Tom L. Clark, L.C.S.W., M.S.W.
Frequently Asked Questions
This is a comprehensive list of answers to questions many individuals or couples have about therapy when considering consulting with a mental health professional. This information is relevant to anyone who is thinking about the prospect of individual psychotherapy, couples therapy, or sex therapy. Furthermore, to state the obvious: my answers reflect my own particular background, training, experience, values and biases. Another therapist might answer at least some of these questions very differently than I have.
lf you have a question about therapy which is not included in this FAQ, send me an email at tomlclark@comcast.net and I will answer you as promptly as I can. For obvious reasons, I cannot and will not “do” therapy online; therefore any answers to questions would only be general in nature.
Depending on the kind of questions I receive from visitors to this site, I will revise this FAQ file from time to time. Also, if you have questions about the structure, meaning, or philosophy of these various kinds of therapy, please refer to my homepage sections on Individual Psychotherapy, Couples Therapy, and Sex Therapy. If you would like to know about my own practice, please read the sections: About My Practice and About Therapy.
TIP on navigating this FAQ: Clicking on the number next to a question will link you to its answer. To return to where you were before you linked, simply hit your browser's ''back'' button.
Questions about Individual Psychotherapy
(I-1) How do I know if I need therapy?
(I-2) How do I go about finding a good therapist?
(I-3) What's the difference between a Psychiatrist, a Psychologist, a Social Worker (L.C.S.W.), and Marriage, Family Therapist (M.F.T.)?
(I-4) How do I know if a therapist is qualified to deal with my problems?
(I-5) Should I see a male or a female therapist?
(I-6) What does a therapist provide?
(I-7) What kinds of questions can I ask the therapist?
(I-8) How often do I need to come in?
(I-9) What are the costs of therapy, and what about insurance coverage?
(I-10) What about confidentiality? Do therapists record sessions?
(I-11) If I use my insurance coverage, will my employer find out, and will this be held against me?
(1-12) As a client, what are my rights in therapy?
(1-13) What difference does the theoretical orientation of the therapist make?
(1-14) How do I know if I've found the “right” therapist?
(1-15) How do I know if therapy is successful or unsuccessful?
(1-16) What is the difference between short-term therapy and long-term therapy?
(1-17) What about the use of drugs for psychological problems?
(1-18) Do therapists give opinions, interpretations, advice? What about therapists who don't say much?
(1-19) ls it a problem if the therapist and the client have very different value systems?
Questions about Couples Therapy
(Note: for generic questions about therapy, see previous section)
(C-1 ) How does couples therapy differ from individual therapy?
(C-2) How do I know if my partner and I need couples therapy?
(C-3) What should I do if I believe we need couples therapy but my partner does not?
(C-4) What kinds of problems are appropriate to couples therapy?
(C-5) What kinds of problems are not appropriate to couples therapy?
(C-6) How do I find a good couples therapist?
(C-7) Do all therapists conduct couples therapy?
(C-8) What should my partner and I expect to get out of couples therapy?
(C-9) I've heard that couples therapists give ''homework.'' Is that true?
(C-10) What happens if one person wants the relationship to continue and the other person does not?
(C-11) Is it helpful to see a couples therapist if my partner and I have already decided the relationship is over?
(C-12) Do couples therapists ever take sides?
(C-13) What’s the difference between couples therapy and family therapy?
Questions about Sex Therapy
(Note: for generic questions about therapy and specific questions about couples therapy, see the previous two sections.)
(S-1) How does one go about finding a good sex therapist?
(S-2) What kinds of problems are dealt with in sex therapy?
(S-3) Can I do sex therapy as an individual client, or does my partner have to come in too?
(S-4) How is sex therapy different from couples therapy?
(S-5) How long does sex therapy usually last?
(S-6) Is ''homework'' part of sex therapy? What if the therapist wants me and my partner to do things we don't want to do?
(S-7) What can we reasonably expect from sex therapy?
(S-8) What about consulting a medical doctor?
(S-9) What about Viagra and other medications for sexual problems?
Answers to Questions about Individual Psychotherapy
(1-1) How do I know if I need therapy? Without listing all the dozens of reasons why a person might think that he or she needs to be in therapy, there are three general reasons why a particular person might need to be in therapy.
One of the most common reasons why people go into therapy is the persistence over time of certain difficult life problems and/or the psychological symptoms which often are present with these problems. If, for example, you have had a lot of difficulty staying in important relationships, maintaining good friendships, etc.; or if you've had persistent problems in the workplace, such as keeping jobs, getting along satisfactorily with fellow employees, or advancing in your career -sometimes these relationship and/or work related problems are indicative of deeper, underlying issues which a therapist could help you understand, so that you might function in more satisfying and productive ways.
Secondly, sometimes people have certain very specific psychological symptoms -- for example, the symptoms of depression: frequent feelings of sadness and melancholy, inability to function well at work or in relationships, sleeping too much or too little, loss of appetite, low sexual interest, etc. Other kinds of symptoms might include persistent problems handling rage, or compulsive behavior, or substance abuse. If any problem or symptom you have makes it difficult for you to carry out your everyday activities, you may get some real benefit from seeing a therapist.
Thirdly, many if not most people who seek psychotherapy have issues with self-esteem. The historical reasons for low self-esteem can vary immensely from person to person, but the results are typically the same: an inclination toward depression or melancholy, persistent difficulty with important relationships, and difficulty figuring out appropriate life goals and following through on them.
Sometimes people in need of therapy have problems which seem somewhat vague - trouble making decisions, being unsure of what you want to do with your life, difficulty making choices you feel good about. But what all of these different problems and psychological symptoms have in common is their persistence: that is, no matter what you do, no matter how much effort you put into solving your problems, nothing seems to work. It is the repetitiveness of these problems and symptoms which is your best clue that you could benefit from talking with a therapist.
The other primary reason why you might need to see a therapist is to deal with some very specific crisis in your life: the death of someone you love, a family crisis, separation and divorce; a serious illness in yourself or someone you care about; the loss of a job. If such a crises leaves you feeling unusually overwhelmed, immobilized, unable to function, then seeing a therapist, perhaps just for a few sessions, could be of great help.
Finally, there are people who do not necessarily have specify symptoms or persistent, inestimable problems, but who choose nonetheless to go into therapy, either as a form of self-exploration, or perhaps to address some not-very-specific malaise of the spirit.
( 1-2) How do I go about finding a good therapist? Without question, the best source is the strong recommendation of a friend or relative, i.e., someone who has been in therapy and therefore knows from direct experience the advantages of seeing a particular therapist. If for reasons of privacy you don't want to discuss this matter with a friend or relative, your next best source would be a professional person whose judgment you trust - your personal physician, for example. Or perhaps a minister, rabbi or priest. lf these options are not ones you care to choose you can find the names of therapists listed with local county medical societies, psychological associations, and other kinds of professional groups. If your town or city has a community mental health center, you can call it for a list of referrals. Other possibilities are the Outpatient Psychotherapy unit in your local hospital, or the counseling center at your local junior college, college, or university - most of these sources could provide you with referrals. If there are any women's organizations in your community, some of them may have referral lists of therapists.
