This basic principle of conversational psychotherapy  not only characterizes one of the most powerful mechanisms of action of psychotherapeutic work in general, but is also of eminent importance for us, especially in the treatment of erectile dysfunction. Too often, therapeutic action is taken in erectile dysfunction without sufficient understanding of the disorder in terms of its etiopathogenesis, history, underlying conditions, and, most importantly, its functional significance. We find this tendency in the application of somatic therapy methods, but certainly also in sex therapy, when a “standard procedure” is resorted to much too quickly and behavioral instructions are given at the wrong time.
The pull to therapeutic activity usually arises from a mostly unreflective, tacit coalition between the patient and his (usually also male) therapist, who agree that the disorder must be eliminated as quickly as possible. Given the considerable psychological stress usually associated with erectile dysfunction, it seems downright absurd and torturous to both in this coalition to consider and take into account functional or even positive aspects of erectile failure. The compulsion to act, which has undoubtedly increased significantly due to the existence of effective somatic methods, thus robs itself of the chance to understand the “message” of the disorder and for this very reason, often does not lead to success, at least not a lasting one.
The high rate of treatment discontinuation for all methods of erectile dysfunction therapy is likely due in large part to a failure to understand and address the stabilizing “holding forces” of the disorder.
Against this background, the maxim in sex therapy for erectile dysfunction should be: No change without understanding, but often change through understanding alone. Understanding, however, does not mean “having understanding” in a common sense, but characterizes a sometimes laborious and lengthy process in which the therapist must empathize as far as possible with the patient's inner frame of reference in order to recognize the manifold, complexly interlocking psychosocial and psychosomatic aspects of the disorder. If, in the therapeutic process, the patient is then able to discover and experience these aspects for himself, a decisive step towards symptom improvement is often already taken. If the disorder is understood in this sense, then other treatment methods—psychotherapeutic as well as somatic—can be used in a targeted manner. For example, the sex-therapeutic behavioral instructions and exercises then fall on much more fertile ground and elicit significantly less resistance from the patient.
Understanding is the therapeutic tool to be able to recognize and consider the functional symptom meaning. Therefore, although both points cannot be separated from each other, the functional symptom meaning will be considered separately again here because of its enormous importance for the therapy practice.
Behind this formal and technical sounding term lies a highly significant and lively process, especially in the therapy of sexual disorders. The function of psychological or psychosomatic symptoms for the intrapsychic balance on the one hand and for interpersonal relationships, on the other hand, has been emphasized especially by the systemic therapy directions. To ask about the function or the “meaning” of a symptom like erectile dysfunction, which at first sight seems to be so disturbing, negative, not bringing any advantages, is unusual, strange or even nonsensical for many physicians or therapists.
A small case vignette will illustrate that such a search attitude is indeed indispensable.
A 35-year-old patient is referred from the urology consultation for a psychological evaluation. He comes to the consultation without being asked to do so, together with his wife of about the same age (which is very rare), and it is taken for granted by both of them that the consultation will take place between the three of them. The patient reports that he has always been unstable in his erectile function. He is easily disturbed, for example, and more often there is a decrease in erection during intercourse. He then very quickly fell into a self-reinforcement mechanism of fear of failure and avoidance behavior, from which he found his way out only with difficulty and with the help of his wife. For a year now, these problems had intensified and become chronic. During coitus, his member stiffness regularly decreased, but he could still reach orgasm with some effort. The erection that almost always develops during foreplay, although not hard and bulging, is now very quickly “used” by both to be able to have sexual intercourse for at least a certain time.
