10 questions you should ask your psychologist or therapist when you first meet.

A while back, a new client showed up at her first session with a printed out list of questions to ask me. Most of her questions I typically try to address with all new clients during the first session. Nonetheless, it got me thinking about the importance of these types of questions and my responses to them. The client generously offered me her list to share with others.

This isn’t intended to be an exhaustive list, nor is it necessary to ask all these questions. The questions are intended to empower you, as someone seeking help, to make sure that you get the best possible care. If your psychologist or therapist can’t answer these questions in a satisfactory way, or answers them in a way that is unhelpful (or even worse, reveals incompetence), then you may want to reconsider working with that person.

Good answers to these questions will also help you feel more confident with the therapeutic process. This should lead to increased trust and comfort.

Don’t be afraid to ask these types of questions – the resulting discussion will help clarify expectations and establish some clear ideas about the treatment process.

The questions:

1. What experience do you have working with the types of difficulties that I am experiencing?
2. What is your approach to doing therapy for difficulties such as mine?
3. How effective is that approach?
4. Do you have an understanding of perspectives that are different than yours (e.g., gender, ethnicity, identity, spirituality, etc.)?
5. What types of things do you expect me to do between sessions (e.g., activities, journaling, etc.)?
6. How do you feel about feedback? How would you respond if I told you that something you said hurt or offended me, or that I didn’t agree with you?
7. How long does it usually take for therapy to be helpful for people with difficulties similar to mine? How many sessions, on average?
8. How will we measure treatment progress? How will we know if treatment is working?
9. What do you do when treatment doesn't seem to be working?
10. How will I know when therapy is finished?

Feel free to add to the list in the comments section.

What is cognitive behavioral therapy (CBT)?

Part 1: The Basic Model

Cognitive behavioral therapy, or CBT, is a very popular type of psychotherapy for several important reasons:

CBT is structured.
CBT provides practical, hands-on skills.
CBT is focused on the present.
CBT is goal-oriented.
CBT is well-supported by science and research.

Sounds pretty good, right?

The underlying theory behind CBT is that thoughts, emotions, and behaviours are all related. CBT focuses on identifying and changing unhelpful thoughts and behaviours that are causing problems and messing up your life. Thoughts, in particular, play an important role in maintaining negative emotions and problem behaviours. Physical sensations accompany emotional states, and are therefore related to thoughts and behaviours. Here's what the model looks like sketched out:

The easiest way to understand the model is to work through examples. So, with that in mind, here are two examples, one related to a non-sexual situation, and one related to a sexual situation.

Example 1: In the first example, Sam, who struggles with bad anxiety, is supposed to meet a friend for a drink but the friend pulls a no-show. Sam doesn't know why.

Sam experiences a strong emotional response - anxiety, sadness, embarrassment, and shame. Behind those emotions are a set of related negative thoughts that often occur automatically for Sam in similar types of situations. Accompanying those negative emotions are several uncomfortable physical sensations. Because of those strong negative emotions and the related uncomfortable physical sensations, Sam is going to be more likely in the future to avoid putting herself in similar situations. This may lead Sam to isolate herself, which isn't really what she wants. What Sam really wants is to have friends and be able to hang out with them. But because of the way that she thinks, doing what she really wants becomes very difficult.

Example 2: Dan suffers from difficulties with his erections, caused by bad anxiety. This is a significant source of distress for Dan. His girlfriend is understanding. She regularly tries to initiate sex with Dan because she finds it enjoyable, even though Dan believes he's letting her down when he doesn't have a full erection. In this example, Dan's girlfriend starts flirting with him.

When Dan's girlfriend starts flirting with him, Dan starts feeling anxious, scared, frustrated and ashamed. He feels this way because he thinks that she's going to want sex, and fears that he won't get an erection. If that happens, which he's sure will, he'll see himself as an inadequate sex partner. He believes that his girlfriend will be unsatisfied and will leave him. Thinking this way makes him feel physically ill. To reduce the negative emotions he's experiencing and mitigate risk of what he fears happening, Dan starts acting in ways that will insure that sex doesn't happen, such as shutting down (disengaging), making excuses not to have sex (avoidance), or making his girlfriend angry with him so that she won't want to have sex. Dan would much rather be able to have awesome sex, but his thoughts associated with his erectile difficulties are ruining it for him.

Once things are sketched with the CBT model, it becomes clear what the targets of therapy are (i.e., the specific maladaptive thinking patterns, negative beliefs, and unhelpful behaviours). 

There is much more to CBT, but this model forms the basis. Using the model can be extremely helpful for clients to learn how to manage emotions and change behaviour.

Some Questions to Ask Yourself

Are there certain situations that cause you distress? What is the nature of your distress (i.e., what are the emotions)? Is there a pattern?

How are you thinking in those situations, and how are those thoughts related to the way that you feel? Are those thoughts distorted, biased, or exaggerated in some way?

Are you behaving in a way that's helpful, desired, and that aligns with your values? If not, what needs to change?

The Sexual Response Cycle and Why It Matters

Significant problems at any stage of the sexual response cycle can lead to sexual difficulties and dysfunctions. But these problems can be addressed and overcome.

Background

Even by today's standards, it's mind-boggling to imagine research participants willing to have sex or masturbate while being directly observed by researchers and hooked up to physiological data capturing equipment. But that's exactly what sex research pioneers Masters and Johnson did, and in late 1950s and early 1960s USA at that!