Licensed therapists are also usually listed in the yellow pages of the phone book, although this is the least desirable way of finding a therapist. If you are not able to obtain a good recommendation from someone you know, and you must therefore get a name from some kind of professional association, you may need to ''shop around'' that is, try more than one therapist. Just because a therapist is properly credentialed does not necessarily mean that he or she is a good therapist or the right therapist for you. Actually, this caveat applies to all recommendations, including the therapist your best friend has so highly recommended. While it is very important to find a therapist who is properly qualified and experienced, the choice is also partly subjective: Do I like this person, do I trust this person, do I really believe that he or she can help me?
(Also, see Answer I-14 in this section, How do I know if I’ve found the “right” therapist?)
(1-3) What's the difference between a Psychiatrist, a Psychologist a Psychiatric Social Worker, and a Marriage, Family, and Child Counselor? A Psychiatrist is a therapist who has been to medical school, completed a residency in psychiatry, and who is a licensed medical doctor. A Psychologist has a Ph.D. (a doctoral degree) in psychology, and the training and experience to be properly licensed in the state in which he or she works. A Psychiatric Social Worker (in California referred to as a Licensed Clinical Social Worker - L.C.S.W.) is a therapist who has completed graduate training at an accredited university Social Work program, and who has completed the training and hours necessary to be licensed as a therapist. A Marriage, Family, Child Counselor is a therapist who has completed a Master's degree in clinical psychology and who has the training and experience required to be licensed as a therapist. Of these different kinds of therapists only Psychiatrists are allowed to prescribe drugs for the treatment of emotional problems. All other kinds of therapists must necessarily use psychiatric consultants for the purpose of prescriptions, if the use of medication is part of the treatment. For example, if I am working with a depressed client whom I think would benefit from medication, I refer that person to a psychopharmacologist with whom I work closely, for a consultation. If the doctor concurs with my recommendation, he will write the prescription, but he will not take over the therapy. The role of the prescribing physician, after the initial consultation, is to talk with the client in person or on the phone every month or six weeks to make sure that the medication is working properly, etc. and to evaluate possible side-effects.
Reflective of the fact that they have had more years of training, you can expect that the fees of a Psychiatrist or Psychologist will be higher than those of an LCSW or and MFCC. However, the length of training does not necessarily correlate with a therapist's ability to work effectively. No matter what the training and background is of a particular therapist, you should evaluate any prospective therapist in exactly the same way. Is this person able to help me? Can I work well with this person? Can I trust this person with my most personal thoughts and feelings? If, after a few sessions, these questions cannot be answered affirmatively, it’s usually a good idea to try someone else.
(For more on this refer to Question I-4.)
(1-4) How do I know if a therapist is qualified to deal with my problems? The first step is to determine whether or not the therapist you are consulting has been properly trained and licensed. Licensed therapists are obliged by law to display their licenses in their offices. While most therapists see clients with a wide range of problems, those same therapists often have areas of specialty, for which they have additional training. If you plan to consult a therapist because you have Obsessive-compulsive Disorder (O.C.D.), it's important that you find a therapist who has quite a bit of experience - and perhaps even specialized training - dealing with this problem. And the only way you can determine this is to ask the therapist directly. This much you can determine over the telephone, too. In other words, why waste your time making an appointment with a therapist, and incur the expense, only to find out that the therapist in question has little or no experience with your particular problem. If you and your family have problems which would require family therapy, then make sure you find a therapist who specializes and is well-trained in family therapy. If your problem is sexual in nature, find someone who has lots of experience doing sex therapy. This is not to suggest that everyone who needs therapy should find a specialist; often this is not necessary. Before you ever pick up the phone to call a therapist, figure out what you want to know about the therapist's background and areas of special interest. And if you happen to speak with a therapist who refuses to answer your questions satisfactorily, you might as well move on to someone who will.
(1-5) Should I see a male or a female therapist? There are too many variables to allow for a simple answer to this question. All things being equal, it shouldn't make any difference. But the world of therapy in some ways mirrors the larger world, and so sometimes it can make a big difference whether you go into therapy with a male or a female. It may be easier for you to talk with someone of your own gender, especially about very personal things, in which case that alone may be the deciding factor. The psychotherapy profession is by no means entirely free of sexism, and if you choose to work with a therapist of the opposite sex, you should of course be sensitive to those issues, and never hesitate to terminate with a therapist who seems to be sexist. Occasionally, working with a therapist of the opposite sex makes good sense, e.g., if the parent with whom you had the most difficulty was the parent of the opposite sex, you may find it to your advantage to work through these issues with a therapist of the same sex as your troublesome parent; on the other hand, if you suffered sexual and/or physical abuse from a parent, working with a therapist of that parent's sex might be too frightening. As a rule of thumb, if you are under the age of 20, you'd generally be better off with a therapist of the same sex. If you’re an adult and choose to work with a therapist of the opposite sex, just make sure you choose someone who seems genuinely comfortable with you and with the issues which might be gender related. There are in fact plenty of good, highly competent therapists who can work well with clients of either sex, but finding such a therapist may require some effort on your part.
(1-6) What does a therapist provide? Assuming you are able to find a good therapist, that person will provide you with a safe haven in which you can discuss with complete confidentiality your current problems, your family history, your feelings about yourself and others in your life. A good therapist will have the training, expertise, and skill to help you gain a better understanding of yourself and your problems --better than you have been able to do on your own, by talking with friends, or by reading self-help books.
A good therapist is by definition a good listener, and someone who will pay very close attention to what you say, so that you feel heard and you know that you are being taken seriously. In the best sense of the term, a good therapist provides an atmosphere of trust, so that eventually you will feel secure in talking about anything of importance to you, no matter how difficult or painful it may be. A therapist should know the resources in your community, and thus provide you with ideas and referrals for problems which may not fall within the parameters of therapy.
And finally, a good therapist will help you create a plan and process to help you actualize your goals---your reasons---for being in therapy. Regardless of the theoretical orientation or the professional background of the therapist, regardless of what a particular therapy is called, the therapist should provide you with the security that you are in fact moving from Point A to Point B - that is: that you're getting somewhere. And if you suffer from specific psychological symptoms, your therapist should be able to help you, in the context of therapy, to find relief from or even eradicate those symptoms.
(1-7) What kind of questions can I ask the therapist? You can ask questions about a therapist's education, training, professional experience, and areas of professional expertise and interest. You can and should ask questions about a therapist's fees, cancellation policies, and any other expectations that he or she might have of clients. You can ask questions about how the therapist works, and what his or her theoretical orientation is. You should ask any questions you may have about confidentiality. In short, you should be able to ask and receive answers to all of the questions you have prior to entering into a very significant professional and contractual relationship. If the therapist refuses to give you answers to your questions, or answers them in ways which are incomplete or not helpful, you might want to consider trying another therapist.
It is not reasonable to expect that therapists will answer highly personal questions. A therapist may choose to disclose, when he or she deems it appropriate to do so, certain basic facts about their lives; while other therapists may believe that any kind of self-disclosure is inappropriate. If it is important to you to work with a therapist who is willing to disclose some things about his or her life, then find a therapist who will. If this doesn't matter to you, then obviously it is not an issue.