The patient talks very eloquently and seemingly without inhibitions, but noticeably covers up an insecurity and uneasiness. The wife appears rather serious and taciturn, but then describes her experience with obvious emotion and commitment. She is not dependent on coitus alone for her sexual pleasure, but it does have an important, especially emotional, significance for her. She enjoys above all the feeling of being filled by her husband's stiff penis, and feels immediately when his erection weakens. Although she doesn't want this to happen, the sexual situation then ends abruptly for her, and she has to fight the disappointment. In the meantime, a kind of “negative programming” had already set in for both of them, and it was hardly possible to be together without tension. As if she wanted to “call herself to order,” she then emphatically emphasizes that all this is not so bad, one can find other ways, and sexuality is not the most important thing in a relationship.
During the interview, it becomes clear that the past year was characterized by considerable professional and illness-related stresses for the patient. He had started his own business and at first had no orders and then too many. He had suffered from constantly recurring sinusitis, which would make a nose operation necessary in the foreseeable future. Worst of all, however, had been a very painful anal fistula, which had been difficult to treat and had tormented him for six months.
In addition, the couple lives in very cramped conditions. He has his “office” in the bedroom, and the three school-age children are right next door. Therefore, according to the wife, they are almost never undisturbed; sexuality can at most take place in the late evening when she is usually too tired. Incidentally, his sexual appetite had also dropped significantly, and she did not want to put him under pressure with her initiative.
Both agree that his problem probably has an underlying organic cause, perhaps a hormonal disorder or increased venous outflow. Both also emphasize that they have become much closer as a result of his problem, have talked to each other a great deal, and can now also talk about sexuality without difficulty. The therapy options presented in detail at the end of the conversation are received rather cautiously or dismissively by both of them. They agree that they do not want to go through “everything”.
The functional significance of erectile dysfunction is not always as clear as in this couple. The erectile dysfunction has brought both of them close together; he was thus able to reassure himself of her affection and loyalty during a very difficult and stressful time for him. A new and very stable balance seems to have been established, and the expression of physical symptoms apparently typical of conflict processing is also reflected in the somatic explanation of the disorder, on which both agree. The motivation for change appears to be highly ambivalent in the highly ambivalent, whereas the stabilizing function of the disorder appears to be very pronounced. Any therapist who does not take this functional constellation into account will most likely be shipwrecked here and fail due to the couple's resistance. The casuistry illustrates that the relationship is structured by the disorder and vice versa. In numerous instances, the sexual symptom is crucially involved in the couple's emotional homeostasis, it helps determine power relations and regulates closeness and distance. LoPiccolo  points out that working through the functional meaning of sexual dysfunction requires from the therapist not only the appropriate insight, but also a great deal of tact. Under no circumstances should the patient or the couple get the impression that the therapist thinks that the disorder is somehow “intentionally” brought about or that there is an active interest that the disorder does not disappear.
Only very cautiously and with emphasis on the suffering in the foreground can the secondary effects of the disorder and the constructive aspects of adapting to it be addressed. Similar to “change through understanding”, the same applies here: Only when the functional symptom meaning has been seen through, at least in its basic features, the disorder has been deciphered, as it were, can behavioral instructions or other therapeutic interventions be applied with promise.
The central importance of couple dynamics in sex therapy for erectile dysfunction hardly needs to be emphasized today, more than 25 years after Masters and Johnson. Although, unlike Masters and Johnson, “the couple as patient” is no longer considered in every case, the basic approach to sex therapy is a couple-dynamic one, and the preferred and most likely setting for success is couple therapy. Couple-related aspects are causally involved in many erectile dysfunctions; however, at least through their secondary effects, every erectile dysfunction also influences couple dynamics, and not only in the sexual domain. Since aspects of couple dynamics are dealt with in Langer's contribution (see chapter 5.2) and some aspects have already been mentioned here, we can content ourselves with a brief outline.
