview, bolh a8reed th.l rhe prcbleh was Mi L'sl$sotinletcn sexand
sexurl experience (upselrirg/|lcNs l l). l).renls rela(ionshjp, alcohol his dellyed ciaculation. lhis hai rcportedly tJegu! abour I year.8o and had gotren
rrd subsrxnce use. nressages abour scx- .rid ny other inlorn)aiion qorse, especially over (he past few nronrhs. Bolh felr that this,niShl be related !o (lre
lhat enrerges as polcntially rcle!rnl Mr. L s job and to lris diabeles (which
stress itr occasion.lly out ot conlrol) MF.
"as
b. ,4do/€r..x... Inquirc rbo l relaliqrshit)s wiih peeri. selfesteem afld L repol1ed (har 6t one tine his diabeles was so nNI oul olconkollhal hc fainled: he
body inrage. dalirE, seit.l exl]eriences (l)oth honrosexual and het could nol bc awakened ald bad lo bc r.ken to lhe hosPirfll Alter a discussio of ihe
erosexurl), nrenar.hc in leDrales, success {rilure in school. sub- .sses$ncqt structure .nd l|e,apy Pro.ess, Nl6. L lelt lhe co sulting unn .rd rctired
siance nse. rnd rn) olhcr illlinrnrlron lhrt enrergcs as pote tially to thc *ai(ing Nom.
Al lhh point. Mt. L said lhat hc was Elieled 0rat lhe (he,apist was lreeting *ilh
c. Ask about signi{ican( relar(nrships anlleverts alier age 20i try him alone, becausc he hdd to telate sorncthing lhat his wile *as unawarc oi Hehad
1o address sell esr.cnr, r[riage/relarioDshif his(ny, sexual experi-
^.ix1l. been laking i rdvenous heroin tor abou( a yer. ind Nrs wcll drvrrc lhat heroir caused
ences, aDd so lor(h. lnquirc about arry urusual $cxtlnl cxlerienccs, as delared ejaculation lhe 'rainlinS" cpisodc rhnr his wile described was acrualll duc kl
well as psychirtric his(or! or trcalnlcnt. an ovcrdose ol heroin. He felr rhar he las nol addicrcd ro hetoirt. rnd he lrad stopped
.1. Cut'e t se.\ndl li tfirrrrt Acquirc dehils regarding sexual and taking ir 3 {eeks prior to beginninB theraPy, bur he,ecognized that he *as still
o|sej{url ext)erierces in the cu11ent rchli(,nshit), re.enl changes in vulnerable. Mr. L would never have r.lealed hk heroir Problenr il he had not nrel with
sexual lirncti{nritrg andlor salislactiolr. llexibiliry ill sexLral altitudes the therapisl alole lle sas not prepa,ed lo discuss it lvilh his $ileihe w.s convinccd
and l)ehaliors. exlra rrri(xl allnirs. slrcDglhs nnd wcaknesscs ol pan- th.t she would leave hirn ii shc c!e. [QU.d out.
ner, likes anlldisllkes reg^r!ling the tttll cr's sej(ual bebavior, and so
lhis case is a good elanrple ol lhe Deed lor inilial separa(e and con-
4. obtain a briel me.licul hist(ny. fidential irterviews.lhe partnels are iold that il is rnore helflul and eflicient
a. Ask about signilicxrr childhood/reerirg. diseases, surgery, nredical 1() complete the assessDent this way, even lhough lhe olerail lherapeutic
care, conBclilxi disordcrs. and the 1ike. Ask nren and wonren about €mphasis will be on llre couple's inleractioD and conrmuDicalion. Ftr(heF
how thet experietrced secondfly sex chrnges (particuhrl)r r)renarche. more, the pa(ners are told at thal lime il may be helPlul to deal wiLh either
in lhc crse ol $on!en). person ahne in order to work through specific issucs. lvlaking these state-
b. thy pa icular allenlion kr the nredical hislory .rller rge 20; ask about rnents al the outsel establishes conditions lhal will allow for wo.king through
any sigllilicanl disenses. surgery, nredical cnre, atrd so forlh. Ile sure problems that preseni la(er during therapy.
(o dsk aborrl the lollo{ing llrs clieol receil,ed rcgrllr medical care? 6. l'rovide each clienl with a second ofl]orliurity to reveal anylhirrg he or
(ll not, reler Ii)r rnedic.l worknp.) Is clienl currenlly lakirg pre'

ItTTIIIIIIII
she (hir)ks rnay bc relcvrnl. ln ihis resard, LoPiccolo and lleinran (1978)

IITITIIII
 72 Assessmenl and Treaimenl Assessment 71

recommend ending the interview by asking, "ls there anything else that you The third assessmenl session should follow this oulline:
would like 1o tell me about your background that you feel bears on your sexual
life?" Arsxn?,iorr. As before, it is useful to begin with some assumplions For
example, you may find it helpful to assume the following:

SESSION 2
'Couple ha' nol drrcusseJ p-evrou\ inrcruFu\
. Couple has trouble discussing sexual mallers and is embarassed'
The second interview is with the other pallner. We ask this patner whether . There may still be a crisis.
anything has cbanged since the first interview and whether his or her partner . Conect terminology is slill not well understood.
has discussed the first interview wilh him or her. The answers to these queries . Sexual attitudes are well developed, rigid, and conservative.
will yield iniormation atout a couple s ioteraction patlern, openness in com- . Avoidance of sex will occur because of fear and discomfon.
munication, and ability to schedule lime for impotunt issues. Il is also
important to ask this panner rvhether there are any issres or que(ions thal he
Godlr. Similarly, you should eslablish goals for this session; possible
or she would like addressed before the inlerview Lregins. This open-ended goals include the following:
approach allows the discussion ot pro.ess issues Guch as a client's doubt
about a iherapisfs qualifications). as well as importaDt persoDal issues that . Revjew your owD observations and discuss inconsistencies with cou-
may have an impact on the therapy (such as a client s affair or a death iD the ple's assumptions and obseNations.
family). . Outline and begin iherapy plan
Once tlre open ended issues are dealt with, then the interview may move . Obtain couple's commitmeni to follow the drerapy plan bv discussing
on 10 the inteFiew proper. The iotervlew follows the structure and content potenlial compliance problems ahead or rime
outline lor the first inlerview. .lnfluence couple to begin conceptualizing problem as learned and trf
without blame.
sEssloN l impotant. Tbus vou may want to
Prrc€rr. Process issues continue to be
The third interview normally includes both padners. (An exception to this cover thcse poiots:
may occur lf one individ{al's needs are so overwhelming that individual
fterapy is indicated prior 1o couples therapy.) 'Ihe interview with both . Ask couple whether there are any developmenls since your last meet
partners should begin in an open-ended Dranner lo delermine what changes ing.
and conversations may have occurred since the last session. A couple s . Ask couple what they have discussed: why or why not?
.esponse to this approach is importanl diagnostically. because it provides an . Ask whether there are any doubts or issues to be discussed before
urderstanding of how tbe couple approaches and discusses important pro' therapy begins.
blematic topics. You can observc whiclr parirer lakes responsibility lor what. ' Ask the couple whelher there are any anlicipated difficrrlties in panicr-
and how effectively each person communicales his or her needs. Consider, pating in therapy with you as therapist (are therc concerns regarding
also, thai a couple nray be overwhclmed with recently occuning problems or the therapist's gender, age, or racel).
stressors. such as job loss or death in the ian ly. Obviously, it is inpodant to
acknowledge exlratrealment issues that may preoccupy clients aod dislract lnteniew Structure and Content. The third session may be ordered as

them from the cu.rent focus ot the assessmenl. The remainder of the third follows.
session should be spent providing your formulalion, idenlifying treatment l. After consideralion ol process issues, begin the inlerview by definirg
goals (sexual ard nonsexual). outlining therapy plans. and explaining details the problem, indicatirg possible contributing factors. and ackDowlcdging tlrat
regarding the initial stages oftherapy. To furlher facililate rapport, maximize you wili coDtirue 10 collect infonnation as therapy starts. Ask each partner to
therapy compliance. and avoid backslidins, you should ask each partner how comment on and clarify any misunderstandings or disagreenrenis.
2. Ask each partner !o discuss his or her reaction to a sexual encounter

fITIITIIII
each feels about the plan and whal prcbl€ms each anricipates as barriers 10
progress. when it is thousht to be a failure.
 75
Assessmenl and Treatment