But if you are the kind of person who requires a certain kind of warmth and self-disclosure on the part of the therapist, then don't waste your time trying to work with a therapist who is remote, distant, and refuses to answer any questions. However, do be wary of the therapist who wants to talk about his or her own problems---this is completely inappropriate and unprofessional.
(1-8) How often do I need to come in for therapy? The answer to this depends on many things: the kind of therapy you are doing: the way your therapist works, your own financial situation, and whether you are at the beginning or the end of the therapy process. Classical psychoanalysis and psychoanalytically oriented psychotherapy require three or even four sessions per week: However, this is not the norm for most kinds of therapy. With but few exceptions, the great majority of therapists see their clients on a weekly basis, for one hour sessions, or for what is commonly called
the ''50 minute hour.'' Most therapists are reluctant, especially at the beginning of the therapy process, to see clients less than once a week, simply because sessions every other week or once a month work against the sense of continuity and momentum which is important to the process of therapy. However, if special factors make weekly meetings impossible, there are certainly therapists who are willing to meet less often. Also, some therapists have a sliding scale of fees, and sometimes this will make weekly sessions possible for people with reduced incomes. Once the more intensive and demanding part of therapy has been completed, it may then be appropriate to switch from once a week to every other week. Clients in crisis may need, at the beginning, more than one session a week.
(1-9) What are the costs of therapy and what about insurance coverage? Therapy fees vary enormously. The fees of Psychiatrists tend to be the highest, typically in the range of $150 to $200 per hour. In California, the range of therapy fees for Psychologists, Licensed Clinical Social Workers and Marriage, Family, Child Therapists is typically between $90 and $150 per session. As previously mentioned, some therapists do have a sliding scale, others do not. Therapy fees in other states are probably lower than those in California, depending on the specific location. For people who elect to see therapists in private practice, it's a fairly considerable expense unless the cost is defrayed partially by health insurance. However, it is wise to avoid any therapy situation which is so expensive that it jeopardizes your lifestyle. If you don't have the personal and/or insurance resources to afford private therapy without making unreasonable sacrifices, then it may be better to consider finding therapy in a clinic setting, where the costs are more in keeping with your income. As part of their public health programs, many cities have mental health clinics, staffed by competent professionals, with a low-cost fee structure.
lf you do have health insurance, be sure and determine exactly what the benefits are for outpatient psychotherapy. Read your insurance benefits book or call your insurance provider. The actual provisions for mental health vary tremendously from provider to provider, so it is important to know what you can count on. There are also government-sponsored health care programs which often have good mental health coverage - including Medicare for people over 65, and insurance plans for government employees, and military personnel.
If you are a student, you can often obtain free counseling sessions at your college healthcare center, although usually only a fairly limited number of sessions. Certain HMO’s (health maintenance organizations) such as Kaiser, offer a limited number of low-cost therapy sessions to members.
In general, insurance coverage for psychotherapy is much less generous than it was a few years ago, especially if you receive your coverage from an HMO. The mental health benefits offered by HMO’s vary considerably, so it is very important to determine your benefits before beginning therapy.
(1-10) What about confidentiality? Is it true that therapists record the sessions? The principal of confidentiality between client and therapist is central to all forms of psychotherapy. No one should have knowledge that you are involved in mental health treatment. If anyone were to contact your
therapist about your treatment, he or she should not even acknowledge that you are in treatment. Written release of records can occur only with your written permission. All therapists are required to keep written notes, but these notes are of course completely confidential. Some therapists do record
sessions, in lieu of taking notes, but your permission should be granted to the therapist for this purpose; and you have the right to decline, if this were to make you uncomfortable. In fact, not very many therapists record sessions; most of us just keep notes. If you have any questions or concerns about confidentiality, be sure to discuss them with your therapist at the beginning of treatment.
You should be aware, also, that there are certain legal limits to confidentiality. In California, the law requires therapists to contact proper authorities if you disclose any information about having abused a child or an elderly person, or if you indicate that you may cause serious harm, to another person or to yourself.
(1-11) If I use my insurance coverage, will my employer find out and will this be used against me? According to the law, your employer has no right to see any of the records relating to your mental health treatment, or even to know that you are using your insurance behests for that purpose.
lf you apply for new insurance coverage and report that you have had prior treatment for psychological problems, it is possible that an employer could use this against you, although this cannot be done legally.
It is unfortunate but true that many insurance companies now are deliberately declining new patients who have had in the past or currently have serious physical or mental illnesses. If you are given what is called a “parity” diagnosis in therapy (i.e., a diagnosis for what is considered a serious illness, such as depression or anxiety), it could prevent you from changing insurance companies in the future—that is, you application could be declined on that basis. Therefore, you should discuss with your therapist the implications of his or her diagnosis.
(1-12) As a clients what are my rights in therapy? Although the laws, legal and professional codes vary from state to state, in most states these laws and codes seek to protect clients from any harm which might result from the rather unique relationship which occur in therapy between the client and therapist: One of your primary rights is that of informed consent; that is, you have a right to all relevant information about the therapist and his or her proposed methods of treatment, the fees involved, the risks and behests of treatment, and an understanding of the limitations of confidentiality. All of this information should be available to you so that you understand everything necessary to give your informed consent. And of course, you have every right to decline treatment, once you have had a discussion of these relevant facts.
You also have a right of access to your files. It is generally a better idea to ask your therapist for a summary of the information in your files, and to ask questions about your therapist's diagnosis, observations, etc. In most therapy situations, a client's access to his or her files does not even come up. However, it may be helpful to know that you do have the right, legally, to see your files, even if you never exercise the right. With a few notable exceptions, you have every right to expect complete confidentially with your therapist. For a longer discussion of this issue, see Answer I-10.
Finally, you should know that there are significant legal penalties for therapists who attempt to or who actually do have sexual relationships with their clients. Should you be unfortunate enough to be in therapy with someone who even suggests the possibility of a sexual relationship with you, you should terminate therapy immediately and report the therapist to the appropriate professional board. (See Answer I-20, below.)
(1-13) What difference, if any, does the theoretical orientation of the therapist make? lf you don't know the theoretical persuasion of the therapist you have chosen to see, it's a good idea to ask this question before you begin treatment. A fair number of therapists, myself included, have what is called an ''eclectic'' approach to theory; that is, I do not subscribe to any one theory of human behavior and psychology, but rather I borrow from many, and thus I have a theory about human behavior and about therapy which is at least somewhat unique to me. Therapists who subscribe to one theory--such as Freudian or Jungian theory--do have a particular focus in therapy, a focus which reflects the tenets of that theory. The theoretical orientation of the therapist does make a difference, but it would not be easy to be very specify about these differences within the limited confines of this FAQ. Your local bookstore or library should have one or more books---guides to therapy---which explain in detail the different kinds of psychological theories and the different kinds of therapeutic approaches. If you have the recommendation for a therapist of someone whose opinion you trust, usually it is not necessary to do a whole lot of reading or research prior to beginning treatment, unless these matters are of particular interest and significance to you. But whether you see an orthodox Freudian therapist or someone who is eclectic, any therapist should be able and willing to describe for you the theoretical underpinnings of his or her approach to therapy.
