Psycho-social issues in

sexual dysfunctions,
genitourinary and renal
conditions: Psychological
and behavioural
interventions

Turfa Ahmed
M.Phil. Trainee, 2nd year
CPCUC
Classification of sexual
dysfunctions

ICD-10 vs DSM 5
Sexual dysfunction can be divided into:
• lifelong (primary)
• acquired (secondary)
• generalised
• situational
MALES FEMALES
– Sometimes a reported sexual dysfunction is not the problem in need of
treatment.
– Erection disorders may actually hide a problem with rapid ejaculation.
– Sometimes the presenting sexual dysfunction is not a dysfunction at all.
– A couple may bemoan a desire disorder when the partners are
actually experiencing differences in their preferences for the
frequency of sexual activity, neither of which falls under clinically
diagnosable conditions.
 What Are the Causes of Sexual
Dysfunctions?
Medical Factors Individual Factors
– any condition or medication that – client’s overall psychological functioning (e.g., anxiety,
affects endocrine (hormonal), mood disorders, trauma) as well as negative views of
cardiovascular (blood flow) or self, body, or sex.
neurological (nerve conduction)
functioning in the pelvic region. – client’s distracting thoughts and feelings, especially
those having to do with the sexual concern.
– These conditions may be the result
of: chronic illnesses (e.g., diabetes, – Examining the client’s sexual experience, techniques,
hypothyroidism); prescribed, non- preferences, awareness of these preferences, and
prescribed medications or “street” knowledge about sexuality in general is also important.
drugs; and/ or medical interventions
(e.g., radiation or prostate surgery). – Historical issues include childhood neglect or abuse,
and differing attachment styles (such as anxious or
avoidant patterns).
 Partner and Relationship Factors Lifestyle Stressors
– Partner’s illnesses, sexual dysfunctions, – What are the professional or job
performance expectations, and responses to responsibilities? How stressful are these?
the sexual problems.
– What about the impact of children,
– Evaluating the partners’ psychological relatives, and others? Is involvement with
functioning, and the partner’s willingness to parents an issue?
participate in therapy.
– Job or personal losses; lack of exercise;
– Partner’s subjective experiences of their own
overeating; and habits that contribute
sexual and relationship history, and the
meaning placed on the presenting sexual negatively to the client’s overall physical
dysfunctions. and psychological health.
– Relationship distress. Sociocultural Influences
– Feelings of rejection, frustration, and
– Family of origin, social, and religious factors.
inadequacy can lead to less positive feelings
about partners, less frequent shows of – Extent and nature of the sexual values,
affection, unhelpful or absent scripts, and misinformation affecting each
communication, and less quality time spent partner
together.
Psychological Treatments
for Sexual Dysfunction
Cognitive–Behavioral Therapy

– Adaptations have been made to standard CBT protocols to

address sexual dysfunctions that aim to modify dysfunctional
beliefs (cognitive restructuring), with a specific emphasis on
homework assignments, out-of-session activities,
psychoeducation, and acquisition of skills.
– According to cognitive–behavioral theory, cognitive schemas are
responsible for the way in which individuals interpret and give
meaning to different experiences.
– In terms of male disorders, when a man experiences a negative
sexual event, he develops schemas that generate negative
thoughts (e.g., demand for performance, anticipation) and
emotions (e.g., sadness, fear), thereby interfering with his sexual
arousal. Theory
– As a result, a negative thought pattern develops and maintains the
individual’s poor sexual performance. Males
– Some research suggests that men with sexual problems attribute
negative sexual events to personal incompetence, thus interpreting
those events as signs of personal failure, and this gives rise to
beliefs of being different, powerless, and weak (Nobre & Pinot-
Gouveia, 2009; Quinta Gomes & Nobre, 2012).
– These findings suggest that the evaluation of an individual’s core
beliefs and a focus on cognitive techniques aimed at restructuring
maladaptive beliefs and behavior patterns are integral in the
treatment of sexual problems.
– By looking at sexual dysfunction as a behavior learned by classical,
operant conditioning and model learning, and the behavior
sequence as characterized by specific sexual stimuli, responses, and
contingencies, CBT can be useful in treating female sexual
dysfunction.
– Sexual signals and bodily reactions may lead to positive or
negative emotional consequences and experiences that are
Theory
stored in the amygdala and hippocampus and that form an Females
individual’s sexual script.
– By helping individuals to become aware of these stimuli, the
reactions they cause, and the consequences of the behavior, CBT
can help them learn what enhances and what inhibits sexual
pleasure, learn to restructure their maladaptive beliefs, reduce
avoidance behavior, and regulate the obsessional antisexual self-talk
in which they are engaged.
Sex Therapy

– Sex therapy is a psychotherapeutic treatment that focuses

on immediate factors (e.g., fear of performance; concerns
about one’s own sexual adequacy, satisfaction, and marital
relationship) within a couple’s sexual interactions.
– Sex therapy consists of educational presentations,
therapeutic discussions, and couples exercises.
– Over a 2-week period, didactic presentations take place and the
couple engages in exercises during daily meetings between the
couple and a dual-sex therapy team.
• In an effort to allow the couple to “think and feel” sexually without a preoccupation
regarding performance, the couple is instructed to refrain from any sexual activity
during the first few days of treatment and, instead, to engage in sensate-focus
exercises.

• In these exercises, couples caress areas of the body other than just the genitals or
breasts, and, while erections commonly occur during these nondemanding pleasuring
exercises, it is most important for the couple to focus on the fact that an erection is a
natural physiological reaction that does not need to be achieved through a conscious
effort.

