New sex therapy (Kaplan)

1. Introduction

Version followed: Helen Singer Kaplan, The New Sex Therapy: Active Treatment of Sexual Dysfunctions (1974), read through the publisher's previews of the authorised Spanish edition (La nueva terapia sexual, vols 1–2, Alianza, 1978/2014). Exercise structure follows the chapter plan of The Illustrated Manual of Sex Therapy (2nd ed., 1988). The three-phase model for desire problems comes from Kaplan's later books (1979, 1995). The step-by-step task protocols in those books are not drawn on here. Where this guide gives steps that go beyond the strategy Kaplan states, they are marked [synthesis].

New sex therapy (Kaplan's "psychosexual therapy") is a brief, symptom-focused outpatient treatment for sexual dysfunctions. Kaplan developed it from 1964 onwards: first at Metropolitan Hospital in East Harlem, then in the Sex Therapy and Education Program of the Payne Whitney Psychiatric Clinic (Cornell). She built it on Masters and Johnson's behavioural work and on Clifford Sager's marital therapy. It combines two things: (a) structured erotic and communication tasks that the couple does at home, and (b) conjoint psychotherapeutic sessions. Kaplan saw dysfunctions as psychosomatic symptoms with several causes at once. Her core idea of change is that most dysfunctions are kept going by immediate causes: anticipation of failure, demands to perform, and fear of rejection or humiliation. Brief tasks can change these causes quickly. Deeper intrapsychic and relationship conflicts are worked on psychodynamically only as far as they block symptom relief. She did not see this as optional: without that work, improvement "suele ser imposible" (is usually impossible). Psychotherapy was "indispensable" to the method. [source: Kaplan 1974/1978, vol. 1 preface; Walker & Robinson 2012; Manuel de sexologie ch. 10]

Kaplan does not claim the techniques as her own invention. She describes them as a combination of psychoanalysis, behaviour therapy, psychosomatic medicine and group methods. She also stated that her book had no controlled outcome data behind it. [source: Kaplan 1974/1978, vol. 1 preface]

2. Framework

Scope. The method treats dysfunctions: inhibited response that prevents intercourse or enjoyment. It does not treat variations (paraphilias). Kaplan referred those to insight-oriented and behavioural methods. She grouped the dysfunctions by which component of the response is inhibited [source: Kaplan 1974/1978, vol. 2, Área IV intro]:

vasocongestive (excitement) phase: erectile dysfunction in men, "general sexual dysfunction" in women (older term "frigidity": little arousal or lubrication);
orgasmic phase: retarded (delayed) ejaculation in men, orgasmic dysfunction in women;
inadequate ejaculatory control: premature ejaculation;
vaginismus: involuntary spasm of the vaginal entrance.

In 1979 Kaplan added a desire phase in front of these, which made the model triphasic: desire, arousal, orgasm. Desire disorders were the hardest to treat [source: Wikipedia, Helen Singer Kaplan; T&F page for Kaplan 1995].

Phases of a course. Kaplan's own term is "principles", not phases. The sequence below is reconstructed from the book's treatment chapters (11 Basic principles, 12 The therapeutic experiences, 13 The psychotherapeutic session, 14 Conjoint treatment, co-therapy, transference and countertransference) and from the text. [source: Kaplan 1974/1978 vol. 1 contents; sequence is [synthesis]]