(1-14) How do I know if I've found the “right'' therapist? Your ability to locate a therapist who is fully qualified to help you with your particular problems or symptoms does not mean, alas, that you've found the right therapist. A properly qualified therapist is only a starting point. While the answer to this question is ultimately somewhat subjective, you can assist your own intuitive evaluation by keeping these questions in mind: Is this someone who really listens carefully to what I have to say? Is this someone who seems to understand me? Is this someone who takes me seriously? Is this someone who seems to be able to help me get a new and different perspective on myself and my problems? Is this someone who cares about me? Is this someone I'm willing to be really open with? To summarize all these questions: Is this someone I can trust? While there are inevitably aspects of therapy which will make you uncomfortable, you need to feel generally comfortable with the therapist you work with. In other words, there needs to be a good ''fit'' between you and your therapist; otherwise, the process of therapy will feel constrained, awkward, and even unpleasant.
In posing a question about the ''right'' therapist, I do not mean to suggest that there is only one such person for you, and that somehow you must find that person. Very likely there are many therapists who could qualify as the ''right'' one, and it is extremely important to you that you make this determination. You may have to try out more than one therapist, perhaps even two or three. It's perfectly okay to tell any prospective therapist that you're ''shopping around.” It's possible you may find the right therapist on your first try, but never assume this will happen. Trust your feelings above all, and your judgment, and your intuition. Don't be intimidated by someone's credentials or their manner.
Before starting the process of looking for a therapist, you might also think about some of the qualities you'd like to see in a therapist. For example, if humor is important to you, then very likely you'd work much better with a therapist who also had a good sense of humor. If it's important to you to get a fair amount of feedback, interpretation, and interaction, then by all means find a therapist who provides this, because you'll be very unhappy with a therapist who says very little.
How long does it take to figure out whether you've found the right therapist? It shouldn't take more than three sessions. By the end of the third hour with a therapist, you should already have a pretty good sense if this is someone you can work with effectively, if this is someone who can really help you, if this is someone you can trust or learn to trust: It's okay to be a consumer in this process; keep looking if you're not satisfied. The only caveat here is that if you keep going through one therapist after another, then it's probably not a question of bad luck or not being able to find the right one. It may be that you're not willing to trust anyone enough to open up and really get involved in therapy. And that, ironically, would be a good thing to talk about with a therapist!
(1-15) How do I know if therapy has been successful or unsuccessful? Because the process of therapy is not nearly as precise or obvious as building a bookcase or making a pie, the evaluation of whether or not therapy has been successful is necessarily somewhat amorphous, unless you go into short-term therapy for the purpose of dealing with one highly specify problem. But in any well-constructed therapy, the client and the therapist should have goals which are known and agreed upon, so that when therapy concludes there is some way of measuring the process or lack thereof. It would be a mistake to think of the process of therapy as an unwavering ascent to the desired goal. While there may in fact be a ''two steps forward one step back'' quality to therapy, the general trend should be unmistakably forward. If you go into therapy for some period of months and nothing improves--- your symptoms are the same or worse, you seem to have no better handle on your problems than before---you should at least question whether or not you are working with the right therapist, and in fact it would be good to take up your concerns directly with the therapist. In a successful therapy, there is typically a sense of completion, that your goals have been generally achieved, and therefore terminating therapy feels like the right thing to do. If your therapy has been unsuccessful, there will be, in contrast, a persistent sense that nothing has really changed, that your symptoms or problems have not noticeably improved, that you go in week after week and ''nothing much happens.'' While there are certainly dry spells in even the most successful therapies, if the pervasive feeling is that of ''stuckness'' and lack of progress, it makes sense to end therapy and perhaps see if you can work more effectively with someone else.
(1-16) What's the difference between short-term therapy and long-term therapy? There is no way to answer this question definitively, because therapists vary tremendously in how they would define these terms, and there is no agreed upon professional norm. In any case, the differences between short-term and long-term therapy involve both time and emphasis. In terms of how I conceive of this matter, short-term therapy would be anything between one session and six months. Of course, if a client terminated after six months of therapy, I would not say that he or she had been in long-term therapy. Most therapists would consider one to three years as long-term therapy. And with respect to clients who come in on a regular basis for several years, some of them do so because their history and current life problems may require the long unfolding of a trusting relationship with a therapist, and the slow but sure process which takes place over the long haul in therapy. Other clients who are in long-term therapy may not need to be in therapy for this amount of time, but choose to do so as part of their own process of growth and self-awareness.
The emphasis in short-term therapy is necessarily much more focused and directly solution-oriented than in long-term work. It is a perfectly legitimate use of therapy to come in for a few times to work on one highly specify problem, to get a better handle on the problem or even solve it. If this is your reason for going to see a therapist, you should check out with the therapist on the phone if he or she works in this short-term, problem-solving manner. Some therapists disdain working in this way, while many others, myself included, believe that short-term therapy is very appropriate for many people.
In long-term therapy there will very likely be a much greater emphasis on family history, and the effort to trace current problems or symptoms to their earlier roots. In long-teen therapy the relationship between client and therapist assumes a much greater importance than in short-term work, and the relationship itself is integral to the treatment process. Also, in long-term work, greater attention will be paid to the unfolding of feelings which have been previously denied or out of conscious awareness; in this sense, there is a mutual effort by the client and therapist to access the deeper levels of the psyche. In long-term work there is less emphasis on the focused, problem-solving aspects of therapy and more emphasis on gradual, evolutions change which rejects increased self-awareness and understanding, and the integration of previously conflicted parts of the Self.
(1-17) What about the use of drugs for psychological problems? During the past twenty years there have been significant advances in our understanding of the biochemical components of certain kinds of psychological problems, and there have been, correspondingly, new drugs created for the treatment of those problems. While a few therapists disdain the use of drugs, many others have adopted a more accepting attitude, and now appreciate that for many clients a combination of psychotherapy and drug treatment may offer the best approach. This has been true especially for different kinds of depression, since certain depressions have a known biochemical component and to ignore this in favor of an exclusively psychotherapeutic approach may leave the client stuck in a seemingly permanent depression. Obsessive-compulsive Disorder (OCD) is another psychiatric problem which has been helped greatly by use of appropriate medications, along with behavior-oriented therapy. There are numerous other problems which may be helped by the use of medication, although medication is typically given in the context of on-going therapy.
There are legitimate concerns among many professionals in medicine and the mental health sold that certain drugs, such as Prozac, are being over-prescribed, and given to people who do not really need them, much in the same way tranquilizers were abused back in the 60's and 70's. Anti-depressant medications are properly prescribed only for people who are clinically depressed, or who suffers from OCD, not for someone in quest of the Prozac ''high.''