if possible, try 1(r discuss all stages of queslionnaires allow you to compare your clienr ro other individuals (with $e
3. Outline lhe theraPy plan;
diiail, whar lhe first stage wi)l involvF-this will help of established nornrs); thus, in difficult diagnoslic cases, lhese qu€stion-
thgrapy. Emphasize, in
Daires can provide a known metric againsi which to make judgments. Sixth,
*Lsii.h t or". S..u." to ask the couple to identify any anticipated problems'
for your next questionnaires can serve as an addilional stinNlus thal encourages a client to
and to commit to the initial step (i. e , set a specific date and time
.hink through aspects of his or her sexuality. Sevenih, if used after the
meeling).
i'rch a' interview, self reporl questionnaires can be used to evaluate the validily of a
FJr n'any.lienr'. runher a"e',rnent inrormrrion $rll be ne'ded
diagnostic or etiological formulation (see Carey et al.. 198'l). Alternatively, if
o,u.ior,e"ri re'irne. p ychophvsioldgicJl a-e$ment' andor medi'al used before the intervjew, self-report measures can serve as screening devices
l",r*u"i r' rh,' i' rhi case. rhen rherdp) rn'rrucrion' mdv ha\e ro be that help you as the inlerviewer to be more efTicient in getting to lhe heart of
nodoone.l unlil Ihe b.'e.'nenl fh Iure r'.ompleled rLarerinlnr'chaPtertre
oi Inrervreu Jdu $ irh inlormarron rbra'neJ Irom orher the presentiDg complainl.
ii.ci,* rtr.
'nree'aion Despile lheir many potential advantages, however, self_repot question'
need for fufiher
merfrods.l ft is"very imponant to explain th€ nature ol and
liustraied naires have nol been widely used in sexualily assessnren$. Conte (1983,
assessment so tbat a client does not get discouraSed or
1986) suggests ihat one reason forlhis disuse is that many questionnaires have
been developed in the contexl ol research projects for very specific purposes'
Conle (1986) points out lhat the inErview is the earliest and most and thus have limited clinical utility. There is certainly some trulh to this
common Drocedure 'or r$.'nng se).u'l Problems Over rlre )ear"
a' our view. It is Fobably also 1 e thai using questionnaires in a careful way mav
ba'e hd\e increa'ed rhe rnleniew
ci;nial 'oon',ri.ari"n and Lno$ledge appear time-consuming and inconvenient in a busy Praclice. An additional
and
;;;:";",. i", a.,e.'mcnr or 'e\udlptobrena has heLomc more 'rrLrcrutedlaluable
reason lbr the limiled use of self:report Dreasures is that good instrurnents
interviewing metlrods are vielding more
ii.naaral"ea. rr,us, toaav's have bEen difficuli lo locale.
about the com-
information than ever before; we are more knowledgeable
nleltie" or.e\Lral itrncrronrng Jn,l rrnde lhe need lor a'sessment pro-
'rand
[.a'".' rt" g.l.yo"a rhe inieniew. The rel'rd;nder or Ihilhapret io'u'es LocatinB Questionnaires on Your L)wn
c, ""
,r..
"* "riaf--p.n
questionoaires, psychophysiological techniques' and
and com'
medical proceduresihat are available lo supplement the inteNiew Oblaining good queslioonaires bas been difficult in lhe pasl. Many research_
plete a comprehensive assessment oriented journals that provided psychometric information (e.g., reliability,
validiry) on new measures did not publish lhe aclual qDestionnaires. Clinical
sources tltat provided ihe items often did nol provide psychometric character-
Self -Report Questionnaires htics. As a result, nuny practitionerc have resoned to homemade instruments
that are of dubious quality. Fotunale)y, it is now easier to leam about and
dre rranddrdt'ed paFr-and pen'il queslionnaites obtain self-report queslionnaires for clinical use.
self-reDun quesrronnarres
(hon perrod ol rrme rhdrcan Several professional journals provide ao oullet for aulhors who wish to
rhar co; be l;lle'i ot'r b) (hc L rrenl ;n d reldrrtel)
give fairly make lheir questionnaires available to o(her users. Of rhe journals available,
be easily administerei and scored bv the practitioner, and that
point in time and/oJ over a we recommend Pstchobsicdl Assessment: A lour al oJ Cansuhing and
accurat; pictures of lhe client's condition at any
p er' Clinical -'fhis joumal is available at most universiiy libraries, or
oi *onv adrrinrr'r"rron: rCor(ordn & li'cher' 1987 These
'.rioa you can ^lchology
subscribe by wriling io the Am€rican Psychological Association in
;;"',i",",,,"';,,. munv porenr'al aJ\dnrascs rit'r' the) provide eircnsr\e
washington, DC.'Ihere are also several recenl books devoted to the use of
i.,o..ut,on ur fiur..o"; (hu'. the) dre Lrsl-eifcJlrte second' rhev allo$ a
wa) rhat i' nol self-repon queslionnajres. For general clinical measures, we have found
ro o,e"n'r. ni. ot r,er Ihoughr' rn J reflecrite. con'idered
"i,.n, Corcoran and Fisher's (1987) book, Meolurcs fot ClinicaL P ctice: A
,i"*' $rth rhe rime conrrrdrntr or an inrervre$' Ihrtd 'elf-repon
**,1r.
Sor/csrooi, to be quite useful. For measures relaied to physical health and
nu"'iioinaire. oermrt.tienlr ro di'clo'e 'en'irr!e inlornrarron lhal they mighr
ditfrculr ro adjustment, we recommend McDowell and Newell's (1987) book. Meas!/i"8
l"t ..*"r lrrira a live inreracrion' or lhar rhe) might lrnd questionnaires Heahh: A G ide to Rdting Scales a el Questionnaires. Finally' for meas res
verUafize tCorco-ran & Fischer, 1987) Fourth, self-repot
of sexual functioning, Davis, Yarbe., and Davis's (1988) book, s?.rrdliry-
,Uo* ,ou ,o u.'.* u.fi.nl s progres\ oter lime makrnS rrealment evdluarion
Related Measurus: A Conpendium, wananis your attenlioo.
;.'.;** and le* proni ro rherdpi'r{elated biase'' Frldr' seli tepon