Evaluation and medical screening. Goal: a full sexual evaluation, rule out biological causes, and decide whether sex therapy is indicated.
- Kaplan analysed causes at five levels: biological (illness, drugs, age), immediate, intrapsychic conflict, dyadic (relationship), and learned [source: vol. 1 contents].
- Unless the problem is clearly situational, every man with erectile problems should have a medical and neurological check before psychological treatment [source: vol. 2 ch. 15].
- If depression is the primary cause, treat it first [source: vol. 2 ch. 15].
- Move on when organic causes are excluded or treated, the formulation is made, and the couple accepts a symptom-focused contract.
Active treatment: tasks plus sessions. Goal: remove the immediate obstacles through graded erotic and communication tasks at home, processed in conjoint sessions.
- Tasks start with Sensate Focus I (non-genital pleasuring) and move to Sensate Focus II (genital pleasuring). Dysfunction-specific techniques follow [source: Illustrated Manual contents].
- Move to the next task when the previous one is done with little anxiety and real pleasure [synthesis].
Psychodynamic work on resistance (when needed). Goal: when tasks are avoided, sabotaged or trigger strong emotion, explore and interpret the intrapsychic or couple conflict behind it, then go back to the tasks [source: Manuel de sexologie ch. 10; Walker & Robinson 2012].
- If one partner's problems block the couple, Kaplan shifted to individual sessions [source: Walker & Robinson 2012].
Ending. End when the symptom is relieved. Kaplan's goal was limited to sexual functioning, not personality change [source: vol. 1 preface]. Kaplan discusses results and relapse in vol. 2 ch. 21 [uncertain].

Format.

Brief, outpatient, with short sessions and heavy reliance on homework [source: vol. 1 preface].
The couple is treated as a unit when both partners can attend. If only one comes, that patient takes the instructions home to the partner [source: vol. 1 preface].
Treatment by one therapist was normal in Kaplan's setting; co-therapy was optional and discussed separately [source: vol. 1 preface and contents].
Session frequency and total session count are not stated in the text [uncertain].
Kaplan's prognosis criteria for erectile dysfunction: the longer the duration, the worse the outlook; secondary (acquired) problems do better than primary (lifelong) ones; primary impotence more often goes with serious psychiatric or endocrine disorder [source: vol. 2 ch. 15].

Certification. No licence or fidelity programme exists for "Kaplan therapy" under that name. Practitioners usually train in sex therapy through national certifying bodies, which vary by country [synthesis].

3. Guiding principles

[source for each: as cited; one-line practical meanings are [synthesis]]

The goal is symptom relief [vol. 1 preface]. Agree a concrete sexual goal. Bring wider personality or marital issues in only when they block that goal.
Several causes, one integrated treatment [vol. 1 preface]. Assess biological, immediate, intrapsychic, dyadic and learned causes. Mix experiential, behavioural and psychodynamic tools to fit.
Work on immediate causes first [vol. 1 preface; Kinsey ch. 5]. Target performance anxiety, spectatoring (watching oneself during sex), ignorance, the excessive need to please, and poor communication before anything deeper.
Psychotherapy is indispensable [Walker & Robinson 2012]. Never run the tasks as a mechanical programme. Every session examines what the tasks stirred up.
The tasks are the main agent of change [vol. 1 preface]. Most of the change happens at home, so every session ends with a clear assignment.
Tasks reveal resistance [Manuel de sexologie ch. 10]. Treat a skipped or spoiled task as information about conflict, not as failure.
Remove the demand to perform [vol. 2 Área IV; Manuel de sexologie]. Build every task so that nothing has to happen. Pleasure and sensation are the only targets.
Match the strategy to the phase that is inhibited [vol. 2 Área IV]. Excitement problems need adequate stimulation without pressure. Orgasm problems need graded extinction of the inhibition. Premature ejaculation needs more attention to sensation.
Rule out organic causes and depression [vol. 2 ch. 15]. Refer for a medical work-up unless the problem is clearly situational. Treat a primary depression first.
The couple is the patient, and cause and effect can run either way [vol. 1 preface; vol. 2 ch. 15]. Work out whether relationship conflict causes the dysfunction or the dysfunction causes the conflict, and plan accordingly.
Be flexible about format [Walker & Robinson 2012]. Move to individual sessions when one partner's problems block progress.
Expect emotional upheaval [Manuel de sexologie ch. 10]. Warn about it, then help the couple through the feelings the prescriptions trigger.
Use active cognitive challenge where needed [Walker & Robinson 2012]. In complex cases, name and directly dispute irrational sexual beliefs.
Watch transference and countertransference [vol. 1 ch. 14 title; content uncertain]. Monitor feelings toward the therapist and your own reactions. They can drive resistance to the tasks.

