|
Article Excerpt
Not everybody with a sexual problem goes to visit a professional. Some individuals, for various reasons, cannot; other individuals do not want to. Moreover, the capacity of the sexual health care service in many countries and regions is insufficient to accommodate the potential demand for help. As a result, in the last 4 decades various forms of "minimal interventions" in the treatment of sexual dysfunctions have been developed. In these interventions, contact with a professional who delivers treatment is limited or absent. Among these minimal interventions are self-help groups, bibliotherapy (i.e., self-help with assistance of a therapy manual, leaflet, or book), video therapy (with assistance of audiovisual material), telephone-based therapy, Internet-based therapy, and computer-based treatment algorithms. Some forms, like bibliotherapy, have proliferated and occupy a stable position in the field of treatment, as they are used by large numbers of individuals and couples that seek help. To accommodate these numbers, hundreds of new self-help titles are published every year. To illustrate, a search on March 25, 2008, of the amazon.com Web site, using self-help and sexual as search terms, resulted in 2,106 hits. Other interventions, such as Internet-based treatments, have only recently been put forward. Still others (like telephone-assisted therapist-administered treatments) are used mainly in specific, natural circumstances, for example, when people live large distances from mental health service centers or because they live abroad or in isolated geographical places rendering direct contact with a therapist difficult or impossible.
Beyond sexual problems, minimal intervention strategies, often termed self-help therapies, exist for a broad range of mental and physical health problems (for a handbook of self-help therapies, see Watkins & Clum, 2008). In this review, the term self-help is used to represent both the constructs of self-help and the minimal interventions that are implemented. Self-help methods can be classified into self-help groups and media-based self-help (Watkins & Clum, 2008, p. 1), the latter including bibliotherapy, video therapy, therapy through telephone contact, Internet-based therapy, and computer-assisted therapy. This review is restricted to media-based self-help.
Self-help methods can further be classified into (a) general, (b) problem-focused, and (c) technique-focused (Pantalon, 1998). General self-help approaches do not address specific disorders or self-help techniques, but focus on general aspects of mental health such as coping skills or the role of health attitudes. This approach contrasts with problem-focused methods, which provide tools for assessment and treatment for specific types of problems, for example, sexual arousal disorder. Technique-focused methods typically offer a method to reach a behavioral goal or emotional change that can be applied across different types of problems. Examples in the field of sexual problems are manuals that aim to teach the user to self-apply the principles of classic and operant conditioning (e.g., Kass & Strauss, 1975) or cognitive restructuring (van Lankveld, 1993, 2004). The majority of empirical outcome studies have been limited to the investigation of problem-focused self-help approaches, rather than general or technique-focused approaches.
The questions addressed in this review are (a) What is the position of media-based self-help approaches among the remedies for sexual problems?, and (b) What is their empirical status with regard to efficacy?
The Position of Self-Help Approaches Among the Remedies for Sexual Problems
Sexual dysfunctions are fairly prevalent among men and women. For example, a recent survey in The Netherlands among more than 4,000 adults between 18 and 70 years of age showed that lifetime prevalence of unspecified sexual dysfunction, meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) dysfunction and distress criteria, amounted to 16.7% in men and 19.5% in women (Kedde & de Haas, 2006). Furthermore, when seeking relief from physical and mental health problems, the number of individuals in the community who initiate a self-help attempt probably surpasses the number of contacts with sexual health care professionals many times (Dean, 1989). This same pattern may also apply to sexual problems, but the private nature of sexuality is likely to obscure the number, nature, process, and outcome of such self-help initiatives.
To define the position of self-help therapies for sexual problems relative to other help formats, similarities of and differences between the various forms of help need to be considered.