If the erectile dysfunction patient has a partner, and she is willing to participate in the treatment, couple therapy should be performed. Exceptions to this rule exist only in some patients with primary erectile dysfunction. Primary psychogenic erectile dysfunction is often based on deep-rooted anxiety, insecure gender identity, traumatic biographical experiences, or related to sexual deviance. These factors are not conscious to the patient or are hidden from the partner. For the psychologically unstable, only with difficulty psychologically balanced men a direct treatment of the erectile dysfunction, which psychodynamically often serves as a protection against more serious psychological conflicts, in the context of a couple therapy would be an excessive demand. In these cases, we first advise individual therapy, but always keep in mind the supplementation and continuation of treatment through a couple therapy setting.
The practice of couples therapy for sexual dysfunction has been described in detail elsewhere [2, 12, 14] and cannot be presented in detail here. Therefore, we will focus on some key points that play into sex therapy from couple dynamics and couple interaction. Basically, in any therapeutic intervention, its impact on couple dynamics or, as Althof  and Levine  put it, the couple's “sexual equilibrium” must be considered and registered. Just as the disorder itself structures the couple balance and is in turn shaped by it, any therapeutic change will affect this delicate and complex balance.
The conscious and unconscious parts and interests of both partners can lead to surprising consequences that are difficult to assess, the most obvious of which is the symptom shift from one partner to the other. This “hot potato syndrome”  can then look like that the partner, who until then was offensive, pushing, and insisting on flawless erections, “suddenly” loses her sexual desire when her partner's symptoms improve. This process can occur in the most different forms and is all the stronger, the more the couple dynamic is characterized by unconscious interlocking or collusion . But even in less dramatic constellations, it is true that every change in one partner causes a change in the other partner.
Leiblum & Rosen  extracted from their experience in couples therapy the following 4 problem areas of couple dynamics that they saw regularly linked to the development and maintenance of erectile dysfunction:
These areas need special attention and treatment in couples therapy. The term “sexual scripts” goes back to the work of sociologists Gagnon & Simon  and refers to the inner scripts that organize and determine our sexual behavior and experience. This concept is also useful in therapeutic work, for which Leiblum u. Rosen  propose a distinction between the overt and conscious behavioral scripts and the more covert, non-conscious cognitive scripts. The latter include our sexual attitudes, guiding principles, ideals, and our “fantasy model” of sexuality. These scripts can be very similar in a partnership, but they can also be very different, which has clear implications, especially in sex therapy.
The sexual scripts in a sexually dysfunctional relationship are often rigid, inflexible, uniform, and allow for few opportunities for satisfaction. Often this can be seen in the attitudes toward and handling of sexual stimulation. The concept of inner sexual scripts can usually be well accepted by the patient couple and provides therapy with a fruitful framework to search for destructive, but also beneficial aspects of sexual interaction.
The question frequently raised in the literature or in continuing education as to when, in the case of a sexual disorder, non-sexual couples therapy is more appropriate after all, actually arises very rarely in practice. In many years of practice, the author remembers less than a handful of cases in which general couple conflicts were so clearly in the foreground and the sexual problem was practically just another (albeit excellently suited) arena for acting out these conflicts. In these cases, therapeutic “entry” via the sexual disorder was impossible because of the destructive interactions and the completely polarized positions of the partners, and couple psychotherapy was first recommended.
In the vast majority of cases where there is a close link between sexual dysfunction and couple conflict, the causality of which can no longer be disentangled, a sex therapy approach is certainly worthwhile. Our experience agrees with that of Vandereycken  that in these patients a sex-therapeutic approach is even more promising than a general couple-therapeutic approach. If one follows the approach proposed here, in which behavior-modifying interventions are given based on an understanding of the symptom and its functional meaning, the targeted treatment of the sexual disorder will not be able to eliminate the couple conflicts anyway, but will often influence them favorably by improving sexual interaction.
According to the guidelines described above, there is no psychotherapeutic change without understanding, but on the other hand, especially in the case of sexual dysfunctions such as erectile dysfunction, this alone is not sufficient. In order to effectively improve the problem, sex therapy has a proven repertoire of experiential, behavior-modifying components that form its second pillar, as it were. These “exercises”, which consist of therapeutically guided and structured sensual-sexual experiences, are nowadays usually no longer used as a standard package that is fixed in terms of time and content, but are selected individually in each case with regard to the time of their use and their therapeutic goal.