4. Intervention inventory

How to read this section. The names, purposes and strategic logic below come from Kaplan's text and the contents of her books. Her own detailed task instructions (in The New Sex Therapy chs. 11–20 and the Illustrated Manual Part II) are not drawn on here. Every numbered step is therefore my clinical rendering of her stated strategy [synthesis], unless a step is tagged [source]. All sexual tasks happen privately between the partners at home. The therapist never touches, demonstrates on or observes the client.

A. Assessment and set-up

4.1 Sexual evaluation and "sexual status examination"

Purpose: Build a multi-level picture of the problem, and get a concrete account of what actually happens during sex. "Sexual status examination" is Kaplan's term for detailed questioning about one recent sexual encounter [source: Kinsey ch. 5; Kaplan 1974, 1983]. The Illustrated Manual has a chapter titled "The Sexual Evaluation" [source: Routledge contents].
Steps:
1. Take the chief complaint. Then classify it: lifelong or acquired, generalised or situational, and which phase is affected (desire, excitement, orgasm, or spasm).
2. Ask for a slow, moment-by-moment account of the last sexual encounter: who started it, what each partner did, thoughts and feelings at each point, where things went wrong, and what happened afterwards.
3. Screen each partner separately for immediate causes: ignorance, fear of failure, excessive need to please, spectatoring, and failure to say what they like [source: Kinsey ch. 5].
4. Screen for remote causes: conflict about pleasure, restrictive upbringing, developmental conflict, lack of trust, and early sexual trauma [source: Kinsey ch. 5].
5. Assess the relationship: hostility, power struggles, and whether the dysfunction is cause or effect [source: vol. 2 ch. 15].
6. The chapter that cites Kaplan advises keeping the detailed recent-encounter inquiry until after the first visit [source: Kinsey ch. 5; uncertain whether this is Kaplan's own advice].
Example language (illustrative): "Take me through the last time you two were intimate, step by step. What was going through your mind just before things changed?"
Watch for: Shame that leads to vague answers. Partners contradicting each other. Signs of trauma, which call for slower pacing (see 5).

4.2 Medical, drug and psychiatric screening

Purpose: Exclude or treat biological causes before psychological treatment [source: vol. 2 Área II, ch. 15].
Steps:
1. Unless the problem is clearly situational (for example, full function in some situations), refer erectile complaints for medical and neurological examination [source: vol. 2 ch. 15].
2. Review illness, alcohol and drugs, ageing and hormones. Kaplan lists among frequent causes: undiagnosed diabetes, low androgens, liver disease, alcohol or narcotic use, neurological disease, Peyronie's disease and some prostate surgery [source: vol. 2 ch. 15].
3. Screen for depression and date it. If depression came first, treat it first. If it followed the dysfunction, it may lift as the dysfunction improves [source: vol. 2 ch. 15].
4. Kaplan has separate chapters on dysfunctions with psychiatric disorders (ch. 23) and with marital discord (ch. 24, by Sager). Read them before taking complex cases [source: vol. 2 contents].
Example language (illustrative): "Before we start the exercises, I'd like your doctor to check a few physical things, so we're not missing anything a medication or condition could explain."
Watch for: A situational pattern, such as erections on waking or with masturbation but not with the partner. This points to a psychogenic cause [synthesis].