Help-Seeking Pathways
Help-seeking behavior typically is a staged process (Wills & De Paulo, 1991). In the first stage a person who self-identifies a problem communicates informally with the partner, relatives, or friends. In this stage as well, the person will try out self-help. In the subsequent stage, help is sought just outside the informal circuit, in the first echelon, from a general practitioner, a pastor or minister, sometimes even a bartender or a hairdresser. It is only in the last stage that the help-seeker turns to a specialist-professional, such as a gynecologist or urologist, a psychiatrist, psychologist, or sexologist. Catania, Pollack, McDermott, Qualls, and Cole (1990) demonstrated the presence of this sequence of help-seeking behavior among people with sexual problems in a U.S. field study. This sequence implies an important and inherent position of self-help approaches in the overall scheme of help-seeking behavior. Among individuals with sexual problems, 80% were found to have sought informal help (first stage), and the same proportion of study participants reported to have attempted some form of self-help (second stage). All participants who turned to specialized professional help (third stage) had received informal help in the preceding period, and 88% had tried self-help. Only when hidden or inconspicuous types of help are unsuccessful are individuals with sexual problems willing to disclose their sexual problem, including the distress associated with it, to a stranger--that is, a health care expert. This general phenomenon is reflected in the low self-disclosure rate of sexual problems in the consultation room of gynecologists (Bachmann, Leiblum, & Grill, 1989; van Lankveld, ter Kuile, Kenter, van Hall, & Weijenborg, 1996), urologists (van Lankveld, van den Hout, Spigt, & van Koeveringe, 2003), and family doctors. In comparison with self-disclosure rates in the doctor's office, the number of patients reporting sexual dysfunctions increases substantially when the doctor directly asks questions regarding sexual functioning and satisfaction.
Treatment Intensity Tailored to Level of the Client's Need
The intensity of contact between client and therapist varies across self-help therapies. Glasgow and Rosen (1978) discerned four levels of intensity of contact. At the first level of "self-administered" help, client--therapist contact is limited to the obligatory assessment contacts. At the second level of "minimal-contact" therapies, some early-stage contact with a therapist is included to introduce the client to the method, and to answer the client's questions for clarification. Some form of ongoing therapist support during the subsequent period may also be included in the protocol, by telephone, through face-to-face sessions, or through e-mail. This ongoing support serves the purpose of increasing treatment integrity and enhancing participant compliance. At the third level of "therapist-assisted" self-help, client--therapist contact is more frequent. The therapist plays a more substantial role and is, for instance, repeatedly involved in direct support of the client and to clarify the self-help material. The client, however, shoulders most of the task of working through the self-help program or method. At the fourth level of regular "therapist-administered treatment," the therapist guides the treatment process, and the momentum of therapy resides in the therapy room, although homework may be an ingredient, and written or videotaped material may be taken home as an adjuvant to treatment.
As early as 1974, Annon (1974) noted that men and women suffering from sexual difficulties vary with respect to the length, intensity, and comprehensiveness of the professional help required to restore their sexual functioning or satisfaction. He, therefore, introduced his so-called PLISSIT model of treatment for sexual problems. PLISSIT is an acronym that stands for Permission, Limited Information, Specific Suggestions, and Intensive Treatment. Some individuals with sexual problems merely require a professional's permission to experience certain aspects of their sexuality as they do. This is sometimes the case when difficulties exist in accepting one's homosexuality within a societal or family environment holding homo-negative attitudes, or when a person experiences sexual arousal with the help of physical or erotic stimulation that he considers embarrassing or shameful, but which is neither harmful to the person himself nor to others. In other cases, psycho-education, providing only limited information, may suffice to help an individual accept a certain condition, such as when medical treatment has resulted in bodily changes that affect sexual functioning, or to explore new ways of being sexual, such as when difficulties to becoming sexually aroused exist in the absence of adequate stimulation. Receiving information on possible ways of providing such stimulation may open up a new road to change. Specific suggestions may be more time-consuming, especially when follow-up contacts with the professional are needed to monitor and assist the therapy process. They may also be more invasive if they involve discussion of intimate details of physical anatomy or sexual behavior. In several cases, the practice of sensate focus therapy will not proceed beyond this stage of providing specific suggestions. Finally, intensive therapy may be needed when somatic or psychological comorbidity complicates the picture. In this event, a prolonged series of consultations is required in which the process of analyzing the elements and connections of the complex problem takes place. In this condition, more importantly, a therapeutic working alliance needs to be established. Within the therapeutic environment, the professional stimulates and monitors the necessary changes in behavioral and emotional responding, either individually or in the context of the partner relationship. The professional gives feedback on this process and helps the person to further adjust.
Stepwise Delivery of Care
Self-help methods are located at the lower end of the PLISSIT hierarchy. The PLISSIT model emphasizes the possibility of tailoring treatment intensity to the needs of the client. These aspects of...
|