While in the early days of sex therapy the behavioral instructions were mainly seen as a means of reducing fear of failure and building up sexual skills, it was later recognized in the course of an expanded “technique theory” of sex therapy that the functional spectrum of the exercises is much broader and can provide the framework, as it were, for a wealth of different psychotherapeutic intentions [21,29]. In the context of erectile dysfunction treatment, Althof  identifies the following goals and effects of the exercises:
In our practice, behavioral guidance is used primarily to achieve 2 main goals of therapy:
In the course of the patient's experience with the exercises, lack of sexual skills, distorted ideas, rigid behavioral scripts, unfavorable couple interactions, negative expectations, inner monologues and other things can be revealed, corrected and modified. In the therapy of erectile dysfunction, the sensate focus exercises (“sensate focus”) and deliberate withdrawal of erection are mostly used. The sensate focus exercises are supposed to relieve from fear of failure and pressure to perform, to interrupt ingrained destructive interaction circles and to enable new access to physical-sensual experience and (in the second step) sexual arousal. Letting go of the erection should allow the patient to consciously experience that erections are “nothing more” than the genital-physiological manifestation of sexual arousal that occurs when the general conditions are met and sexual stimulation is sufficient – provided, of course, that no significant organic factors make this impossible.
The experience that erections can come under these conditions, recede when stimulation is stopped, and return when stimulation is renewed is often very important for both partners, since in the wake of erectile dysfunction a destructive pattern of behavior often sets in, in which—with considerable cramping and inspired more by will than by desire—any erection that still sets in is immediately “exploited”. Here the exercises can lead to a new confidence in the sexual function and especially in the active control by the man and his partner.
Another important experience that can be made clear to patients by means of the exercises is the need to be “selfish,” i.e., to turn not only to the satisfaction of the partner but also—and at times even predominantly—to one's own arousal and pleasure. This is by no means a return to the old “machismo”, which had only one's own satisfaction in mind, but the correction of a behavior which we find in a large number of patients and which is possibly associated with the development of the disorder, but mostly came to its full expression in its wake. Due to his own sexual problems, the man gets more and more on the defensive and compensates for this by concentrating more and more on the satisfaction of his partner, who, however, can usually enjoy this only to a limited extent because she feels that this is a reactive behavior.
Zilbergeld  emphatically emphasizes the importance of fulfilling the individual sexual framework conditions for every man and points out that many men have difficulties in introducing and fulfilling their desires in personal relationships. In the course of erectile dysfunction, the general conditions are increasingly less fulfilled, to which the outlined focus on the satisfaction of the partner plays a not insignificant role. In therapy, the necessary framework conditions must be explored, and it must be tried out how they can be realized concretely in the sexual situation. In the process, the patient is guided to pay attention to his or her sensations and to register when, for example, fears, negative thoughts or distractions occur. Being “egoistic” in this sense also means taking responsibility for one's own arousal and optimizing it with the help of the partner.
After an initial euphoric phase in its early days, sex therapy has become much more modest since the 1980s, especially with regard to the effectiveness and universal applicability of the exercises. The sexual disorders seem to have become more complex on the whole, and in the case of the very frequent appetence problems, the exercises often cannot be used at all.
However, there are also some points to consider with erectile dysfunction, which LoPiccolo  in particular points out. His experience with his erectile dysfunction patients, especially with sensuality exercises, is that paradoxical reactions in the sense of a “meta-failure anxiety” can occur when the patients get into self-observation and pressure of expectation in a relaxed, sensual, erotic situation, where an erection should “actually” occur. The real intention of these exercises is thus turned into the opposite, which can have a demoralizing effect and very unfavorable long-term effects.