4.3 Formulation and treatment contract

Purpose: Agree a limited, symptom-focused goal, and share a model of cause in which performance anxiety and other immediate factors are central [source: vol. 1 preface].
Steps:
1. Explain the formulation in plain terms: which phase is blocked, which immediate factors keep it going, and which deeper factors may come up.
2. Agree that both partners are working on a shared problem. Neither is "the patient" alone [source: vol. 1 preface].
3. Explain the method: tasks at home, discussion in sessions, no sexual demands outside the assignments.
4. Warn that the tasks may bring up strong feelings or reluctance, and that this is useful material [source: Manuel de sexologie ch. 10].
Example language (illustrative): "What keeps this going is mostly the pressure of watching and worrying. So for now, intercourse is off the table and your only job at home is to notice sensation."
Watch for: One partner treating the other as the problem. Hidden agendas, such as wanting a separation.

4.4 Sex education and anatomy teaching

Purpose: Correct ignorance and myths, which are among the immediate causes.
Steps:
1. Explain the phases of the response and their physiology in plain language [source: vol. 1 Area I].
2. Kaplan gave women a sketch of the female genitals with the clitoris emphasised, to take home and show their partner where they are sensitive [source: vol. 1 preface]. Use a neutral anatomical diagram, not a reproduction of hers.
3. Correct specific myths that came up in the evaluation [synthesis].
Example language (illustrative): "Most women need direct clitoral stimulation to reach orgasm. That's anatomy, not a failing."
Watch for: Embarrassment, or a partner who rejects the information.

4.5 Prescribing structured erotic and communication tasks (general method)

Purpose: The central therapeutic instrument: "systematically structured sexual experiences" done at home [source: vol. 1 preface].
Steps:
1. Set one specific task per interval: what to do, who starts, how long, and what is off limits [synthesis].
2. Ban intercourse and orgasm-directed activity until the task sequence allows them [synthesis, consistent with the pressure-free principle; source for the sensate focus ban: Wikipedia Sensate focus].
3. Include a communication part: each partner says or shows what feels good.
4. With only one partner attending, give written or clear verbal instructions for that partner to pass on [source: vol. 1 preface].
5. Start the next session by reviewing the task (4.8).
Example language (illustrative): "Twice before we meet next, set aside about half an hour when you won't be interrupted. Take turns. Nothing has to happen."
Watch for: Tasks done mechanically or under time pressure. Hidden attempts at intercourse.

4.6 Sensate Focus I: non-genital pleasuring

Purpose: The base exercise used for many dysfunctions [source: Illustrated Manual contents]. It reduces performance anxiety by moving attention to shared sensuality and away from performance [source: Manuel de sexologie ch. 10]. The technique comes from Masters and Johnson [source: Wikipedia Sensate focus].
Steps (in the published Masters–Johnson outline [source: Wikipedia Sensate focus]; Kaplan's exact wording not drawn on):
1. Partners undress (or wear underwear if needed) somewhere private and comfortable.
2. They take turns as giver and receiver. The giver touches the whole body except breasts and genitals.
3. The giver touches for their own interest, noticing temperature, texture and pressure.
4. The receiver attends to sensation and says if anything is unpleasant.
5. No intercourse and no orgasm-directed activity.
6. Hugging and kissing may be explored [source: Wikipedia Sensate focus].
Example language (illustrative): "When your mind drifts to 'Am I doing this right?' or 'Is anything happening?', just bring it back to what your hand is feeling."
Watch for: Signs it is working: reports of relaxation, enjoyment, spontaneous arousal without pressure, and easier talk. Problems: avoidance, scheduling failures, rushing, or one partner "performing" for the other (see 4.9).

4.7 Sensate Focus II: genital pleasuring

Purpose: Add breasts and genitals to the touching without demand for arousal or orgasm [source: Illustrated Manual contents; Wikipedia Sensate focus].
Steps:
1. Begin with a short version of Sensate Focus I.
2. Include breasts, then genitals, with light, teasing, non-demanding touch [synthesis].
3. Use hand-over-hand guidance: the receiver places a hand over the giver's to show pace and pressure [source: Wikipedia Sensate focus].
4. Arousal is allowed to come and go. Do not continue to orgasm unless the task says so [synthesis].
5. Intercourse stays banned until the dysfunction-specific stage allows it.
Example language (illustrative): "If arousal builds, enjoy it. If it fades, that's fine too. It's not a test."
Watch for: Anxiety returning once genitals are included. Spectatoring. One partner pushing toward intercourse.