ITIIIIIIII IIIIIII
76 Assessmcnt and Treahnenl
77

EvalLraiins Questionnaires Specific Self-Report (luestionnatres

Once you learn ol a questionnaire, you will want lo evaluate iI along several SEXUAL INTERACTION LNVENTORY
iInporlani dimensions.
LPs!&omettic strenBth. ls it reliable (i.e., are fie individual items As slated previonsly. we typicatly see sexualfrrlnels togelher. Thtrs, we are
coDsistent wiih one another, and are scores stable over time?) and valid
(i'e very concemed lvith thc inteu.rion beNeen the fadners rbour sexual nrat
'
does it measure what i1 purpons to measure' or is il some other ters. Thereiore, we hav! used lhe Se\ual l)teraclion Inveni(ny (SIt;l-oPicco-
'neasuring
coDslruct, such as inlelligence or social desirability)? These crileria may se€ln lo & Steger, 1971) to co oborlre rnd suf,plcmcnr infonnItrion obranred in rtre
ove.ly rcchnical, but we lvo ld encou.age you not to overlook lhen A interview. The Sllconsjsrs ol l7hererosexu.rlbehavio.s(scetalrle6I),each
nrensure lhal is nol reliabl€ and/or not valid is not only lvorthless, but
il could of which atu rated by l)(irlr farners l(ntg six dinrensors isec t'able 6 2)
also disiori your underslanding ol your client. Thus, the Unal qneslhnnaire coollrins t02 qLrestions rhar Dreasurc borh saris-
2. Clitlical rele,ance. Does lhe measure address lhe clinical issues at faclion wilh, dDd fr.quen.y ol, s.xual heluvior in hcteroscxnata couptes. The
hand? For exanrple, if you arc concerned p.imarily with evAluating a client's SII is pa(icnhrly va[uble li, rsscssing problem rreas wirhin a couple,s
level oi sexual d;sire. it would not be fruilful to ask him or her to complele the lnler,,, r',,r 't.,1 t',t ,r.\..\rnt lt,..,r.r. rit ,i. , Le oler llrir
',
Minnesola Mrltiphasic Personalilv Inventory (MMl'li a global Personalitv AccoftIng ro Jens.n ct al. (1987), lhe inst rcrions ftrr rhe SII are at a
easure), or even lhe Sexual Opiiion SuNev (SOS) because rhese io- sixlh-grade reading leveli unfuilu nlely, however , lhc ile.rs ll)ernselves are al
slruments provide no inlormalion on desire. Also, il is lnre lhat nrany lhe collegc lcvel lacsei!'ch suggcsts thrr lhc Sll is valrd and retiable (see
insrnunenri are no1 intended lor clinical use and have lirrle or no clinical LoPiccolo & Steger, 1i)74). Mosr teotlc can conlplerd thc SII ir less rhan 30
utilily; however, there are also a large ounber of well conceived and rseful minutes, and il can be s.ored in aboul h.li rlrar linre l._inalty, rhe SII is
you
nieasurcs. You need to determine the clinical relevance for each oreasure relatilely inexpensivei ir rh. (iDre oi rhi\ writint, ir ( r bepurchasedIor$l0
U,r wrth . ach b).r'e bJ'is
3. PrnctiLntitv. k the questionnaire at a reading and vocabulary level .l
antroprldle lor vou-.lrenl''We rr!\e lbund Ihal many quenronnartes trse rABt[6r.lrrhnvos L6ren Llrt Suxri t]le'n.ro. tr!.nkxv(s[] 5)
uocauula.y ttrar is l,eyond nlosi clienls. One source for inforNallon on reading l. TIE nral. sceh8 r[c lln Le \h.n \li. r ntrn.
levels of a variely oi sexually relevant questionnaircs is a Paper bv Jensen' 2. Thc teD{lc secile rhe nuLr rhcn he rs iud!
Witclrer, and Upton (i987). Moreover, rlrere now exists user friendlv com' 3. Thc nrrls rl r[e lc nrL! kr\trr( li)r ok irrrdco rjtr!.lsLy
puler soflware that can assess readin8 level on lnost personal computers' 4. 'llrc n'al. givir! rfu l.nrtrL I l)orly nr.tr'rlr n.r rLrLltring trcr L,crns o. gcn rk.
4. Comparubihr. Are lhgre normative data agaiisl which io conpare 5. Thc tin'rle Bivi,U rlt n].'lc I bol] lsr!! L.r t0,ctl g hr b,rrn\ or g.iikts.
your client's scoresl Herc you will need 1o be sure that the nomrative sample 6 The nrrlc .rrersitrts llre J.r)r|.5 Lr.Ns \rrlr [b Lnntr
L upp.opriur" for your clients. Thus, il a qucstionnaire was norm€d wilh ?. The 0uL. .rr.rsin-! rIe l. al. ! l)'.i!5 uir]r nnrtrll
males agea SO IO years, and your clienls iend to be young females' fie 3 TIE mrle lmssnrg llte rrDriLe's C.n rLJ \riltr 'tr trtr l,rnn\
normalive data are probably not usefuL. Also, be aware lhal many quesnon 9 The nalc curessr! 0r tunule's g.o(rL! wir[ l]ir hrxt:,fut she,arLEs orgrjn.
10. The ld lc . a$np rlr! rnrlu I letr iLl\ \Ilr [J' l]rD\tj
naires have been normed on college sturlents, who may not be representalitie
ll. 1be lcn[lo c t$in! r][ ]rrlesEetrrri\ \yrLlL Lrlr hroJs rnnrLl,c.rrort .s
l2 Tlre nral. .x..$ir)-! 1l)c Ju'trxlo\ B. ht! $irt, r\ nntur
5 Cosl. Does rhe nr€asure cost vou or your client loo much time and/or ll. The nrals c e$itr! rl,s l.rnile s !cn'rrl\ \y tr his i(n,rh trnLit sl,. t.r.lr.s o;gA,n
money to use? Sonre insrruments (e.g, the MMPI) arc so long that manv l,l The f.'nalc crre$,ig rh. s B.nildt: \y h hci nruh
clients find rhem annoying and, as a result. do not rcspond in a cooperative ls The fenfule.aE$itrs rh. 'nrtc gefirils wnh h.r nnn'rI unrit ho c],ctrlares.
fasbion. Other n.utui.t u." expensive to obtain and/or adminisler' You 'niLc's
16 The malc add icr le hr\ing n(e(. r! $
I
slrould koow, however, that many meastrres ar€ in lhe public domain and can 17 The nrnie MJ ior le [r\LDg trrr.rco!^. tr]r I lr.Lh L,j r[.ir [r\]ir uD org6nr.
,l
that
Civen these crrleria, we have idenliiied several worthwlrile measures i
you may want to coosider lor use in your work'

TIIIIIIITI
 rasr[ 6.2. RalinSs L]s.rl in ltre 5fruil trle,rLt 1) r hr!.ft() y (st l 79
t. b, . ,, ," td.r ,. , v.g rtr"
,rollowinE !ix dinensi(rs
whenIouadyou.nmreenBrgeirscxu.tLrehtrior.tl.esrhhr)1r{lcutrrr.fviryu,alt,o.curl r. I sould like my nfre to lird this a.rivny:
llutr.,r'-'v,rJ)!,tLc1r..'..d) ., r.,i 1,.1)..f-.rpt,r.^Dt L Ertrenely rndeaslnt
c!nr0ct wtich is i'nstrded 1o be scxuat trl etrlrl lotr rryorr nralc ) 2. Moderitely unpleasaDr
3. SliChtly unplersanr

2 Rarcl! (107. ol rhe (ln'e) 5. Moderarel! pleNatr(

3 OccasioniLlt (25% ot (he rijne) 6 Exirenrcly plcosart
4 Fxnly ofictr (J0% ot the rirn.)
5 LIsurlU (75% ot rtE (inre)
N,t Frch Ths SlntrL lnreHcrior sesnefrorscruxtDrdundiotr byj
LoPkcoro hd J c srestr, r9r4, /1r.ri!.r {y'J.tr(o/ E coFrdghr l9r1 by pGDunr
Pubrnrri,rs corrcslnD Rerriikd hr pennnsio. or rtludrr( and Fobrish{
b I would like it r, occur

2
Rrrcly il0% ol thc rnnc)
l.
occ.sionattv (25q. oi rhe lnne) fron Joseph LoPiccolo, l,hD, Deparlnreol of l'sycholosy. Universi(y ol
.1. fairly olien (50E oi l[e I nie) Missouri, Colurnbus, MO 6521 l.
5. Lrsuallv {75% ot lhc (nne)

Ilowpleasa i do yotr.0renltr tiln (tih nclivilv r, t).1 0\! !or lhirk todr frte DY DIC ADIUSTMENT SCAI F
ftcr\aft rto turds
il
The Dyadic Adjuslment Scale (DASi Spanier. 1976) is par(ictrlarly valuable
,<] L EltEnrely trnpleasanr for assessnrg problem areas wilhin a colple s interaction oucide ol the sexual
2 [,rodera{elt unplexs,nr domain. The DAS consisls of a list of 32 items (see Table 6 3) designed to
I Slisntlt hFloasrnr assess tlre quality of lhe relatioflship as perceived by married or cohabitating
,1. Sliehtly fleasanr
couples. As with llle SlI, each parlner conrpletes rhe quesrionnaire scpararely.
5 Modentety ttcasanr
Scorirg yields tour subscales an(l a lotal scorci however, we lend to use oDly
6 Lxt.nriy pleas n
lhe tc'lal score in our work. lt provides a general nreasure of rnariial/
d I rhn,k ithr n,r mre rn,ds (tris a.r rir)-
cohabitating satislaclion. According ro Jenseo et al. (1987), rhe insrruciions
I ExlrenEly unfleasddt
oI the DAS are at a seventh grade reading level, whereas the iiems the,nsetves
2. Nlodcr.{.tynnpter5afl
3. SliBhtly unpleasanr
are at the eighth-grade reading level:lhus, il should be possible to use (he
DAS with most clienls. Resea.ch sugges(s rlrat lhe DAS is valid and rcliable
s Moderarelt ftersanl (see Spanier, 1976). Most people can complere the DAS in l5 nrioures, and it
6 Exlrehel, tle.sanr can be scored in aboui 5 minutes. 'lhe DAS is i
rhe public donrain and
therctore can be used free of charge.
How $ould you !ike ro rcsBnrd to ris ac(ivirr? !N \rjutd
),ou Ik. tour nrde b rcsmndr (tn
!rher sords, how rlens. do lou ltriik lhts acttrtr), d?rA 5/rdrr? r. n{ lou unt yotr, n{rcl)

e I world ll[e ro In lI( a.tiviry:

DEROCAIIS SEXU L TUNCTION]NC INDEX
I ExtrenEly utrpte$ror
2. Moderalely LD!teasanl
I Slightl), unpleasarl Although we focus on tbe couple. it is also inrporlant ro undersrand lhe
individual scpamtely frorD lhe coople. To obt.in extensive inrornration on the
5. lVodcrar.l, Dteas jodividual, we use lhe Derogitis Sexual FuDcrioning Index (DSFli Derosatis

IIIIIITII
6. Extre ely tl.asrn, & l\.lclisaratos. 1979). lhe DSFI is a wi(lely used, oDrDibus scalc of sexual
T
T
I
r
IABLa 6 3. The Dyadic Ad,limenl Scale

idi.aie bso* rh€approi'maie exie ola8reemem

orr sasrcement b€rweei You and
I

rherrelatonsh ps Please
M.{ oe&ns have dGasreements in
'

you' padne.lor ea.h em on he lollowin8 lisl

r 1 Handliis hm ly I'nai.6

r 7 convenrionaritv (core.r or props beh'tun

I c wr*
10 a'm5,
ol deiln* w h p,renc o'
sdl1..nd rhns! ber'€*d
d{6'om
hirq!
'Fpon
L

J
1?. Mrlfs maior

14. i€i5urc rime inEe,s aid adivirre!

r b H* on'n do ,oL dru]' or hJvr Yo' rch'6'r'o dFor'