Whether or not you have a problem which might be helped with medication is up to you and your therapist to decide. If your therapist does recommend the use of medication, remember that the decision to do so is yours and yours alone. It is a very important aspect of informed consent: that you have all the information you need, that all your questions answered, and that you have a full understanding of the risks and rewards, the possible side effects, of any medication which might be recommended. Never allow anyone to pressure you into taking medication if you feel opposed to this idea.
lf you are not working in therapy with a psychiatrist, then your therapist will refer you to one for a consultation, assuming that you and your therapist have agreed upon this course of action. The consulting psychiatrist will do an evaluation, usually an hour or hour and a half and, based on this evaluation, he or she will either concur or not with the recommendations of your therapist. Future consultations with the psychiatrist who prescribes the medication will typically be once every month or six weeks, usually just for 15 minutes and often over the phone, just to make sure the medication is working properly and that there are no unacceptable side effects. The consulting psychiatrist is not someone with whom you will also be doing therapy. There are many books and articles written for the general public about the use of these kinds of medications, and if you want to inform yourself more extensively, see what's available in your local bookstore or library, or use the Amazon.com search engine.
(1-18) Do therapists give opinions, interpretations, advice? What about therapists who don't say much? Yes, of course, but how much you get of any of these will depend entirely on the person you are seeing. In certain kinds of therapy---such as psychoanalysis or the more orthodox kinds of psychotherapy---you would discover that the therapist does not say a great deal, and the talking is largely left up to you. In these kinds of therapy, interpretations and opinions are given infrequently, and advice rarely. These days, however, most therapists are considerably more interactive than the models just mentioned. Most clients who come into therapy prefer to have therapists who are at least moderately interactive, who ask questions and reply to questions, who give opinions and interpretations with greater frequency than one might find in the more orthodox therapies. Giving specific advice is something therapists should do sparingly, if at all, since one of the objectives of therapy is to enable the client to be able to make his or her own choices in life. Since therapists vary a great deal in the degree to which they interact with clients, you should have some idea what your own needs are in this respect. lf you're a person who wants a therapist who engages with you, gives opinions and interpretations, then you might find yourself uncomfortable with a therapist who is from the ''Uh, huh'' school, and who doesn't say much. Remember, it is of great importance that you work with someone with whom you feel comfortable, and the degree of interaction from the therapist is part of that equation.
(1-19) Is it a problem if the therapist and the client have very deferent value systems or belief systems? It shouldn't be a problem, not if you're fortunate enough to find yourself a really good therapist. If you're a practicing Roman Catholic, could you work well with a therapist who happens to be an atheist? Absolutely, unless it's a problem for you. Therapists are not (or shouldn't be) in the business of foisting their values and beliefs on clients; that's not what therapy is about. The exception to this would be if you happen to be engaged in behavior which is harmful to yourself or others----it would not be reasonable to expect a therapist to endorse this, in the same way he or she might endorse your religious beliefs. Therapists should never do any kind of proselytizing with their clients---and should you end up with such a therapist, that should be your clue to terminate and find someone else. Gays and Lesbians can work effectively with straight therapists, just as straight clients can work well with gay therapists---assuming, of course, that the basics for a good therapy relationship are there. There is, of course, a certain amount of self-sorting that goes on in this area, but there need be no hard and fast rules.
(C-1) How does couples therapy differ from individuals therapy? There are a member of differences between the two kinds of therapy, including amount of time, focus, and participants. Couples therapy only rarely becomes what one might reasonably call long-term therapy. Typically, couples therapy lasts anywhere from three months to a year, sometimes less, sometimes more. As with individual therapy, once a week sessions is the usual time commitment expected of clients. In my experience most couples can deal satisfactorily with the issues which brought them into therapy in six months; and so often when couples I work with continue past that point it's because they want to, rather than need to.
Because couples therapy tends to be much more time-limited than individual therapy, the focus is necessarily more present-oriented. There is an emphasis in dealing with specific, here-and-now issues: conflict resolution, communication, money matters, trust & commitment, sex, etc. Because problems are inevitably part of every long-term relationship, the primary effort in couples therapy is to help couples get to the point at which they can deal effectively with their own issues, and resolve their own problems without professional assistance.
Although some therapists may structure couples therapy differently, most therapists expect to see both people in every session. When I begin working with a couple, unless they are in crisis, I will take the time at the beginning of therapy to do a one-hour individual family history with each person, so that I can have a better sense of each person's family-of-origin issues. Beyond that, however, I rarely have occasion to meet separately with either person, and do only with the permission of the person not coming in. And such individual sessions deal only with the problems of that person, not that of the relationship.
(C-2) How do I know if my partner and I need couples therapy? The main criterion for determining whether or not you and your partner need couples therapy is the presence of significant problems which do not improve over time, despite your best efforts, and which ultimately come to trouble and even threaten the viability of the relationship. Couples who enter couples therapy are typically beset by problems which seem to be circular in nature---that is, the same problems keep coming up again and again, so that they have a repetitious and circular quality to them. The persistence of problems often causes the two individuals in the couple to polarize, which serves only to exacerbate the problems and to cause, sometimes, feelings of hopelessness and despair. It's easy for couples to get into their own versions of the proverbial vicious circle, in which one bad thing leads to another. There is a certain commonality to the problems which couples bring into therapy because, after all, there are only so many things people can fight about. Money, children, sex, conflict resolution (or the lack thereof), communication problems, unmet needs and expectations, in-law problems---while individuals may differ greatly, the problems they bring into couples therapy are fairly similar. Most couples predictably have problems of one kind or another with communication; similarly, most couples have problems with anger—that is, how to express it effectively and non-destructively.
Unless you happen to be of the persuasion that couples should never fight and never have bad feelings for each other, then the main thing you should think about is whether or not your problems are persistent, unchanging, or perhaps even becoming worse. If this is the case, you and your partner could probably make good use of couples therapy.
(C-3) What should I do if I think we need couples therapy but my partner does not? This is a difficult and surprisingly common problem. When I meet with a new couple, I often find that one person is there only with great reluctance, and sometimes with quite a bit of trepidation about what is going to happen. If you really have reason to believe that your relationship is in trouble and that couples therapy would be helpful, if your partner is opposed to this idea, then propose going just one time.
This arrangement provides your partner with an escape hatch, if he or she really needs one, but at the same time may actually get the two of you into a therapist's office.
Often the first session will be sufficient to convince the reluctant partner that there is some merit in the process. You could also try the ''just-do-it-for-me'' approach---and while that would not serve as a basis for any kind of continuing therapy, it might be enough to get you started. If al1 else fails, you can always go in by yourself, but doing what I call couples-therapy-minus-one has a lot of obvious drawbacks. Sometimes, however, it's better than nothing, because at least you have the chance of getting a competent professional's feedback about your relationship.