4.8 Processing the experiences in the psychotherapeutic session

Purpose: The session links the tasks to the person's inner life and to the relationship [source: vol. 1 ch. 13 title; Manuel de sexologie ch. 10].
Steps:
1. Ask each partner for a detailed account of each task: what they did, sensations, thoughts and feelings.
2. Note pleasure and anxiety points, and any avoidance.
3. Explore the meaning of any emotional reaction or resistance (4.9).
4. Decide: repeat the task, move to the next step, or change it.
5. Give the next assignment.
Example language (illustrative): "You both stopped after ten minutes on Thursday. What was happening just before you stopped?"
Watch for: Reports that are only factual. Partners blaming each other.

4.9 Psychodynamic work with resistance to the tasks

Purpose: The tasks bring resistances to the surface, rooted in individual conflict or in the relationship. These are explored across sessions and used to steer the change process [source: Manuel de sexologie ch. 10]. Kaplan's 1995 work is described as psychodynamically oriented sex therapy [source: T&F page, Kaplan 1995].
Steps:
1. Name the resistance without blame (task skipped, sabotaged, "forgotten", hurried).
2. Explore what came up just before or during the avoidance: fears, images, memories.
3. Link it to the deeper conflict in the formulation, such as guilt about pleasure, fear of intimacy, or anger at the partner.
4. Offer an interpretation at the level the couple can use, and keep it focused on the sexual goal.
5. Go back to the task, changing it if needed (smaller step, different lead partner).
Example language (illustrative): "It seems that whenever it starts to feel good, something gets in the way. I wonder if feeling pleasure is somehow not allowed for you."
Watch for: Interpretations that turn into long insight work cut off from the tasks. That is outside the method's limited goals [source: vol. 1 preface].

4.10 Direct challenge of irrational sexual beliefs

Purpose: In complex cases, Kaplan identified clients' irrational beliefs and challenged them directly [source: Walker & Robinson 2012].
Steps:
1. Pick out the belief from what the client says ("If I don't get an erection she'll leave").
2. Examine the evidence and the consequences of the belief.
3. Offer a more realistic alternative and test it in the next task.
Example language (illustrative): "You're treating one lost erection as proof you're finished. What else could it mean?"
Watch for: Agreeing intellectually while the anxiety stays unchanged.

4.11 Conjoint couple work and switching format

Purpose: Treat the couple as the unit, and deal with relationship causes such as hostility, rejection and pressure to perform [source: vol. 1 preface and ch. 14 title; vol. 2 ch. 15].
Steps:
1. In conjoint sessions, look at relationship patterns as they show up around the tasks.
2. Work on pressure to perform, including where a loving but anxious partner adds tension [source: vol. 2 ch. 15].
3. When one partner's individual problems block progress, add or switch to individual sessions [source: Walker & Robinson 2012].
4. When both partners are dysfunctional, see Kaplan vol. 2 ch. 22 [uncertain]. Generally sequence the tasks so that neither partner's problem dominates [synthesis].
5. Where marital discord is severe, consider marital therapy first (Sager's chapter 24) [source: vol. 2 contents; content uncertain].
Example language (illustrative): "When you check whether he's aroused, how do you think that lands for him?"
Watch for: Hostility being acted out through the tasks.