""*a."a....,.-."
rs
-J@- p *, ". s.,.'g *rtr
oo vou.onr'de n Fu' mr.?
lh.n nd ooliooll)

n. H@ orEn do }!u rdrd Fnmr qun'lr

- .,*.-.--,.a---

aery dr, o@ioEl,

^lh6'

lhm
-
ra. Dovou ind @ur rure ensas€,n ouuid: int.r.ns bselherr
How otu€i would youeythe {olldin! occu, b€!!€en you d vour m e:

J
- Nns nonlh r modh w.el d.Y dh€n

h 6elow'aueddr{erencBorooh'on!o'trre
s rhe Psr iewwee[!.lcheck Ys oi no]

J
-

".h,,Pt ,"h.ppy
- ns bBr ds. he5 how rer 's
'tu rculd so Io slmon riv le'Brh! beerha n doer
s .-, a.p.-.iy r.. -y*r,.onshrp b 3u.c.ed.nd
I r*-, *'y -*r'1.,., -t.!o hrp ro su..ed:nd willdo ar rh'r r'ai ro 5erh { de!
I r* r €ry hudi roi mv Ebr'onrhip to 5u.Rd ind wil do Dv Lil shn€ ro +erh' n d*l
I xwdrd b.ni..il hyr.Erio.rhr *c.€d.d,..d lc.n' do mu'h no'irh'n rrmdoins nowrohtlp succtd

E
- i , *"oa * "o. ir i, -*a"d, ; l rerus b do v ms€ fi'n r :m doins no* 1o Lt€p rh? ErariotrhP 3oin3
no mor'rh rondo b l"p fieGhion5hip soins
..d, rnd rhe,. ii

,\-r Fom M.6unng Dyadic Adiusmcic Na* scles lor As.$'ns dre Qulrq oI Mmiase ed Smild Dvad; \ C B Speier ' t9'16 Jo not ot M ras?

I
.,n tn" r.^ttt,:A, )gz copFshr 1976 bv lhe Natihal Corn.jl otr Frmily R'htons Reprided by p*mnnon or $e publhher'

rl 44
 82 Arse$nrcnl and TreatrneDl A$essrnent 83 u

fuDc(ionirrg. ll conlains 245 ilellis tli l nrcasurc 1O dourrins consklered ro be MoLeover. we wish (o tre clear about "t!aditionai' psychological nreasures
essential lo cttecli!e sexual liurctbringr Inlinrnrlion, Ilr(pcdence. Drive, such as the MIvIPI (Hathaway & McKinley. i967) or the Rorschach inkblot
Atliludes. I'slchological Sl,nrplonrs.s A1ltrl. Ge dcr-ltole Deliniti(nr, Fan- test (Exner. 1986). These measures havc rdr been found uselul for diagoosing
the presence ol sexual dysfunctioD ot ior delinealitrg its eliology (Conte,
,i
tasy, Body lDr.ge. and Sexual Sa(istac(ior Accor.ling (J Je ScD et al. ( 1987),
llre inslrrctious ol the DSFI nre dt rrinlh Brade readin8 levcl, whereas rhe 1986). Therelbre. we discourase their use, urless it is lor some olher purpose I
ilenN theDrselves sre at the coilege lelel. Ilesearch suggcsls that lhe 1)SFl is for which that instrunrent has been demonskated 10 be reliable and valid (see
reliable aod val . and nornrs are avrilnble (see l)erogr(is, 19751. Most Anastasi, t988, for further discussioo ol this lopic).
people can conrplete rhe DSFI within 45 Drinrt.si scoring. however, is
cooplicaled. The DSFI can be purchascd fionr Leurrard It. Dcrog ris. PhD.
Clinical I'sychor)relric Research, Bal(inxnc, Nll) Psychophysiological Assessme t

Psychophysiology pennits iflferenccs alrort psychological plocesses thal e

SEXUAL OPINIoN SURVIY based upon physiological measures (Cacioppo & Tassinary, 1990). Thus' il
used approprjalely, these rneasures can be powerlul lools in your assess'nent
The SOS (Fishcr, I988: Fisher, Byrne. while. & l(elle!- 1988) is rlso used to annaDrent.rium. Among other s(renglhs. psyclrophysiological oreasures tend
aid our understandi g oI lhe individrlri. Ihe SOS.onsists ol 2l irems to be less susceptible (o lhe dislo,lions and biases lhat can occur with
inlended to assess 'r{leclive and elllurlile respo|scs t). rIIge ot sexual in(erviews and questionnaires. h addilion. pslchophysiological measures
stinruli (atlosexual, l)eterosexuAl, and lnrDxxcxral bclrario| scrual lirnlasy; penlrit a bettcr underslanding of lhe physioloSical underpiDnings' and some
lisualsexual slirnuli) ' (Fisher, 1988. p. l4).Erchol thesc 2 l irerrrs dcscrilres times the actual mechanisms, of a dysfunc(ion.
a sexual situalion, alrd a negative or tositi\c allecrive resl)orrsei clienrs rhen ln practice, psychophysiological nleilrods6 are used iolrequeDrly' and
iodicate lhe extent io whi.h lhey ngree (or disagreel wirh the alfective lend to be used prinarily wilh men. The infrequent use of psy-
(} response. I{esearch s!ggests thal the SOS is !alid and relirble. and norDrs are
chophysiologicai methods reflects several lactors. !-irsl, tlrese meftods re-
.1

available (see Fisher et al., 1988). Ilost l)eoplc cz r conr etetheSOSinl0 qrire a significant an)ounl of technical skill to achieve a minimal level of
nrinutes or less, arrd it can be scorcd in aboul hall rhrr tiDre. lt is our competence. Most training plograrns simply do not provide the requisi(e
uoderstandirg ihat the SOS is ir ihe IUb!ic dorDai . so il cnn he used lor Iiee.
oppoltunities 10 acquire such skill. Second, psychopl)vsiological recording
ti
appaLatus anrl supplics are expensive. lt is uDlikely lhal yoLr could 8et started
tor less rhao $t.000. and a stale_ol_lhe_a assessnlenl laboItllory can cost i$
$15,000 or more. Third, the exlernal validity ol laboratory-based sexual $
l here are a nnnrber oi other excelleol n)easures lhrt Iou nright want to measures has beeo challenged (Heiman, i978) Ahlrough debatable, this
coosider adoptiog in your wo*. Co[(e s (198]) rcvicw rnd thc Davis et al. poinl has discouraged some pracliiioners Finallv, sevetaloilbe factors thal
(1988) voluo1e are good sources lor olhcr rneasurcs lo corisider. We also are involved in sexual funclioning (e-9., relationsbip qualitv) occur at a
recoumend that )ou obtaio a good nredi.al hisrory scrcenir)g queslionraire different ,evel ol analysis.
(llese are ofieD av.ilable lionr local health Drainrelance organizaliors) it you The limited use of psychophysiolog ical rteasurcs wi(h wornen is also the
do not already have acccss 10 your clieot's nrcdical chart. product ol seyeral influences. Hoon (1979) suggesled tbat this reflecls (l)
sexist biases among sex researcbers and clinicians' (2) a culturc-wide failure
to recogniTe how widespread sexual problems are, and (3) a lack of technolo-
Concluding Conrments on lhe Usc gy for ass€ssing sexual problems of women. Since llootr's review a(icle'
of Self-Report Questiortnaires some prosress has been made Gee Ceer, 19871 Rosen & Dcck, 1988)' and
addilional progress is anlicipated. At the present tjme, however' lillle clinical
Although we encourage )ou to use carelully selecrcd s.l reporl quesrion- ly relevanr surk wrrh women r\ bcing dun€
naires io your work, we also wish to be cl.ar rbour (heir linri(ariurs. Su.h The two psychophysiological methods mosi connnonlv enr oved wiih

r r r r r rrr r r rrr tf f I
measures shoukl never be rsed blindly. or wilho(t a carclLrt irrtervicw meo are no.lurnal penile tumescence (NPT) and davlirne arousal strdies