(C-4) What kind of problems are appropriate to couples therapy? As indicated by Answer C-1 in this section, the problems most suitable for couples therapy are those which are persistent, circular, repetitive, and which seem to resist your own best efforts to solve them. Anger is almost always a problem in relationships: either there's too much expression of it or, ironically, not enough. Most couples handle anger poorly and need a 1ot of work in creating a space in which anger can be expressed in nondestructive ways. Communication is virtually a universal issue in couples therapy: everyone can use some improvement in this area. Statistically speaking, money is the top issue in couples therapy: more people conflict about money than any other single issue. The reason for that is usually not so much the actual numbers of dollars available in the couples life, as much as the fact that individuals often attach different meanings to money. For couples who have children, parenting is a frequent point of conflict and difficulty, and often comes up in couples therapy. Contact is another common problem: two people in a relationship rarely have identical needs for contact: one person wants more than the other, and this issue then gets acted out in all kinds of complicated ways. Decision making and the sharing of power is another common issue. If both people in the relationship work full time, there are often convicts about household chores, who does what, etc. While sex is often a problem in long-term relationships, in many relationships it is not dealt with as a problem---but only because sex is the most under-discussed issue there is. Sex will often stay submerged as a problem, even in couples therapy, unless you happen to end up with a couples therapist who is comfortable with and knowledgeable about the topic. On a deeper level, there are problems in long-term relationships which result from the fact that either or both people may not have successfully completed their basic psychological developmental tasks, with the result that a 1ot of unfinished business impinges on the relationship. For this reason, it is sometimes essential for people in couples therapy to do some individual therapy concurrently.
(C-5) What kind of problems are not appropriate to couples therapy? It is not reasonable to expect couples therapy to deal with those individual symptoms and problems which are properly the domain of individual psychotherapy. (See Answer I-1 in the first section of this FAQ: “How do I know if I need therapy?') For example, if one person in a couple happened to be clinically depressed, then couples therapy should be postponed until the depression is satisfactorily treated; or, if the depression is not too severe, then that person could conceivably do individual therapy and couples therapy concurrently. Also, couples therapy is never appropriate when one or both people in a couple is actively involved in alcohol or drug abuse; couples therapy can proceed only when that person has received treatment and is part of an on-going program. And finally, couples therapy is not an appropriate treatment modality if the relationship is characterized by physical or sexual abuse; in such an instance, the physically or sexually abusive person would require treatment prior to couples therapy. There are some couples in which the level of verbal abuse is so severe and so toxic that couples therapy is not a helpful treatment modality.
(C-6) How do I find a good couples therapist? For a general response to this question, refer to Answer 1-2: ''How do I find a good therapist?'' in the first section of this FAQ). More specifically than that, it is of paramount importance that you find a therapist who is experienced in working with couples. This you can determine by asking the person who made the referral to you, and by asking the therapist about his experience when you call to make the appointment. Although many therapists will say they do couples therapy, it's important to find out if this is a specialty of theirs, by virtue of training and interest. Other than that, the best thing you can do is to try out a few therapists before you make up your mind. It is of great importance that both you and your partner are comfortable with the therapist. There is no way of avoiding the fact that couples therapy is a triangular relationship, which means it contains all the hazards of three-way relationships. A good therapist will avoid the trap of taking sides, because nothing will undo couples therapy faster than that. While therapists must, from time to time, ''lean'' in the direction of one person's point of view, this is quite different from taking sides. A good couples therapist will establish goals which are reasonable for this kind help you define your issues clearly, work with you to of therapy, and fairly quickly create a context in which there is a sense of process and change. A good therapist will help to contain conflict, rather than letting it get out of hand, and will offer ways and means of creating a system of conflict resolution.
(C-7) Do all therapists do couples therapy? Absolutely not. Couples therapy is not typically part of a psychiatric residency and it may be only a token part of the curriculums of graduate schools which train therapists; therefore, therapists who do couples therapy are those who have taken the trouble to do additional training, reading, workshops, etc., and who have taken a particular professional interest, therefore, in developing a way of working effectively with couples. There are very few therapists who do only couples therapy. If you're looking for a couples therapist, it's generally best to go and find someone who has had a fair amount of experience doing it, and for whom couples comprise at least a substantial minority of his or her practice. If you do not know this information when you contact a therapist to make an appointment, it is perfectly reasonable to find this out over the phone. And finally-- -as I indicated in the previous question---the best thing you and your partner can do is ''shop around'' a bit and try out more than one therapist, unless you happen to find the right person on your first appointment. Make sure you are both reasonably comfortable with the therapist. (I say “reasonably,” precisely because it is in fact a little daunting for two people to sit down with a complete stranger and start talking about the most difficult aspects of their relationship.)
(C-8) What should my partner and I expect to get out of couples therapy? Unless you are going in for the express purpose of ending your relationship, the best thing you and your partner can expect from couples therapy is to acquire an ability to handle your problems as a couple effectively. And sometimes this means acquiring, in the process, an awareness that some problems never really go away entirely. Not only do a majority of marriages end in divorce, a fair number of couples who stay together do not, in fact, have healthy, growthful relationships. Perhaps more than any other single factor, what separates successful couples from unsuccessful couples is that the former accept the fact that there will always be problems in a relationship, and they work out effective ways of handling them. This is really what good couples therapy is a11 about. You can expect to learn better ways of communicating. You can expect to learn greater acceptance of your partner. You can expect to learn how to take responsibility for your own contributions to the issues. You can expect to learn more about your partner's needs and wants. You can expect to learn to handle conflicts more effectively than when you first entered therapy. You can expect to learn something about truly listening to your partner. You can expect to learn how to define your own needs and wants more completely than you have in the past. You can expect to learn something about your own family of origin and how some of the issues from your childhood and adolescence currently impact on your relationship. And if a11 of these expectations are met in couples therapy, you and your partner will have learned how to stop ''acting out'' your problems on a day-to-day basis, by creating a context in which you can step outside of the relationship, so to speak, and talk effectively about anything that is troubling you.
(C-9) I've heard that couples therapists give ''homework.'' Is that true? It is true that many couples therapists make suggestions for things a couple can work on between sessions, and that sometimes these things are labeled ''homework.'' It's not a very good term, however, because it connotes the classroom, with the teacher making assignments and then giving grades. There are two reasons that I give ''homework'' to the couples I work with: first of all, it very much speeds up the process of therapy when a couple is willing to put time and energy into their relationship between sessions. If the progress of a couple is dependent entirely on the one hour a week they spend in therapy, then progress can be glacially slow. The other reason for ''homework'' is that creatively constructed suggestions provide the couple with new contexts for experiencing themselves, their relationship, and the ways they have of dealing with problems. Since the o1d ways are by definition inadequate, the process of therapy should generate new ways of being, doing, and understanding--- and this is very much enhanced, in my experience, by giving ''homework.'' Every couple has complete freedom to follow or not to follow any particular suggestion of mine. And there are no grades!