4.12 Co-therapy, transference and countertransference

Purpose: Kaplan discusses co-therapy as an option, and the management of transference and countertransference [source: vol. 1 ch. 14 title]. In her original East Harlem setting, co-therapy was an "inconceivable luxury", so she worked as a single therapist [source: vol. 1 preface].
Steps [synthesis]:
1. Note the client's feelings about the therapist, especially erotic, competitive or parental ones.
2. Monitor your own reactions: embarrassment, siding with one partner, voyeuristic curiosity.
3. Use supervision.
4. Keep strict physical and verbal boundaries.
Watch for: A client using the therapist as an ally against the partner.

B. Dysfunction-specific strategies

Kaplan pairs the dysfunctions by which phase is inhibited, and gives each pair a shared strategy [source: vol. 2 Área IV intro]. The Illustrated Manual has a chapter of erotic techniques for each of the six dysfunctions [source: Routledge contents]. Those techniques are not drawn on here. All steps below are [synthesis] built on her stated strategy. Each one starts after Sensate Focus I–II is going reasonably well.

4.13 Erectile dysfunction ("impotence")

Purpose: Provide adequate stimulation in a relaxed, pressure-free setting, so that the erection reflex is not blocked by anxiety [source: vol. 2 Área IV intro]. Clinical variants show which moment triggers the anxiety: loss at penetration, loss on undressing, potency only when the partner leads (or only when he leads), potency only with some partners [source: vol. 2 ch. 15].
Steps [synthesis]:
1. Use the evaluation to find the anxiety-provoking moment.
2. During genital pleasuring, let erections come and go deliberately: stimulation stops, the erection subsides, stimulation resumes. This teaches that a lost erection can return.
3. Then allow brief containment without thrusting, in whatever position the man finds least demanding.
4. Then move to slow, non-demanding intercourse, with permission to stop at any point.
5. Throughout, treat spectatoring by redirecting attention to sensation.
Example language (illustrative): "This week the task is to let the erection go and notice it come back. Losing it is part of the exercise, not a failure."
Watch for: Working: morning or task erections returning, less dread. Not working: relationship patterns Kaplan describes, either a hostile, undermining partner or a loving but anxious partner who presses for performance [source: vol. 2 ch. 15]. Address these in conjoint work (4.11).

4.14 Female general sexual dysfunction (low arousal or lubrication)

Purpose: The female counterpart of erectile dysfunction: adequate stimulation in a relaxed, pressure-free setting [source: vol. 2 Área IV intro].
Steps [synthesis]:
1. Lengthen Sensate Focus II with the woman leading, and use hand-guiding to show the kind of touch she wants.
2. Use education (4.4) about clitoral sensitivity.
3. Introduce intercourse only once arousal is reliable, at a pace she controls, without pressure to have orgasm.
Example language (illustrative): "You're in charge of pace this week. Your partner's job is to follow your hand."
Watch for: Guilt about pleasure, which is a remote cause [source: Kinsey ch. 5]. Use 4.9.

4.15 Premature ejaculation (inadequate ejaculatory control)

Purpose: Teach the man to focus on his erotic sensations, especially the sensations before ejaculation. This is the opposite of the distraction many men use [source: vol. 2 Área IV intro]. The Illustrated Manual has a chapter on "inadequate ejaculatory control" [source: Routledge contents].
Steps (widely used stop–start method; Kaplan's own version not drawn on) [synthesis]:
1. The partner stimulates the penis manually while the man focuses fully on the rising sensation.
2. Just before the point of inevitability, he signals. Stimulation stops until the urgency fades, then starts again.
3. Repeat several times before allowing ejaculation.
4. Then move to containment without movement, then slow movement with pauses, and finally to more varied movement.
Example language (illustrative): "Don't think about baseball. Do the opposite. Pay close attention to how the sensation builds, so you learn to read it."
Watch for: Working: longer intervals and the man reporting he can read his arousal levels. Problems: the partner's resentment or sexual frustration, which needs attention in the session.