lr rr r
 84 Assessmcnl and Trealmeni Ase$menl 85

Nocturnal Penile Tumescence qE hdve cle.le.l nol 1., lr, .nr J rel J) rcl f,irJ( r., e r,l,lr'lirng d
laboratory.'r Neverlheless, we wish to provide a brief overview oi rhese
The physiological recording of NPT, usually i0 a full slEep laboratory or procedures for your intomlalion.
cent€r, has been considered lhe "gold siandard" of differentjal diagnosis in In briel, oLrr proc€dure uses videotapes of erotic slin rlalion presenled
mgn. Briefly, the raiionale ior this procedLrre is as follows: ll a man can obtain for approximalely 8 lo l0 nrinntes.i? Tlrroughorl the roce.lurc, the .lieni is
an erection during sleep (which most men do oo four or five occasions per seated in a separate roonl in privdcy StinNli are selected c refrrlly so ihal they
nighl), but cannor oblain an erection drring padner nimulation, it is assumed are appropriaie ro a person's sc\ual orieDtation antlexclLrde tnalerial a clieol
rhal rhe source of the erectile dyslunction is 'psychogeoic" (someiimes mighr r'n,l orren'r\(' t',ng , rn,r.,ry .rr.,r1 f..trge.
relerred ro as "funciional '). In conlrast, il a nran cannot obtain aD ereclion at precisely the a.rount ol lunrescence and thc Poinl in lhe videolrPe al which
night, it has been assumed that bis dysfunction is "orgaoic.'3 rhe tum€sceDce atpeurs. I'he dcbrieling iollowing thi$ assess enl procedure
Desprte rhe promise of NPT, there are several important chall€nges lo iis can be especially valrrble; we use it lo help Lrs to unilersun(l the client's
use and inlerpreration. Ao extended discussion ofthese challenges is provided cognitivc reaction ro erolic ninnrlalion We ask queslbns aborrt the client's
elsewhere (see Meisler & Carey, 1990), and we wisb lo mention only two ability to concentrate on the erclic slirnuli arrd his cnmlional reuclion to the
here. First, tiorn a purely technical viewpoint, recent data indicale lhat NPT stioruli. For exrlnple, one 56'year o1(l mrle clienl exPericncirg erectile difli-
n1ay be influenced by sleep problems (e.9., apnea, hypopnea, or periodic leg culties expressed detrchnrent iionr lhe cdic slinnrlationr "Thrl stuff doesn l
movenrenls) ool routinely assessed in lhe lypical NPT evaluation. These sleep borher Dre. I know they are iust rclinE, and 1 need (lre real lhing " Fudher
parametec may produce anifacts llral can interttre wilh inlerpretalion ofNPT inquiry rcvealed rhat rlris .li.nt hrd very liruiled use ol erulic linlasy and, in
tracings. Secood, tiom a practical perspective, NPT monitoring is very lact, ielt ii w0s wr)nB ' to lAnusize. l he conilict between his obligalioo" to
costly. The typical procedure requires expensive equiprDent, is labor- have sex wilh his wil. and his renlrcle(lviews abotrt sexualexpressions laler
intensive, and necesshates that a clielt spend ttvo or three nighls in a sleeP became the focus of lherany.
cenrer. As a resDll, this assess,nenl procedure is well beyond the financial To repeat: When yoLr see your iirsl clienr, ir is unlikcly rh l you willhavc
means of most.lienrs. Even when a clienl can afford it, NPT requires a full the lechnical expertise or labofulory cquiprnent rreeded to condncl a psy-
if you anticiPrrc thrr you will
(q
sleep laboralory and a well-trained lechnical slaff-resources rarely found chophysrclogicdl assessrnent. llowevcr, be
5.]
ortside of major research hospilals.e conducling a large nunrber ol assessnrenls, tre would errcour ge you to obtain
Fortrnately. however, tbere is a much more affordable and perhaps more lhis eqripnrenl, and lo seek fulher sop.rvised clinical tr^ining.
valid psychophysiological assessnenl procedure that you nray want to con-
Medical Evaluati<rn

Daytime Arousal Evaluation In addirion lo the inii)nnrli( you obtain lronr lhe inleNiew, scll rePorl
questioDnaircs. and rsychophysioloSi.:rtl cvxlualion, yon will also need lo
Measuring sexual arousal directly (i.e.. in resPonse lo erotic stimulation) can know (l) when (rrnd how) ro r.ler r clienr lor nre(lica1 lcsring; and (2) how lo
be extremely valuablei iodeed, il is lh€ lack of such a respons€ lha( is often jnierprel, and inlegrate inlo your case lbr,nulatrorl. lhe resulls ol lhe mosl
rcpo.led as lhe problem in erectile dysfuncrion. Psychophvsiological common nredicrl tesls.
measurement olsexual arousalorers an objecrive view ola person's respons' As nrenlioned eadie., inlarDirion iboul r pulient's nrcdicrl hislory and
to erotic stinruli Psyclroplrysiological studies (Libnan et al . 1989; Sakheim, visits kr physicians slxnrld be n rou(ine p"rI ol yotrr irririal screeni ginlerview.
Barlow, Abrahamson, & Beck, 1987; Wincze el al., 1988) hav€ provided As we have also dis.ussed prtviously, yotrt inrerview nrly hc supPlemented
valuable iniornratio for lhe assessment process.r0For example, Wincze e1al. with a meilical hist(ny questi rn ire ll r asks lor trisic intbrmrlion aboul
(1988) found lhal exposing some dysfunctioBal men 1() erotic stimulatioo chronic and icuie medicil condilions. Dredicaiion use, surgicrl hislo.y, con
resulred in tull erection responses, ev€n rhough tlrose men reported an inabil- gen;ral disorders, hospitaliz ti(ms, si-!r)ilicant medical problenrs within the
iry ro obtain an erection. Such dara can be critically helplul in formularing a extended lamily, and visirs ro fhysicirns This will save you time (luriog yoLrr
inieNies,, and help to alelt yotr lo inrpofunt redical consi(lerations
CulTenl psychophysiological procedures are technicallv challenging, ex' Even when you have con(lucied a.drelirl inlerview.nd collected addi-
pensile, and erhically conplex. Because ol rhese (and other) considerations, tional infirmalion wilh sell rcporl queslionnrires, it nrry be necessrry lo rclir

IfIITIIIII ,IIIIIIIITI
 a7
Assesstrtenl nnd I reahrenl
ru lreck willt
.lealing wrrL "e{ual tompleinl'' lt pos(rbh' ir r' $orrhslile '
r,r rut'n'rrreJ:.rl '\'rru:'r'{r lrrltfrt v' t'elie\e rhrl tr i'
goud rn
tcsardins soo'] c'n\ultanr''
ro,rr rlierrr
i,i- 'r. 1,,, . r, ,,r rur r rleJ:L: I \urrJl 'r lr u' 'lr hr' rror rec"nrlv
i,*-."i.'.*.a \ex rherrpi'r' alu
'lion )ou
whFn vnd tleenr il imporunt Io oDrarn iddiriorralrnedi'ale\
',',.,"'
i,.." .'."'r,".,. Clienr. u l,u J.'c ir e lr: rrr' Jr'c'irrlurr' Incc'LrrF' JisLltirge l;illl;,,i n. *eg*, a,so'.'ixse srrr o*h f i'i'r
a prr){cun
;;;;;,;;;;,,*"i ,t,,r orr)s thrt have o( beer) Ie'enr)v eYihated shourd ",, i"*
ll ,*ntl ir t ctptL't ro catt rne pt'1'rcia" rt vo rrra^ou
":J;lJ:ffi;;i': are '
^llins
;";;i.;;',: ;,,,i i,r r' trrc ;.'. -.rrr's tr,rr, a I\\' rr ""'rrr)'irenred l: lii. ;,, ;1;;;; ;;; ;;;1 (a' *
"',r'o
r"tt it'''"'"n""ni\r hdvc a tarierrr
ph)'icran'
i'.,",.',i"pp'""ir,'r"*' '"".'i'r'"'' '"'" '''ce'':''r'""r'rrrurer'rroa rhe 'b&k as mocr
::1"",,.';;;n;;.;,; haue
'irunrber"
physrcirrr iI lhere r( Jtr) (!ftcrrr $lLtr\"e!er' ;'"';;;;"";,,."haveror .Lr.h p"rsonar'"'l:;
' clieIr La' huJ I re''r'L r'('1" rl er:rr"r"""'
tlt,en a
1 t'"'1''1s11t ctr
t\ rLen ir
i'
lrouble. \ou may \\ai( se!cral
10 l,l,::":ffi i:::,lli:,:il:
rnanile(eLt o l\ , ,Jcr (ara r .rr' ,rrIJ rtre'. ,'r
silli ' Ir:'irr I' rln'
.'"r'
'lays
vou have esrablishcd
telephone contact' and
ll''\c\et lo'r ,.1"iJ.,'1,."""il urll wanl ro
i'-i." i'l"rt 'rr rur'lrr rlc,ir"'l e\a rlrr'1r '\ 'ctc''rr)'require i"",.i".a ,r., t'" "nce i' an aprr'rriare rerenal vorr
phvsnran
.i."i,.""f i,*i. 1,. vigilanr ror conr icnri(nrs that rniv additional
l[',,ii'ti"'.,'r"; 'i;ii a bricr $rirren rep'rrr ro suiJ' trre
€srecsrnenr'
,
rlre spectrrc-
medical consuhatior. ''" 'it,;';;""";;' rhar vour srrrren re[e'.,r he hrict and 'urlrne
p'\'rrorrrson' Irere i' an e\ampre or a
,.,""11 l:' ;l;;,;i";;;i isain avoi'r
lerrer releninp one ol out clien'' lo a ph)stc'an
Wha( to Look for in a Mct]lcal Clrnsultarrt
great care' Ro: Nlrs Jane Snilh
It is exheDrely inrporlant to select y''n'nrclllcal consull nls !vilh
D O.B. 6/5/61
i"".r.r."i.i, shouki be baserl ulon rhe [olk)\vilg consi(lerarioDs'
^ --
r' S"i..i pr'v'r"i'' who is willnrs to \!ork coopcr{tivelv wirh vou and
qurkltrs {lLlr a Dear Dr Parker,
n, resneLr
^
\ou. r.,n"rl.lllrur,c. $( Jr'.orrl rP" Yu" l"'lr'
rrerrtcrt'$iru'ur \u11'rrltirrs
'I ;l',il;;"'n,'"."'u'errle r'e 'rrJr\t'rrr r'l l\rrrre rre(rrrr I am *riting ro request an e!aluaiion
of Nlrs' Jane Smirh regadir8 hcr
I
complanrt