(C-10) What happens if one person wants the relationship to continue and the other person does not? It's not uncommon for two people to come into couples therapy with different agendas. This in itself is not a problem, especially since once each person’s agendas are discussed in full, there will be some commonality after all. However, sometimes one person will announce, to the complete surprise of the other, that he or she wants out of the marriage. Usually means that the person who wants to exit the relationship has not had the courage to bring this up with the partner, and therapy is chosen as a safer context for this. This can be a very difficult point in therapy, since the person wanting to maintain the relationship may feel---quite legitimately---blindsided. There is no way of realistically predicting the final outcome when one person wants in and the other wants out, unless a truly irrevocable decision has already been reached by the person wanting to end the relationship. Often enough, two people will decide to stay together after they've had a chance to work on things in therapy, but this result is by no means guaranteed. It is of course important that the therapist be neutral, which means in turn that the therapist must be ideologically open to the concept of divorce. There are some therapists who act like marriage brokers and seem to take it personally if a couple breaks up; stay away from therapists like this, if at all possible. A good couples therapist will work overtime to help two people make their relationship better, lf that's what they want; but that same therapist should also have the ability to help people separate as non-destructively as possible, if it comes to that.
(C-11) Is it helpful to see a couples therapist if my partner and I have already decided the relationship is over? Yes, absolutely. This is especially so if you've been in the relationship for a number of years, and even more so if you have children. It is regrettably common for marriages to end with a lot of hostility and mutual recrimination, to the point where little is left but deep antagonism. Ending a long-term relationship is one of the most difficult of life's transitions, and few people are equipped to do it gracefully. In the best of a11 possible worlds, two people would mutually decide that their reasons for being together have changed or no longer exist; and that, following the process of separation and/or divorce, both people would remain in contact with each other and in fact would remain good friends. This does happen, of course, but not very often. More typically, when a long-term relationship ends, very deep feelings are stirred up, and there is often an effort by each person in the couple to blame the failure of the relationship on the other. There are a number of problems with this approach. First of all, it feels terrible for two people who once loved each other to take leave of each other as virtual enemies. Secondly, people who split up in this antagonistic manner rarely learn anything about themselves in the process, and so they are very likely to repeat a11 the same mistakes in their next relationship. Finally, and most significantly, if children are involved, the process of their parents getting divorced is extremely painful, even in the best of circumstances; but if the separating parents indulge in rage and vituperation and moral character assassination, the psychological damage to children is always much greater. While this may sound a bit moralistic, I feel that if children are involved in a parental separation, the parents have a responsibility to achieve a reasonably amicable separation, and often this can only be done with professional help.
(C-12) Do couples therapists ever take sides? A good couples therapist will maintain, most of the time, a posture of neutrality. The therapist is not there to serve as a judge, assigning blame to this or that person. If the therapist does not take sides, then each person will feel safe, and will believe that his or her feelings and opinions are as valid as the other's. I distinguish the process of directly taking sides from what I call ''leaning'' in one person's direction. Suppose one person has had an affair, and the couple is attempting to deal with this. While it would never do for the therapist to harshly judge the person who'd had the affair, it would be appropriate to be more supportive of the person who had been betrayed---this is what I mean by ''leaning.'' In the general course of couples therapy, one person may have a more reasonable position about something, and then in another session his or her partner may have the more reasonable voice. Without sacrificing his therapeutic neutrality, the therapist can certainly ''lean'' one way or the other, as long as there is a balance in this process, so that one person does not feel ganged up on. Of course, it is of crucial importance that the therapist is aware enough of his/her own ''leanings'' so that they are deliberate rather than unconscious. In my estimation, complete neutrality on the part of the therapist is a myth: The best you can hope for in couples therapy is to find someone who is very conscious, who likes and respects both men and women, and who is determined that, overall, each person's viewpoint and feelings are respected.
(C-13) What’s the difference between couples therapy and family therapy? There’s a big difference and it’s very important. Couples therapy is just that: it’s a type of therapy in which two people in a relationship consult with a therapist to deal with the issues of that relationship. Family therapy deals with the larger context of the family, i.e., the therapist would expect to see parents and children together; occasionally, relevant other family members might be included: grandparents, uncles, aunts, etc. If you are considering family therapy, it is very important that you find someone who has been trained in family therapy and who has a lot of experience doing it. (I do not do family therapy myself, because I have not had that kind of training.)
Answers to Questions about Sex Therapy
(S-1) How does one go about finding a good sex therapist? To start with, read Answer I-2 in the FAQ section on individual therapy, entitled ''How do I find a good therapist?'' Additionally, it is well to keep in mind that sex therapy is a specialized form of treatment, and that most therapists do not have the training required to do it. While a special kind of license is not required to do this kind of therapy, the appropriate training is required. If you are unsure if the therapist to whom you have been referred is properly trained in sex therapy, be sure to determine this information over the telephone. If you are beginning your search for a sex therapist without any referral, call the American Association of Sex Educators, Counselors, and Therapists (A.A.S.E.C.T.) in Washington, D.C., and request a referral from this organization. If there are several qualified therapists in your area, get all of the necessary information, since you may not be satisfied with the first therapist you see. It is very important that you not work with a therapist only because he or she happens to be qualified; this is only a starting place. Another way to and a sex therapist is to call various other therapists and see if they can recommend anyone; most therapists know someone in the are who is qualified to do this kind of work. Your physician or minister might be able to make a referral for sex therapy, but I wouldn't count on it.
(S-2) What kinds of problems are dealt with in sex therapy? Sex therapy is the appropriate form of treatment for anyone what has what is called a sexual dysfunction. For men, the dysfunctions include: premature ejaculation, erectile disorder (impotence), retarded ejaculation (difficulty in reaching orgasm), and low sexual desire. For women, the sexual dysfunctions include: arousal disorder (difficulty in becoming sexually aroused), orgasmic disorder (difficulty in reaching orgasm), dyspareunia (genital pain before, during, or after intercourse), vaginismus (a muscular contraction of the outer third of the vagina which interferes with or makes intercourse impossible; and 1ow or inhibited sexual desire. As a method of treatment, sex therapy is particularly well suited for a person with any of the above-mentioned sexual dysfunctions. However, one does not have to have one of these dysfunctions in order to benefit from sex therapy. This kind of therapy also works well with couples who are simply having difficulty with sex--- i.e., when the various stresses and stains of a relationship have negatively effected a couple's sex life. Sometimes couples have troubled sex lives only because they have never learned effective sexual communication, and this can usually be helped quite a bit by doing a few sessions with a good sex therapist. Certain kinds of sexual problems, called the paraphilias, are generally not treated with traditional sex therapy, although some sex therapists are qualified to treat them. The paraphilias include: exhibitionism, a male problem which involves the compulsive exposure of genitals to strangers; fetishism (also almost always a male problem), which involves the use of inanimate objects such as shoes, stockings, underwear, boots, etc., to achieve sexual excitement; pedophilia which involves persistent sexual urges, fantasies, or sexual behavior with underage children; sexual masochism, which means obtaining sexual satisfaction and pleasure by receiving physical or psychological pain; sexual sadism, which means obtaining sexual arousal by inflicting physical or mental pain; transvestism, or becoming sexually aroused by wearing the clothes of the opposite sex; and voyeurism, which involves a persistent pattern of sexual arousal obtained by secretly observing others involved in nudity or sexual activity. (Note: mild forms of sado-masochistic behavior, such as light spanking or bondage, are not uncommon in many ''normal'' sexual relationships; S&M behavior is considered to be a paraphilia only in its extreme forms, when it dominates a person's entire sexual experience, and may in fact spill over into other aspects of a person's life.) The paraphilias are likely to be treated by psychotherapy, behavior therapy, medication, or a combination thereof.