4.16 Retarded (delayed) ejaculation

Purpose: Gradual in vivo extinction of the inhibition [source: vol. 2 Área IV intro]. The strategy has three parts:
1. Maximise stimulation to raise ejaculatory urgency.
2. Step by step, reduce the anxiety linked to ejaculation.
3. Distract the man from consciously monitoring and controlling the reflex, ending spectatoring [source: vol. 2 Área IV intro].
Steps [synthesis]:
1. Build a hierarchy, starting with the situations where ejaculation is easiest (often solo masturbation) and working toward intercourse with the partner.
2. Move up one step at a time: ejaculation alone in the partner's presence, then by the partner's manual stimulation, then near the vagina, then inside.
3. At each step, increase stimulation intensity and use erotic fantasy as a distraction from monitoring.
Example language (illustrative): "Let your mind go to a fantasy that excites you. Stop watching whether it's going to happen."
Watch for: Anger, control or fear of letting go with the partner. These are common deeper themes [synthesis]; explore with 4.9.

4.17 Female orgasmic dysfunction

Purpose: The same three-part extinction strategy as delayed ejaculation [source: vol. 2 Área IV intro]. Kaplan names orgasmic dysfunction as the most common female complaint [source: vol. 2 Área IV intro]. She held that women who are orgasmic only without intercourse do not necessarily have a disorder [source: Wikipedia, Helen Singer Kaplan].
Steps [synthesis]:
1. If the woman has never had an orgasm and is willing, offer private self-exploration and self-stimulation to learn her own response.
2. Respect a client who regards masturbation as unacceptable. Requiring it would be ethically unreasonable [source: Kinsey ch. 5].
3. Move to orgasm with the partner present, then with partner stimulation, then during or alongside intercourse (for example, with added clitoral stimulation).
4. Use fantasy to distract from monitoring.
Example language (illustrative): "Orgasm can't be forced. It comes when you stop watching for it."
Watch for: Defining success too narrowly. Agree the goal (orgasm by any means, or during intercourse) at the start.

4.18 Vaginismus

Purpose: Overcome the conditioned spasm of the vaginal entrance [source: vol. 2 Área IV definition]. The Illustrated Manual has a vaginismus chapter [source: Routledge contents].
Steps [synthesis; graded exposure]:
1. Gynaecological assessment first, to exclude pain conditions.
2. Get informed consent for graded exposure, and agree the woman controls every step and can stop at any time.
3. Teach relaxation and education about the anatomy.
4. In private, she inserts her own fingertip, then more, over sessions. Medical dilators can be used if her doctor provides them.
5. Then the partner's finger, with her guiding.
6. Then containment of the penis under her control, then intercourse.
Example language (illustrative): "You set the pace. Stopping is always allowed, and stopping doesn't undo progress."
Watch for: Contraindications to pushing on: trauma history, panic, or dissociation. If these appear, slow down, use trauma-informed work, and never continue through distress [synthesis].

4.19 Disorders of desire (triphasic model, 1979 onward)

Purpose: Kaplan saw low desire as tied to deeper psychological difficulty and as the hardest dysfunction to treat [source: Wikipedia, Helen Singer Kaplan]. She treated it with a "comprehensive, integrated, psychodynamically oriented" approach [source: T&F page, Kaplan 1995].
Steps [synthesis]:
1. Screen carefully for depression, hormonal and medication causes, and relationship anger.
2. Give pleasurable sensate tasks without demand.
3. Explore in session what the person does internally that turns desire off: negative thoughts, focusing on the partner's flaws, avoidance.
4. Interpret the deeper conflict (intimacy, anger, guilt).
5. Kaplan's specific techniques for desire disorders, and her later work on sexual aversion and panic, are not drawn on here [uncertain]. Do not attribute specific procedures to her from this guide.
Example language (illustrative): "When you notice a flicker of interest, what happens next in your mind?"
Watch for: Slow progress is expected. The relationship may need to be the main focus.