+ ."" rn, exr"'0t., ir luu r"ler l Llr"nr iur'\ilJr'r"rr B"etl uPon a 'linnrl rnre|ren '84o0" ' r 'harc rhc
,'i",i* f*'ri*u.',ne. I rha' rhe'' I'ul ar" uilr teL b \k ro )uLr bcru e'he
".",*,, 'r",1"'''' wtth vod'
followrns bac\Eround iniormalrou rni"d L{ r
or he sta;is lrealirrg lhe clie|t with !asoactile
agenls' Su'h a treannenl nray '"' ""i,,l t."i.lt'A,,' \urc'+rdrr'errrh're $'{\d: rr hAbemr
i,i*t,,.,' t,,, Lli"trr rtrl 'trlh 'ir''
r \"J' 'redibrl;r) srrI hrr' .. .. ,., l' .1," ,:;;;;;,.;, .i" "*: -, "n,\_YU
' i i'1 t" irr'Ll r trr" ' r"r' rlr' :
q''lin"' +ilrrr rc1- rrb'r lirr'irs,' tu ::;I:;ill:T,::.,::l'il l'il'; :Tii;
rirr' JuIirg inr"rc'Jr'P' II'r onlv
"aucx.
yri, ,eg*dl"g l'li or her sl)e'ixlrv
'as
I'iolcssi(tr[ls dillcr wilh r'tsard to
{ell as il rheir inrerest in.edrcaG
ence.
;ffi!;.;.;,1 .,,;,;'.
'
. *: '1ll"l
:'l::1|;T,'i,:*;lllllll- .". ,,",
,r*i. ,lriity ," i*,"'i"r'are krrowledge nul hJd 6 ecnloEical e\annnr
M,,,v werconre the cha,ce ro share rhcn'exper(isc an!r' ir so
Mrs Smirh hss -sv
i;;'";;;;1 Ie' 'e'us problcm' I soulLl
,. ,,*^ i" 0"",.." '* role ur medral conJiriors tn
Uoirrg, to eaucate lheir colleag es aDd clients'
-- '.'
;,Il'\ ;;;:; ;;', ;;,;, -ourd'rami.elulclron'nF'Mr' snnr" a"d rnrol'1 mp cr a,v redicar
interpersonal skills or' as.thev-are
i rf ," assess the co;slrlt nr's"bedside
nranneN'" I1 woukl rellecl ia((orr rhal tnsv be alle'rins lFr 'e\ual
t."aiti-"ir'y ..r"""4 io. his or her
neg"ri'ef1 ,,r 1",rr i"'le"rcrr il )uu !e e rerl )uur'li'rrlruiph\
r''!riuh ic
u, e\en rrFrrlliIg' wc lr'\c In"'r'l renJrl\'cp'rrJrrrF
irr tvpes or
,frof,.rrA
unDrute\siorrllbeh.triut' l-u e\0rIple "rerrl'utrnr' l rfli)(i'r3t'grrtrbrng
;;';;;;;"i;r- ,nire rrienr ir' "t''t" ''" 'rrrLt 'r:rrirg'phvsicia'rs \'1r rre r"o Iar ro 1
"'' ha\e also krown ot lvho have lnterpreting Medical Test Results
irr" r.-, ;'" *r,)r bother?" we
medical consultation' vou will need
to
- --+.
en.uurag"a .ti.ni, to t'u'e extranralitnl riliirs 1o solve their sexual probl€nrs' Alter vou have referred a Patienl for a
wifi sexual rnto rour as"sncrrr,'lo d" Lhis vou
iiy r" o"r*tni,* the plrvsician s conrpetence and corrrlo( /' lliJ,i",i'. '.',t" "' rhi's evaruati'n Arronrhv'i'ian 'hould ulcource rerv
orirl le\ ltelJ' t'eirrt xlrtred a I'h\qrcian'
nroblc'ns MeJicine i( a ldrtse rrrd '
l'"^ u' " g.,'ir"l "ltti'risL ri'e in P)ttr\ul P! or urulrp\' J"e' n' r PU arr
ll'l,i',"^
:il
r*"ro,.r re\( re'ult\
""''",",";';i;;;;.:,ii"" *"a-"r'".'' *'
"*r'' n"" " \ r'burrr rl'e tnn\r
*' t't'"*

IIIIII
u''ulrrurr {rrllc\u'r'l bl rr'' lr rq e\trerrFrv ;:,;:,:i; "i rou(h"uldrcarrrrlrebr\i
*h)
*..*,.,i t,'o"i",rg" ii,,,fi",'. "i o".

rrllrllrlli,"","!a' 1,,ili{ ns(IDnrrtrrrrl'urr"rllrrtl\lllerr 'Pll clliL:r \ rId 'urIlull ","J,"d'"ns

1A Asessmert and Treah€nt
a9
common procedures, tests, and resulrs. First. this knowledge will help you to
during the last 20 days, it averages 125 pg/ml. (Men normally average 20
obiain rhe mos( crucial inrormarion io an etficient manner when you com-
pglml at all times.) Values below the normal raoge for a particular phase may
municate with your consulrants. Second, lhis knowledge wi allow you to
prepare clients for lhe tes$ lhey are likely to undergo, and ro discuss the adversely affect vaginal lubricalion.
results of these lesrs as rhey aifecl your iormulaiion and lrearmert planning. ln men, iestosterone and prolactin are considered importanl. For testos
terone, values are typically expressed in nanogranrs per deciliter (ng/dl) or in
Third, srch knowledge willenhance your undersrnnding ofyour ctient, which
will help you to be a better rh€rapist. To get you starred, we discuss briefly nanograms per milliliter (ngrnl). In laboralories thal we work wilh, the
several common procedures and results below. In addition, we can recorn- normal range irr men is usually irom 280 io I 100 ng/dl, or frorn 2.8 to I1.0
mend Pinckney and Pinckney's (1986) book, T/re pntiekt s Gtide lo Me.ticat ng/ml. (The normal range in women is 6.0 86.0 ng/dl.)Testosterone values
krb, need to be obtained during lhe early morning. This is because testosterone in
for further infoniarion.
males responds 1() a diurnalcycle, witlr the highest values reco ed during the
morning. Y.u should also know thrt leslosteron€ values are usually expressed
PENILE 8R,\CI IIAL INDEX as lotal testosteronei this includes bolh bioavailable and irac(ive testoslerooe.
The bioavailable testosterone lhat influence sextral behavior is a fraction oi
Men who are being €valuaied lor erectile diiticulties wi often underso a the tolal and is composed of bolh free testosterooe and albumin bonnd
penile blood pressure examinarion. The penile-brachjalindex is al) expression
of the relalionship between the brachiat systolic pressure aDd penite btood Prolaclin is a piiuitary hormone that causes the breasts (o enlarge and to
pressure. This relationship is exprcssed as the ratio ot penile systolic blood secrele nilk; i1 is also believed io bc important ior evaluating sexual desire in
pressure lo brachialblood pressure. Normally, the pressures should be about men. Specifically, higher levels of prolactin have been associated with de-
equali and yield a ratio of 1.0. lf the penile pressure is less (i.e., representa- creased sexual deske. The normal raoge for prolactin in men arld women
q
live of a decreased blood flow), lhe rario wifi be tess (han 1.0 Mosr (except for wonen during pregoancy and while nursing, when higher levels s-)
professionals in the lield accept a level below 0.7 as abnormal, indicaring are observ€d) is 0 20 ng/ori A value grealer than 20 ng/nrl warranls a repeal
vascular impairment of the caliber thal would contribule to erectile problenrs. tesl, because it nay in(imate, among otber conditions, the fresence of a
Typically, ratios are obtained lor both the righl and Ieft dorsal aneries of the pilritary tumor.
penis. Both need to be in the normal rarge to rule our a vascutar etioloAy.
Finally, like most diagnostic prccedures, rhis nrcasure is no1 compleiety
reliable, and il should not be the sole nrcasurc used lo deterlnirre vascutar lntegrating Mulliple Data Sources inlo a Coherenl
Case Formulation

