The first step to any couples therapy, where the focus is on improving sex and intimacy, is to gauge physiological causes of sexual problems. These can include drug side effects and medical conditions (diabetes, cancer, and menopause) and will need to be taken into account when discussing achievable goals. Individuals with chronic illnesses, such as brain tumour (especially pituitary tumours), may have a neurophysiological basis to their problems, including loss of arousal or inability to achieve an orgasm. Importantly, such individuals may still benefit from therapy even if physiological aspects of sexual functioning cannot be restored or improved. In addition, depression and performance anxiety are common factors in sexual dysfunction; even though there may be no physical reason for sexual dysfunction (e.g., erectile dysfunction), depression and anxiety can affect physical functioning. More generally, while positive sexual thoughts (e.g., fantasies) can increase physical arousal, anxiety-provoking thoughts decrease arousal and sexual performance.
Problems with sexual functioning are often associated with negative thoughts and feeling towards sex in general, a partner, or oneself. There may be fears regarding increased vulnerability, inability to maintain an erection, inability to secrete fluid for lubrication (especially for women with pituitary tumours), and performance fears. Many fears are related to the perception of the other person and being judged. It is important to address distracting and anxiety-provoking thoughts when these occur. The aim is to focus on positive thoughts that are conducive to enhancing intimacy through: exploring thought processes before, during and after intimacy and uncovering the basis of the anxiety; working towards recalling thoughts that occurred during previously satisfying sexual experiences and to engage with these thoughts again; and then engaging in behavioural strategies (such as sensate focus). Sensate focus involves creating an exposure hierarchy of exercises that have the potential to enhance pleasure during sexual activity, starting with the least performance based activities first.