5. Handling problems

Sourced points: resistance is surfaced by the tasks and worked through in session; expect emotional upheaval; switch to individual sessions when one partner blocks progress; treat primary depression first; separate cause from effect in marital conflict [source: Manuel de sexologie ch. 10; Walker & Robinson 2012; vol. 2 ch. 15]. Everything else in this section is [synthesis].

Tasks not done (non-adherence).
1. First check the practical side: time, privacy, children, fatigue.
2. Then treat the avoidance as resistance (4.9). Ask what the person expected to feel had they done the task.
3. Make the next step smaller and more specific, with a fixed day and time.
4. Agree which partner initiates.
Ban broken (intercourse attempted early).
1. Don't scold. Explore what the urge to rush meant: proving something, reassuring the partner, ending the uncertainty.
2. Restate the rationale that pressure feeds the symptom.
3. Give the task again.
Stuck at one stage.
1. Re-examine the formulation: a missed organic factor, medication, depression, or a hidden relationship conflict.
2. Ask whether the remote causes now need more of the session time.
3. Consider individual sessions, or marital therapy first.
Overwhelm, panic, or trauma memories during tasks.
1. Stop the task.
2. Stabilise in session: grounding, pacing, trauma-informed assessment.
3. Return to an earlier, safe step, or pause sex therapy for trauma-focused treatment.
4. Never push exposure through distress.
Partner sabotage or hostility.
1. Name the pattern in conjoint session.
2. Explore what the symptom protects in the relationship, for example avoiding closeness or holding power.
3. If hostility dominates, prioritise couple therapy.
One partner unwilling to attend. Kaplan's own fallback: work with the attending patient, who carries the instructions home [source: vol. 1 preface]. Check that the absent partner actually consents to the tasks.
Rupture with the therapist (feeling judged, embarrassed, or that the therapist sides with one partner).
1. Name it openly.
2. Invite criticism.
3. Rebalance attention between the partners.
4. Check your own countertransference in supervision.
Success with the symptom but no satisfaction, or the other partner developing a symptom. Re-assess both partners. Kaplan has a chapter on dysfunction in both partners, which is not drawn on here [uncertain].
Relapse after ending. Before ending, plan for setbacks: return to Sensate Focus I under stress, and offer booster sessions.
Cultural, religious or values conflicts (for example about masturbation or fantasy). Adapt tasks to the client's values rather than requiring them [source for masturbation: Kinsey ch. 5].
Scope and safety.
- Paraphilias are outside this method [source: vol. 2 Área IV intro].
- Screen for coercion and intimate-partner violence before prescribing couple tasks. Never prescribe sexual tasks where consent is not free.
- The therapist never observes or physically takes part in the tasks.
Medication. Medical treatments for erectile or ejaculatory problems need a physician. Coordinate with them, and keep the psychological tasks alongside medication. No dosing is given here.

Sources

Sources

Further reading (not drawn on)

Kaplan, H. S. (1974). The New Sex Therapy: Active Treatment of Sexual Dysfunctions. Brunner/Mazel.
Kaplan, H. S. (1975; 2nd ed. 1988). The Illustrated Manual of Sex Therapy. Brunner/Mazel / Routledge.
Kaplan, H. S. (1979). Disorders of Sexual Desire. Brunner/Mazel.
Kaplan, H. S. (1983). The Evaluation of Sexual Disorders: Psychological and Medical Aspects. Brunner/Mazel.
Kaplan, H. S. (1995). Sexual Desire Disorders: Dysfunctional Regulation of Sexual Motivation. Brunner/Mazel.
Weiner, L., & Avery-Clark, C. (2017). Sensate Focus in Sex Therapy: The Illustrated Manual. Routledge.

Limits [uncertain]: Kaplan's step-by-step task instructions, session frequency and count, her desire-disorder and sexual-aversion techniques, and the content of her chapters on outcomes, co-therapy and transference are not drawn on here. The steps in 4.13–4.19 are clinical synthesis aligned with her stated strategies, not her protocols.

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