A second reason that can make the application of the exercises in erectile dysfunctions problematic is the combination of psychological and somatic causative factors that is so common in practice (also in sexual therapy). With these often older men, it is not enough to reduce anxiety and create a relaxed situation with the help of exercises, since the elimination of inhibiting factors alone will not result in an erection. Rather, these men must be taught that they need specific, direct genital stimulation and how to get it. This often requires considerable changes in attitude, since this is not provided for in their own sexual behavior pattern (and that of their partners), especially in men who have been used to “quasi-automatic” functioning all their lives. An important therapeutic step is the development and expansion of mutual stimulation techniques that can bring arousal and satisfaction even without a stiff penis. Acceptance of such techniques, as a supplement rather than a substitute or stopgap, is a significant predictor of therapeutic success in our experience.
In view of the described limitations and problems of behavioral instructions and exercises, various authors argue for greater consideration of cognitive aspects and techniques in sex therapy [27, 32]. Rosen et al. list a number of “cognitive fallacies” that they have often found in erectile dysfunction patients , but which, we believe, do not add anything new and have long been known in sex therapy practice. We have pointed out that every therapy is about capturing the inner world, the inner experience of the patient, including his “scripts”. This, of course, includes the cognitions, but these are so closely linked with emotions and affects that it does not seem to make much sense to look at them in isolation. Similar to Althof , we consider the emotional and relational factors to be more significant etiopathogenetically and therapeutically in case of doubt.
More useful seems to us another reference by Rosen et al. , which emphasizes the importance of “relapse avoidance training” in the context of sex therapy. In the sense of a self-management approach , the patient should be taught mechanisms with the help of which he himself can manage to prevent himself from relapsing into destructive behaviors and fears. Further systematic experience should be made with this interesting approach in the future.
The combination of sex-therapeutic approach with somatic therapy options corresponds to the psychosomatic character of erectile dysfunctions, should make less invasive somatic interventions necessary in many cases, could shorten sex therapy and improve the prognosis of all treatment approaches – and yet is hardly used in practice. For quite a few years, we have pointed out the possibilities and necessity of a combined approach, tested appropriate approaches in practice, and reported our results and experiences [8, 15, 16, 18]. The reasons why combined approaches have a shadowy existence, even internationally , are manifold and apparently difficult to change. Since a more detailed account would exceed the scope given here, the reader interested in the possibilities and problems of an integrative approach is referred to the publications indicated.
At this point, we would like to limit ourselves to some aspects that are of practical importance from the perspective of sex therapy. Despite all criticism of a hasty and ill-considered application of somatic methods, which are invasive in the majority, we have always pleaded for an examination of the possibilities of these treatment options with regard to an integrative therapy [6-8]. Within the framework of our joint urological-psychological consultation, the task usually consists of introducing psychological or couple-related points of view to patients, most of whom are convinced of a physical cause for their problem, and convincing them of the chances of sexual counseling or sexual therapy. This succeeds only or much better if the sex counselor or sex therapist is well-informed about the advantages and disadvantages of the medical treatment options, discusses them with the patient and signals his or her willingness to try certain methods – if the examination findings suggest it makes sense and the patient wishes it.
If the therapist can convey to the patient that it is not a matter of “withholding” certain somatic options, such as self-injections, from him, but that he would like to explore their possibilities and limits together, especially regarding the couple relationship, then the establishment of a sustainable working alliance is often successful, which also makes it possible to work on psychological and partnership problems. The sex therapist can thus “reach” patients with an integrative approach whom he would not reach with a purely psychotherapeutic approach, which, by the way, is in no way to be confused with a denial of the psychotherapeutic identity and the main goals of sex therapy. Many patients, with some of whom we have worked intensively and long-term psychotherapeutically, came to us quasi on the “somatic track” and could only be won over for psychological aspects after they had been thoroughly somatically examined, all medical options had been discussed in detail, and they had perhaps even tried the erectile tissue injections once.