Over the course of their ground-breaking study, Masters, Johnson, and their team of research assistants observed 10,000 sexual response cycles. And from their observations, they derived the four-stage sexual response model, which best represented the complex physiological changes that typically occur in females and males during a sexual experience. The four stages of response were labelled excitement, plateau, orgasm, and resolution.

While the Masters and Johnson model has had a significant and lasting influence on the way sexual dysfunctions are understood and diagnosed, it has been criticized for being simplistic, too linear, and non-representative of many people, especially women.

A newer model has been established that is much more comprehensive. It was developed and studied by local clinician and research rockstar, Dr. Rosemary Basson at the BC Centre for Sexual Medicine. Based on her vast clinical experience, Dr. Basson proposed a model of sexual response that is circular and more complex. One can enter the cycle at several points, and prior experiences affect future experiences. Perhaps most importantly, psychological and relational aspects are included.

Basson's Sexual Response Cycle Model

Motivations. Motivations to have sex are quite diverse. In fact, one study discovered 237 unique motivations to have sex. They include things that you'd expect like emotional intimacy, physical pleasure, to express love, and attraction. Less frequently experienced motivations are to punish oneself, as an exchange for something, and to hurt someone. Motivations can be divided into approach motivations and avoidance motivations. Approach motivations are those that focus on something positive (e.g., pleasure, intimacy). Avoidance motivations are characterized by a desire to stop or prevent something (e.g., to stop a partner from leaving the relationship, fear of not being loved).

Sexual Stimuli. Certain stimuli will turn you on or increases your interest in having sex. Perhaps a kiss, or certain type of touch from your partner that says Let's get it on! Maybe it's seeing your partner naked. It could even be a smell or a sound. This is what initiates sexual arousal should all other conditions be met - like throwing a lit match into a pile of dry kindling.

Context and Mind. This may be the most important part of the cycle. Context refers to the current situation or environment in which sex could happen. The predominant context is your relationship. So, for example, a relationship characterized by trust, emotional connection, and flirty playfulness is much more likely going to increase strength of sexual response as opposed to a relationship that is in turmoil, with evident resentment, contempt, and conflict. Mind includes all your inner psychological processes such as emotions, thoughts, beliefs, and schemas. If you are feeling calm, confident, hot, and secure, you're going to be much more likely to become aroused and desire sex than if you're feeling anxious, unattractive, distracted, or unsafe. Your sexual scripts (i.e., what you think sex looks like) will also have an impact. If you have a particularly negative views about sex, you're probably less likely to be open to sex, particularly if it deviates from the type of sexual behaviour that you feel is appropriate.

Sexual Arousal. Sexual arousal typically occurs if there is motivation, sufficient sexual stimuli, and context and mind are good to go. Sexual arousal can be physiological (e.g., erection, vaginal lubrication, etc.) and/or psychological (e.g., feeling sexually aroused, horny, turned on, etc.).

Responsive Desire. Not all sexual encounters begin with spontaneous sexual desire. You have likely had many of these experiences, especially if you've been in a long-term relationship. The most common of these experiences is being approached by a partner who initiates when you haven't been thinking about, or desiring sex. However, you find yourself quickly getting in the mood - that's responsive sexual desire.

Satisfaction. A rewarding sexual experience, as you define it (which may or may not involve orgasm), will lead you to want more in the future. This is true about pretty much all of our experiences. On the other hand, a pattern of negative experiences may decrease your interest in sex in the future.

Spontaneous Sexual Desire. Spontaneous sexual desire can super-charge the sexual response cycle. It is that sense of sexual urgency, passion, or horniness that you've likely experienced. It can feed into the model at several points, and is particularly evident at the beginning of relationships during the honeymoon phase when sex is frequent. But, spontaneous sexual desire is not necessary to become aroused and have awesome sex. Responsive sexual desire can be as powerful a force.

Why It Matters

Significant problems at any stage of the sexual response cycle can lead to sexual difficulties and dysfunctions.

• Avoidance motivations are related to, and increase, anxiety and negative emotions that may hinder interest in sex and arousal.
• Insufficient or inappropriate sexual stimuli, such as partner who does not touch or stimulate you in a way that turns you on, will be a barrier to becoming aroused.
• A troubled relationship or negative emotions, thoughts, or schemas will typically stop the cycle from progressing.
• Unsatisfying, unpleasant, painful, or traumatic sexual experiences will decrease motivation to have sex in the future.

When these types of problems are adequately addressed, your sexual experiences will improve substantially.

Some Questions to Ask Yourself

What are your motivations to have sex? Are they approach motivations, or avoidance motivations? Are your motivations helpful or unhelpful?

How do your motivations affect your desire and arousal?

What sort of thoughts and feelings arise when you think about having sex? Are you anxious, fearful, uncomfortable, etc.? Or calm, confident, and secure?

Is there appropriate and sufficient stimuli  to get you aroused (e.g., your partner's touch and stimulation, cues, etc.)? If not, what do you need and how do you get it?

If you're in a relationship, are you experiencing relationship problems that are impacting your desire for sex and your ability to be aroused (e.g., conflict, resentment, anger, etc.)? If so, what needs to change?

Have you had positive sexual experiences that increase your desire to have sex in the future? Or have they been mostly negative? If so, how can you increase the frequency of positive experiences and reduce those that are negative?

References

Basson, R. (2001). The female sexual response: A different model. Journal of Sex and Marital Therapy, 26(1). 51-65. (link)
Masters, W. H., & Johnson, V. E. (1966). Human Sexual Response. Toronto, New York: Bantam Books.
Meston, C. M., & Buss, D. M. (2007). Why humans have sex. Archives of Sexual Behaviour, 36(4), 477-507. (link)