We have mentioned ar rhe beginning oirhis chapter (har one ofthe goals oIthe
ENDOCRINE MEASI]RFS
assessment is to develop a coher€nt case lornulation (i.e., a working hypoth
esis of lhe eliology of lhe problem). 1l)is formulation should relate aU aspects
Hormonal levels may be imporrant to the sexual healrh of both men and
women. ln iolerpretiDg the resulls of hormonal levels. several facrors are ot a clienl's cornplaints lo ore another and explain why the iodividual bas
developed rhese diffi.ulr ies (Carey er al . , I 984) . One purpose of rhis formula-
impodanr. First, it is importanr lo remember that levels nray vary, depending
on th€ assay procedure used; lhus, levels iypical), vary somewhai across lion is lo aid you in the devclopment oi a lreahrent plan. A second prrpose is
to comnrunicare to your clients that (l) their problenr is an underslandable
laboraiories. Second, values should be understood as ialling along a con-
tinrum of possible values, and the concept of a nomral range is inrporrant. one, given their physiology, medical history, life exteriences, and so fo(h
(i.e., lhey are not crazy); (2) tlrere is reason ior hope aDd oprimism; and (3)
Third, it is critical to know the measurement units ihar are being used.
you have a conceplual "road map'and rationale upon which to build a
In women, estradiol is considered inrporianr. Typically. resulrs are
presented in picograms per nrilliljle. (i.e., pglml). Because esrradiol values lherapeutic plan. Finally, developing a case formulation allows 10 check with
the client to see wbether you have obtained all the necessary information, and
fluctuate with the phases of the mensrrual cycle, menstrual phase should be
whe(her the information that you hav6 is correct.
known when the sample is obrained and inrerprered. The nonral range of
plasma estradiol duriog the lirsl l0 days oi rlre cycle averages 50 ps/mli One of lhe more challenging aspects ol sex lherapy is inlegraling mu,ti
plc levcls ofinUucncc (i.c., bioldgic l,psychological,dyadic,cullurai)iroa
 Acs.ssnrenl and Treahlenl

llLrscll prcvides. lo.ounrer ihese nrflDcnccs, l'd like ro lcach you how m bc 'nore
coherenl case lorn,ulari(rr. Despile its (lillicultv, a biopsvclrosocial case i
rclaxed at all linres, in.lLrdinC llurnrg sexu.l .ciivi(ics AIso, 1ve can dis.uss ,nore
ronnulation caDlucs rhe Iichuess ofsexual funclion and dvslunclnnr. A client
detail ways xr set ihings nf so lhdl ,ou have scx only at less shesslul limes. As anolher
is irue likely to asree to rry a psychosocial alfroaclr il vou rccognize that Ihu
,pproach, we will work tolard m cmphisis on rxual Plelsu,e nther sexual
biological causes are nor irrclevaol, l)ut that thev mav be overridden or
compensared for. A clierrt is also rlrore likcly lo agree ro rrv a psvchosocial
''Mrs Russcll, lo hdlc nrenlioncd tlr.t you do 'l llways sly whal vou wanl,
approach il you irlrl!ire about xnd recogDize sl)ecilic dladic and sociocrltural
whcn hdving sex or even *heD deciding what lo walch o! lvl We can work on
iniluences. You Dced io bc sensitile to specitlc riluals ard lradilions that a
helping y.u to lecl nore cohloriabit exuessing )our necds and desitesi rhis wiU helP
couple has eslablished, as well as lo erhnic, culluml, or religious issues.
Your case lo.mularbn should include bblogical psvchological, and
Mr Russellto undest..d you berrer. lr wijl aho ra\e sonte ol the prc$ure he feeh otl
social areas eve. ii you bclievc that one urea does nol contlibule to the
''I dho know, lun our lliscussn)ns, thal you a,e a deePly rcli8i.trs couPlc l
problem at thc oromeot. lt is alw.ys hatrl lo predict the iuure, and vou will
undersland lhal bolh ol you incl lcry un&nrlo(rblc wirh regard lo nraslurbalion and
hale la the sroundwork should additiontl inlomatio,r become alailable
vie*ingero(ic nure,idl AlthouBh rhe use oln,ast!ibdtn an(lerolic nralerialis lIelpf!l
and/or luture developments occur. Nloreover, dris comfrehensivc approach k)
ro some people, it will nor be nece$q lol us ro use cilher.
case formulation will give the client conirdence thut vou have coosidered all "
"Ler de srop at rhis foi t, and linen lo lou. reacrion to m! coDnnetrls
poisibilities. h{iireclly, you connn'roicaie to the client lhrl be or she should
also thiDk abour lhe problenr in a nNllitaceled. biopsvchosocinl trame\lork'
This saDrple formulrtxnr ilhslrales how we rry lo integrare biological,
1o ilhstrale how you DiUht preselt your fbrnmlari(nr lo a couple. we
psychological, and social laclors fbr a pafticular cdse ln general, we liod that
provide the lollowing exam e
this approach gives rhe clienls co lidence that you havc considered all
possibililies, and that you are nol Jusl providirtg a "packaged' trealmenl
"Mr. and M6. Ru$el|, I wart lo revie( with you all of rhe nriormalion rliat I
program. lnstead, this afproach makes clear 1(] clients lhal all data are
have g.theredi please.onect me il t stalc anlrhing llrt you beliele lo be a nristake. I
considercd, aod thar a specialized, customized treatrncnt is adopted.
? also *ant lo present to yor d aPprolch thal i lhink wiu help you silh lhe ereciion
problem. lle,e, too, I wel.onre your inPur
''FiIst. let nre,cvie* ihe inlormxlior lhat I h!ve. the nrcdical lesk that Dr
Special Challenges to Assessment
I\'lirchcll conrplered tells me lhal you Nlt. Ru$e11. ure in l€llv good health. Dr'
Mitchelldidrepo.however,llrallhcblo.dpre$ureir)youlPeniswasalinleb*,and Before ending rhis chnPter, we want to acknowledgc tlrnt the assessment
rhis nighr explai some oi you, floblem 'lhis triolosicil diiliculrv me ns thai process h not withorr ns pirialls, potholes, and ptoblenrs. We have already
l
psychologicrl aod rclarioDshil condirions have to be ideal fo. vour Penis to vorki this nlluded to lhe technical skills, cost, and olher obslacles lo conducling a
h because your physical does nol appear to be as skong as it used ro be state-of-the-a,l assessnrent. we norv luln our allention lo more prosaic chal-
'esponse
However. I beliele thar yo r penis sill luDclion if lvls Rusell and)ou.anwo'k lenges 10 the assessDrcnl Focess.
logelher to creale the righl enlirotrnreDt This is good news beca se il nreans we cad
rry lo i,np,ove rhe sitration wnhout $tr8ery. Il lhis doesr't rvork, tl'e
qe can dis.u$
rhe pros and cons of sursery. The Uncooperaiive Pallner
''I'd alvi like ro say a telv lhings about the psychobgy oi thls siluation. lt seems,
In a small number ol o r cases, a clienl will enler therapy without the lull
irom nry dis.usioD wilh both olyou. tha( Mt. Ru$ellgers fiutrared when he wanls k)
cooperalion ol his or her panner. SoDre ol these clienrs have partners who are
please you, NIs. Russell, trul is unable ML ltussell, yotr can ser lerr upset when vou
reponed to be shy but cooperntive; io olher cases. the partner believes tlut the
are Dnable ro obtah aD crecli{rn It ever seen$ thal somelimes you defeal vourself
problem is lhe client's and rcltses lo parliciPale. This always presents a
bcfore )on evcn get *armed uP. As you heard wirh your own edrs tod.v, whsr Mrs.
difflculi sitration, and oDe io wl)ich you can oever be sure whelher you have
Ru$cllwanrs most of allare your lffe.rior, hu8s, and kind qo,ds whelherornotvou
have an erecrim does nol seenr to be lhe ctucial rsfcct k) her This is a relief for vou lo
all the pertinent facls. To help an uncooperative panner become engaged in
therapy, you can suggesl lalking to the pa(ner by phone. If ihere is still
know We can ialk nrore about pleasins Nlrs. Rusell, bul it is Eood to know lhat lhe
refusal, lhen yo can snggest reading Draierial lhal is pertinent to the problem.
absence oi an e,ection will not ,!in her dayl
''M'. Russell, n also secms ttar you brins d lot of worries with vou-nnne from Crucial componenls ol therapeuric change (e 9., effective communica'
your work and this ,nay inlerfere wirl, you, abihv to eniov rlt caiessils that M6 lion, cognitive reslructurinS, and dispellins blame) can alnrost nevcr be
 92 Assessmenl and Trertment