We have pointed out that we consider it a legitimate and self-evident principle of therapy that the therapist must first ally himself with the patient's goals and accept his initial frame of reference in order to establish a sustainable relationship . Only in this way does the patient's receptivity often open up to therapeutic interventions that can then modify the initial goals and ideas. Neither sex therapy nor somatic therapies should press the patient into the Procrustean bed of their explanatory models and approaches, but should strive for an improvement of the problem in a “joint venture”, in a common and open course, as also Lue  tries to do with his “patient's goal directed approach”.
We will conclude with a brief look at the existing data on the efficiency of sex therapy and prognostic criteria. Contrary to the view sometimes expressed in the literature [e.g., 26] that there are no reliable control studies on sex therapy, we do have several studies in which the efficiency and prognostic criteria of this approach have been scrutinized.
In the pioneering work of Masters and Johnson themselves, success rates were 69% for secondary and 59% for primary erectile dysfunction . The results of the large Hamburg study on sex therapy, conducted in the second half of the 1970s, were also very good for erectile dysfunction, with 79% significant improvements, and relatively stable after the end of therapy . In a study by Hawton u. Catalan , the success rate was 68% and was also catamnestically quite stable, and in another study by Hawton et al.  on 36 couples, the improvement rate was very similar at 69% and was still 56% 3 months after the end of therapy, although not all couples could be followed up.
Especially, the Briton Hawton provided important results on the effectiveness and prognostic criteria of sex therapy with his methodologically sophisticated studies. From his statistical evaluations, the following prognostic factors for therapeutic success emerged:
The chances of success for the classic sexual therapy approach are thus most favorable with a higher socioeconomic status, with a basally good and sustainable partner relationship, if the woman has a self-motivated sexual interest, and it is possible for both partners to engage in the therapeutic process at an early stage (after 4-5 sessions).
These criteria correspond quite well with our experience and are, incidentally, not dissimilar to the factors we have calculated in the application of somatic therapy methods . It should be noted that—also according to the review by Mohr and Beutler —about two thirds of the erectile dysfunctional men treated with sexual therapy show significant improvements in symptoms at the end of therapy, which are catamnestically quite stable at least in an average period (up to one year). It is still noteworthy that sex therapy seems to improve sexual satisfaction in the long term, even when sexual functioning slightly deteriorates again. This may indicate that sex therapy succeeds in permanently changing sexual behavior patterns and scripts, and thus perhaps in avoiding relapse in several cases.
The large psychotherapy evaluation by Grawe et al  also attests to a quite good but markedly differential effectiveness of sex therapy. This corresponds with the described prognostic criteria and shows that sex therapy has excellent effects in a part of the patients, but only unsatisfactory effects in another part.
For the practice of sex therapy, it follows that in the future it will be a matter of developing flexible and unbiased strategies for patients who have been difficult to reach so far, based on the proven and effective approach. Especially for these older patients, in whom somatic disturbance causes co-determine erectile dysfunction and complicate the sex therapy approach, further testing of integrative approaches should be very rewarding.
However, a regular therapy guideline would clearly go beyond the given framework and, considering the diversity and individuality of the patients and their disorders, would hardly be possible to compile. Therefore, it can only be the aim to highlight and illustrate some points which we consider to be particularly significant or even problematic. In doing so, we rely mainly on our experience of many years. However, we also owe many suggestions to the excellent contributions of Althof , LoPiccolo , and Rosen et al. . For the reader who would like more comprehensive and systematic information, we would like to refer to the books by Kaplan  and Arentewicz and Schmidt  on sex therapy in general and by Langer and Hartmann  on the approach to erectile dysfunction in particular.
So, there is a lot to be said for not falling into rapid actionism in sex therapy for erectile dysfunction, which may relieve the patient and therapist in the short term because something seems to be “happening,” but is almost always counterproductive in the long term.