What Are the Five Steps of CBT for Erectile Issues?

Many men experience erectile dysfunction (ED) due to reasons other than physical causes such as high blood pressure or diabetes. Rather, their ED is tied to psychological factors such as depression and anxiety. The latter category—an inability to achieve or maintain an erection entirely or largely related to psychological or interpersonal factors—is known as psychogenic ED.

Men whose ED is psychogenic may benefit from cognitive behavioral therapy (CBT) for their erectile problems.

CBT is a common form of talk therapy that involves various types of research-supported treatment methods. This therapy can help men change the way they think and feel, alter their behaviors, and work on specific ways to cope with and treat ED.

Psychological factors such as stress, anxiety, guilt, depression and low self-esteem may all contribute to ED; so can lifestyle choices, according to Louis Pagano, Ph.D., a clinical psychologist in St. Cloud, Minnesota. A good CBT practitioner both addresses these thoughts and feelings, and assists the client in modifying the unproductive and unhealthy behaviors that have a role in ED.

"We know from decades of research and experience that these approaches grounded in behavioral and cognitive science are really effective in aiding people in achieving specific goals and improving their quality of life," Pagano said.

What is the five-step process for treating erectile dysfunction with CBT?

CBT generally uses a five-step approach for treating ED, according to Douglas Ruben, Ph.D., a licensed clinical psychologist in Okemos, Michigan, and the author of "How to Raise Your Sexual IQ," among other books. Ruben said his CBT sessions for ED are held weekly or biweekly, and patients typically attend them for four to six months.

The five steps to treating ED with CBT include:

1. Clinical assessment

An initial clinical assessment rules out underlying physical medical conditions. Physical causes of ED may require the man to schedule an appointment with a urologist before he undergoes cognitive behavioral therapy for erectile issues.

2. Follow-up clinical assessment

A second clinical assessment is conducted to rule out problems with sexual arousal or related sexual disorders that impact erection potency and sustainability.

Ruben said these first couple of steps are often overlooked or CBT therapists assume the client has already disqualified any physical conditions. Most people have no concept of the array of medical conditions that can contribute to ED, which can vary from autoimmune and skeletomuscular diseases to respiratory and pulmonary diseases.

"For example, lupus and fibromyalgia produce digestive and soft muscle tissue disorders associated with pain," Ruben said. "Pain is a natural inhibitor of sexual arousal."

Medications can also get in the way of sexual function. For instance, if a man has a heart condition that requires him to take a blood thinner, the drug can reduce his erection strength.

"Awareness of medical problems allows the proper action from the physician to alter the medication dose or possibly titrate high-risk ED medications to low-risk ED medications," Ruben said.

3. Building skills

The third step has a component of skill-building. Therapists teach their patients methods of penile arousal and incremental retention of the erection, ideally without using ED medications.

"Sexual enhancement methods are a hallmark of the cognitive behavioral approach," Ruben said. "Male clients are taught step-by-step instructions on how to get aroused, interrupt arousal or maintain arousal during preplay, foreplay and intercourse."

Clients learn how to better control their levels of arousal during certain sexual stages. They can also learn how to be resilient and recognize the importance of continuing foreplay and intercourse even if the erection is lost.

"Continuing partner sexual play even if the penis is flaccid prevents unwanted effects of escape behavior," Ruben said.

Escape behavior is accidental coitus interruptus, when the man withdraws his penis from his partner's orifice due to feeling embarrassed or annoyed by the malfunction. This escape response increases the probability of subsequent ED the next time intercourse is attempted.

"By preventing escape behavior and keeping his flaccid penis inside the orifice, two important changes occur," Ruben explained. "First, stimulation is still delivered to the fine nerve endings of the partner's vaginal opening, pleasing the partner. Second, through the partner's arousal, stimulation returned to the penis may allow for reerection."

4. Cognitive restructuring

The fourth step involves a component of cognitive restructuring, which consists of changing the thinking or feelings associated with the preerection, erection and post-erection phases.

"Sometimes it might feel like you're in a courtroom evaluating the evidence for or against a belief," Pagano said. "At other times, cognitive restructuring may look more so like learning how to develop different thoughts; not necessarily arguing with the negative ones but just learning how to develop alternative ways of perceiving the situation by developing neutral or maybe more positive thoughts."

For instance, if performance anxiety is causing or worsening ED, the CBT provider may initiate interventions to change anxious or depressive thought patterns. This approach could mean first identifying inaccurate or unhelpful beliefs about sexual function. The client then has the opportunity to modify those beliefs.

"Modifying those unrealistic expectations men often have about their performance is going to help decrease those expectations and that performance anxiety," Pagano said. "A lot of men may have certain thoughts that are counterproductive to having a healthy sexual experience or counterproductive to maintaining a strong erection. For example, 'I have to be 100 percent hard to satisfy my partner' or 'If I lose my erection again, I'll disappoint my partner.'"

5. Putting new skills into practice

The final step centers on practicing these new skills in various settings.

"What preserves the skills, anchors it into the natural world and builds personal confidence is the transfer or generality of the skill," Ruben explained. "Skill transfer is simply when a successful erectile retention is practiced in more than one place."

Many cues inside the bedroom are comfortable and trigger a successful erection. The goal is to take the cues of the bedroom into other places for the erection to follow, Ruben said. The practice of preplay, foreplay and intercourse is advised in other rooms in the household—or in hotel rooms when traveling and in tents when camping—and at different times of the day.

This process transitions the steps from skill practice to skill mastery, which is when erectile retention occurs and remains intact in many different settings and under different circumstances.

An overall clinical approach to treating ED with CBT

Pagano said cognitive behavioral therapy for erectile issues is the best form of integrating psychological science, social learning and behavioral research into a clinical form that helps people.

"CBT is effective for so many things because so many of our problems, including medical conditions and sexual problems, are caused by or maintained by our thoughts, our feelings and behavior," Pagano said. "CBT really is that current gold standard of psychotherapy. It's the best we have at this time to help people improve their symptoms and their quality of life."