achieved when one partner refuses to participste. This is especially true when er, if you are helerosexual and are uncomfortable ireadng homosexuals, then
the uncooperative partner is puryorled ao be angry and blaming. You can, of you should refer ihem to another therapisi. Also, if a homosexual client is
course, offer some therapeutic benefit to the participanr client by providing uncomfo(able with the idea of a heterosexual lherapist, then a referral to a
etiological explanations and ioformation, clearing up misunderstandings, gay therapist may also be a good idea.
puuing the problem in perspecri\e, and ourlining srraregjes lor change.
However, you must also describe the limitations of therapy and try rct to shift
blame or fuel anger toward the absen( partner. The end resulr of therapy is Concluding Comments
often a client who has an improved understanding of the problem and feels
betier about himself or herself, bur still has a dysfunctional relationship with The assessment procedure necessa.y for accurate diagnosis ofsexual dysfunc-
his or her par!fler. tion has definitely become morc oomplex in recenl years. We now understand
that most sexual problems prcsenl with an interplay of medical and psy-
chosocial factors, and demand a wide range ofexpert diagnostic input. This is
Single Clients an €xpensive and, at times, a long-drawn-oul process; we look forward lo
more streamlining in the future.
Clients wilhout partners who are experiencing sexual dysfirnclion problems A comprehensive assessment interview cannot be separated from lher,
may require a few special considerations; in general, however, most of what apy. Within the assessment process, a client's attitudes are ofteo challenged,
has been discussed is applicable to these clienrs. It is common for a siogle rew information is learned, and nrisnnderstandings are corected. By asking
client to enter therapy after having experienced a "sexual failure." For rRen the client about various factors lhat influence his or her sexual response, yol'
ihis may have been an experience ofpremature ejacularion or erection failure, are helping the client to view the sexual problem as a state rather lhan as an
whereas for womefl this is likely to have been vaginismus, dyspareunia, or unchangeable trait. This conceptua)ization is impoaanl to restore optimism to o
loss ofdesire. Regardless ofthe nature of the problem, singleclients are likely lhe client and to his or h€r partner. Similarly therapeuric is the rednc(ion or o.
to enter therapy with low self-esteem, sexual insecurities, and avoidance of removal of blame for the sexual problem. Assessmenr solicits information
social interactions. You must be sensitive to rhese likely areas ofconcem and from each pa(ner; il thus helps redirecl blame and guilt, and focuses the
spend more time in idenlifying barri€rs that may impede social interactions. couple's energies on solving problenrs. Assessmenr also lacilirales the break-
Some single clients offer to brinS in a casual partner to help with rhe down of bar ers to communication. This process is begun during the assess
therapy process. Our general approach is to allow a partner to participate only ment, since the client is asked to dlscuss details of his or her own sexual
if there is a Senuine commitment. The reason for this is to protect the client, behavior and detrils of his or her partner's sexual behavior. Clients observe
since assessment afld thempy require the revelation and open discussion of you as the therapist discussing sexual matlers in an open and nonthreatening
vuloerabilities and intimacies that the client may later regret having discussed. mdnner, and Ihi, model, ettecri\e comrnunrcation.
We have had some occasions when manied clients offered ro bring in lovers Thus, through the assessment process, couples are exposed to an appro,
rather than their marriage patners. This siauation presenrs obvious legal and priate communication style and are encouraged to discuss sexual matlers in a
ethical concerns that are in your best interests to avoid. We \r,ill counsel conslructive, ratherthan a destruclive or avoidant, manner. Il is not surprising
clieots on the pros and cons of legal separation and divorce. tf a client chooses that many couples report positive change in their attitudes and, in some cases,
to take no action, thelt the limitations and value of rherapy must be fuliy in actual sexual behavior lollowing assessnent and before tberapy proper
discussed with the client. begins.

Cay Clients Notes

Single gay clients or gay couples should be approached no differently from rin lonre extreme cases, olten *herc prior relarionships huve been qune unsrable, ir will be
single heterosexual clients or heterosexual couples. Gay clients who are necesaiy lo devore seleral sessions to e$ablishing trus.
perfectly comfortable with their homosexuality are likely io present with lThe outline prolided here h meanr solely as a suide. This su8gescd order should not be

IITTTIIIII
sexual dysfunction concems similar to those of heterosexual clients. Howev, followed blindl),, but should be nodificd dcpcnding up.n rhe clinicalcn!umsrances. You may

,IXXITTXITT
 94 Assessment and Treatmetrl

al.otr'1 rurp,.etrot.'.1to'1rtrc.r,:.fd1-oecnfJbt..ed,eg q.u.il. to8r,Lop,-.oo

& Hein,,n rarn
iwhen2sking abe(
srurl abuse or rratr r. weencouraaelou lolollow rhe recohme.dation
Dr lki,h o,
B(f . cn .hr.
erpp r ij i ea B-. lcr, la8,. E.Jnn, nd, t J Jou J.k. rns trherher
n,. or,ir.!1,.d.e,ua. a.N U- .r rhe tr,1d rr {!r.,1..
clients lo repon exp{ierc4 rhar rhe} mighr nor Evcat
slo\:
if asked 0bour ,rape,, u .,jbNc. " i;ihi;
reEard. it should be menlioned rllal many $onen ,*
*r,o",r r. ta."try **a
coDmirted by boytriends, husbantls. ara orrer nho "i"raii""s
ue rnoqn ro lhem, we atso wish lo aten
:::.'_:'i' r::''"'r .r'|nunpr" or
,i,,.., ele,.1 e..a( Iui, eob|rre.*eri.lo;
'The fa.r rhar rh; Sn x inretrded for use !nl] silh hekrosexurl c.uptes is a tinririn8
facror
'lm P{ T,loEr.,r s .or. m. . .b1.. F d dnr r, rn \otoC., i-rtur r krrFr rhe BIcr
sjn p-ul rrLe loJ rBsl. D" ,s. .. d. sppn er. t082, score... ,n B(t
ItTd'/srron ob.p.!i\rr^'orn.", ) ..d r,.ne ,ub..;;.
I1." ner\u Jr \en!-\ r. o.p,"..t.,. r...1 n.,.1.
ry. Phob. Anrie'), Pa noJ tdcarion. a.dp$cttrnnr r
sli",r,y r"a"i, rJ,,ir""-iy.p,,;;:,:...',i1il':il!;.1i,:."lfiilfi+:';ll",1.""ti?::l
lone in hqnd\ q' h dF n. td qt-.m .,.d .u.p"., ,,,* *,,",
r"p;,,";r,.
" -
6We
C'"..,
us rhe tem "psychophvsjologi.at..in rhe nanos sense ol noninvasiv€, sud,ce measlres.
cenainly, oie a. consrrue rhe a*e$nenr or homonat tereh L. ,r" or*a
.hoDl)(ioloG..alrra.L'e Hotre.er. tre rer- lo nFr.ne. rtk eina..\ean,o,rh
n.,l,rJ e\e.rF. and .uF . nr. I a, . I ed., ,t tr,ea.d e. ,*.r"",*.,,., - "",'f.r-
- ,..i..
,_"'
'It i. iere.,,ng rhAr r
^r r.er r ..a-,rb...p rt.e \pt ,c.DUre r. 1d ns a.{ Ddo,le.. lh_!
m qr,riouriotr u o'b-Jl) .pkfctrne1u,.e rp:.n.3.,ro
dc\"tuD-,l De.
1a\eflqr'oh trhi.1 rre.Jc'rnr..er.epF,uriu,.or u e , , t .u-a tr,!r. te,orcn
, ., iun, .p.u, oi
<) ''fullbladder erections, shosinE rIat thh disundcr.\randjas " 6
is ii r"9",a _"ir""a .
h( mu.aeo p.dk tr ( n ".ri."rr4 ror,.c,,lrr,.r .ee11,n.or.Je1i)rnrre ""it -,
toC.t.
ba.ed 01 hrl or .Ecron , tri1g 1e d,v. rne a ,en ,t,1 \"
h. ru r,rdrc
:l.l",r^r1",".11:.\.dpry..!e,,.o r..n.-hre1u....n.Lird.]rlr"beer,.,dc \ee
cirerd(Jro). ,i.cr.roqerrr...p e.rrs,. rh \pt ,t.non\a
ha] be abse durnre ctinicat depro$j!tr tRoose, cLsnrrn, WaLlh, & Cullen, 193Z).
tInlieu.ofatult NPtu nir)nrbn. srne pruIesidjrls hrve usld rhe snjp
Eau8e to assess

,,Fapparn'1."'rc..,t t,1, p, i..nn^,bere,UnrerJed.,,.tioen,)

b(ause oi the lalsjEgarive pn)btem (ie.. Dr0 wh. do nor
or8anic patholosy). This is dkcu$ed tunher ttr Ntcister
trave e,ecrions, tIr also have n;
and C cr d990)

ll'..-^*.,,1.Jr_,.r-rD .. h., .\e\.rgj,. \fJJ.ir.ii.r,..,.bJk.{rohoru,e

" ror reaa.n *rro *rn ro p-sue rtris iunher. *e rccommend t(,sen and Beck gSS)asaguide
rrThe viewiig
lnne 6 tonger rhan is oflcn noled i,r reseri!h studres, bI
in ourctin].atse inss il
allows a pe6on ro retar ard ger njeoralh livohed in rhe
5rnnutus presenrarion
ue u,e
'h" rlrp'L e,. I F stl. .,I rt.e sO, o,retp I roorer,r-ur,.r.,rriarcnon
,nDroDriare