(S-3) Can I do sex therapy as an individual client, or does my partner have to come in, too? There is little question that sex therapy is most effective when both people in a couple participate in the treatment. In long-term relationship, especially, it is unusual for a sexual problem to be confined, so to speak, to one person. Even when one person ''has'' the problem (e.g., a man who has erection problems but whose partner functions adequately), sexual problems almost always affect both people, and so when only one person is treated, it is much more difficult to resolve the problems. It's not uncommon for one person to be the ''identified patient'' (the one who has the problem), and for the other person to be angry, hurt, withdrawn, etc., and therefore not especially walling to participate in treatment. If you are involved with someone who is reluctant to consult with a therapist, see if you can get your partner to agree at least to do one session, which would give the therapist a chance to explain what is involved in therapy, and how much more effective it is if both people participate. Many of the most commonly given ''exercises'' in sex therapy involve two people---massage, sensate focus, and so on. participation of both people----for example, a previously orgasmic, or a man with premature ejaculation may learn some measure of ejaculatory control---but without the participation of a partner, the results of therapy tend to be less successful. Finally, if you're involved with a person who is so afraid, or so uptight, or so selfish that he or she absolutely refuses to participate in treatment, you might reasonably ask yourself what you are doing with such a person.
(S-4) How is sex therapy different from couples therapy? The main difference between the two kinds of therapy is that there will necessarily be more of a focus on sex in sex therapy. Most qualified sex therapists no longer practice ''pure'' sex therapy, i.e., an exclusively sexual focus in therapy. We have learned over time that it is very important to pay attention to the dynamics and issues of the entire relationship, and that it is neither possible nor desirably to treat sex as an isolated problem, as though one could separate sex from the rest of the relationship. In this day and age most qualified and competent sex therapists approach sex therapy as a kind of couples therapy, with somewhat more emphasis on sexual issues. Because of this emphasis on sex, and because sexual dysfunctions are so often ''curable,'' sex therapy tends to be somewhat shorter in duration that regular couples therapy, although not always.
(S-5) How long does sex therapy usually last? Most practitioners see couples in sex therapy on a weekly basis, from 8 to 10 weeks at least. This amount of time may be sufficient to resolve a specify sexual problem, and reasonably increase the effectiveness of sexual communication. However, if a couple has other significant issues to deal with, then four or five months of weekly sessions might be necessary. Most couples appreciate the opportunity to work on their entire relationship, and understand the need to take this approach. It is certainly possible to take a short-term, highly focused approached to sexual problems, but again the outcome is generally less successful than the more broad-based approach which is now common to sex therapists.
(S-6) Is ''homework'' part of sex therapy? What if the therapist wants us to do things we don't want to do? Homework is not only part of sex therapy, it is a critically important part of the treatment. Sexual problems do not go away by simply talking about them. While I would never underestimate the importance of clear, effective communication in the area of sex, this in itself is not going to ''cure'' a sexual dysfunction. Although properly done sex therapy will pay attention to the dynamics of the entire relationship, sexual problems are solved by learning to do things differently, which is the reason that sex therapy is at least partially behavioristic in its approach. A man with premature ejaculation could talk to a therapist for five years without making a dent on the problem, if talking is all he did. Competent sex therapists give homework or exercises for couples to do which are partially tailored to each couple, and which are partially based on research and scientist understanding about sexual response, and sexual anatomy and physiology. A good sex therapist will never give exercises for you and your partner to do which are offensive or troublesome.
(S-7) What can we reasonably expect from sex therapy? If you or your partner has one of the sexual dysfunctions described above in Answer S-2 (''What kinds of problems are dealt with in sex therapy?''), you can reasonably expect a resolution to this problem, such that it will no longer actively interfere with your sex life. You can expect your communication about sex to improve significantly, so that both of you will fully understand each others needs and wants, and therefore be more able to create a mutually satisfying sex life. You can expect to learn things about your partner you didn't know before, and you can expect to learn things about the sexuality of the opposite sex which you may not have known. What constitutes a good sex life is fairly easy to define: both people in a relationship get most of their sexual needs and wants met most of the time. (The operative word here is most.) You can expect your sex life to become a more natural part of your relationship . And if it fits with your values and needs, you can expect your sex life to become expansive, changing, experimental, rather than completely predictable and static. And finally, if you've been fortunate enough to find a good sex therapist, you and your partner will have a much better understanding about the totality of your relationship, as well as effective ways of addressing the problems and issues which may have been troublesome, other than your sex life.
(S-8) What about consulting with a medical doctor? If you have had a persistent sexual problem of any kind, it is always a good idea to consult with a physician prior to beginning any kind of sex therapy. The reason for this is that sometimes the genesis of a sexual problem can be physical rather than psychological, in which case sex therapy would not be an appropriate treatment. For example, sometimes the onset of erectile dysfunction is the first symptom of diabetes. Dyspareunia (painful intercourse) can be a medical problem or a psychological one, and only a properly trained medical specialist can make this determination. Therefore, prior to beginning sex therapy, the person who has “the problem” should first have a medical consultation---males should see a Urologist, females an Ob-Gyn. There are physicians who have had lots of experience diagnosing problems of this nature; for any Bay area person who needs such a referral, I can provide one.
(S-9) What about Viagra and other medications for sexual problems?
There are two very effective medications available for erectile dysfunction, Viagra and Cialis. Both of these medications work on the same principle: increasing the blood flow to the penis, thus enabling a fuller erection. Cialis has the advantage of lasting longer than Viagra---36 hours rather than 8 hours. For men who respond positively to either of these drugs, this is a perfectly valid way of dealing with erectile dysfunction, and it obviates the need for sex therapy. It does mean, however, that one becomes dependent on this drug as a way of dealing with the problem of erectile dysfunction. It should be noted that neither Cialis or Viagra has any effect on sexual desire; these drugs only facilitate erection once sexual desire occurs. The use of either of these drugs should always be under the supervision of a qualified physician. It is never appropriate to obtain these drugs via an Internet connection. For men whose erectile dysfunction has resulted from surgery (sometimes from prostate or colon surgery), the problem can almost always be solved with self-administered injections prior to intercourse. Caverject is perhaps the best known of these medications.
Because the body manufactures less testosterone in middle age and old age, men often have a decrease in sexual desire as they age, and the erectile function is not as immediate or as reliable as it was at a younger age. Usually such problems can be successfully addressed with additional sexual stimulation. However, if testosterone drops below what is considered to be the correct therapeutic level, then supplemental testosterone will be prescribed, and it can be very helpful. This can be determined by a simple blood test. It is wise to avoid testosterone supplements unless it is medically necessary. A competent Urologist can make this determination.
For women, there is as yet nothing comparable to Viagra or Cialis. While there is a great deal of research being done and there are some promising drugs on the horizon, there is still no reliable, available drug for female sexual problems. Some women with low sexual desire report good results from using a testosterone cream, but the results vary considerably. A consultation with an experienced Ob-Gyn would be essential prior to trying the testosterone cream.