• Eventually, the couple is instructed to engage in sensate focus with genitals. During
these exercises, the partners take turns providing manual stimulation to the genitals;
the receiver provides verbal and nonverbal feedback concerning preferences in the
positioning, pressure, direction, and rapidity of the caress. With an increase in
communication, it is ascertained that both partners will begin to experience an
increase in effective stimulation.
• Once a man is able to achieve a full erection during sensate exercises, the couple is
instructed to engage in the “teasing technique,” in which periods of manipulative play
and cessation of penile stimulation are alternated.

• This exercise is designed to demonstrate that there is no impairment in the erectile

response to effective stimulation and to alleviate fear and anxiety regarding a loss of
erection.

• After a week of these noncoital exercises, the couple is instructed to approach

intercourse with spontaneous sexual activity with continued emphasis on mutual
pleasuring rather than an erection or orgasm.
– The underlying rationale behind sex therapy is rooted in the belief
that a redirection of the male’s attention from sexual performance
to sensual reception, combined with increased communication of
preferences and reactions by both partners, will result in an

Theory
erectile response that is an involuntary response to erotic
stimulation.
– According to Masters and Johnson (1970), the dysfunction is
typically maintained by a man’s preoccupation with achieving an
erection, which results in continued fear of erectile difficulty. In this
view, such fear makes a man a “spectator” to his own sexual
experience rather than an active participant, thereby inhibiting his
ability to access the physical and psychological stimulation
necessary for heightened sexual arousal and erections. This
interference is frequently exacerbated by negative reactions from
a sexual partner, which results in further detumescence and even
Sensate Focus is a series of structured touching
and discovery suggestions that provides
opportunities for experiencing your own and
your partner’s bodies in a non-demand, Sensate
focus
exploratory way without having to read each
other’s minds. Non-demand exploration is
defined as touching for your own interest
without regard for trying to make sexual
response, pleasure, enjoyment or relaxation
happen for yourself or your partner, or prevent
them from happening. Touching for your own
interest is further defined as focusing on the
touch sensations of temperature, pressure, and
texture. Temperature, pressure, and texture are
even more specifically defined as cool or warm,
hard or soft (firm or light), and smooth or rough.
identifying the
psychological,
relationship,
lifestyle, and
sociocultural
issues that
contribute to
sexual
difficulties
 Why Does Focusing on Touch Sensations
Help with Sexual Dysfunctions?
The Gateway to Relating
Reliability and Tangibility The Gateway to Arousal Sexually
– As clinicians, if we suggest to our – Focus on tactile – Focusing on the touch sensations
not only leads to your own arousal
clients that they stop focusing on sensations, get the but also to your partner’s.
their conscious anxiety about conscious mind out of the
sexual responsiveness we have way, and the body knows – William Masters often said that the
main sources of sexual stimulation
to give them something else on what to do. are threefold:
which to focus instead.
– The benefits of this – your touching; your being touched;
– Turning your attention to include decreased blood and your partner’s arousal.
sensations is a reliable, neutral, pressure, the release of – Each person’s arousal becomes
and tangible alternative to oxytocin (the bonding part of an ongoing, positive
focusing on the worrisome hormone), and blood flow feedback loop that serves as
thoughts and feelings that are to the pelvis. another gateway into the other
person’s arousal.
often powerful contributors to
sexual problems. – This loop moves the partners
beyond merely self- focused
touching into sexual relatedness
 The Paradox of Sexual
Responsiveness
❑ The paradox of sexual desire, arousal, and orgasm
is that the harder you consciously try to make
them happen, the less likely they are to happen,
and the more intent you are on trying to keep
them from happening, the more likely they are to
happen.

❑ Conscious intentionality produces tremendous

anxiety because you simply do not have direct,
voluntary control over making yourself, or
someone else, sexually aroused.

❑ The anxiety associated with trying to turn on

yourself or your partner is at the heart of many
non- medically-based sexual dysfunctions and
disorders. In a world in which most successful
people have been rewarded for working hard for
results, this paradox is very different from the
usual manner in which we approach tasks.
The Formula for Implementing
Sensate Focus Using Research-
Based Techniques
– People who are functioning well sexually practice three skills
that honour sex as a paradoxical natural function:
(1)while touching their partners, they touch for themselves
rather than for their partners
(2)while touching or being touched, they focus on touching
for their own interest, curiosity, or exploration (defined
as focusing on tactile sensations) rather than for arousal,
pleasure, relaxation, enjoyment, or any other emotion
(3)they redirect their attention back to sensations when
they are distracted.
Purpose of Sensate Focus/
Process of Sensate Focus
– to get in touch with senses
– to reduce spectatoring → goal orientation – i.e., to
get at neutrality …
– to get at self- representation and responsibility
– to get at the neutrality – staying in here- and- now
(Avery- Clark,
1983)
 Behavioral Therapies

– Behavioral therapy for sexual dysfunction consists of physical techniques that are utilized to
help individuals develop skills necessary to improve sexual self-confidence.
– Common behavioral techniques include the “stop–start technique,” the “squeeze technique,”
and pelvic floor muscle rehabilitation.
– The stop–start technique involves stimulating the penis until the man feels the urge to
ejaculate; once this feeling emerges, either the partner or the man discontinues the stimulation,
thus allowing the urge to ejaculate to pass. This technique is repeated multiple times in order for
the man to learn how to recognize feelings of arousal in order to improve control over
ejaculation.
– The squeeze technique teaches the man how to stimulate his penis until he feels the urge to
ejaculate; he then squeezes the glans of the penis until the sensation passes. This is repeated
before allowing ejaculation to occur.
– Behavior therapy can also be useful for sexual dysfunction in females as it views disorders as
conditioned fear responses causing spasms or pain. Therefore, behavioral therapy can be useful
by deconditioning these learned responses with gradual desensitization.
– Behavior therapy views sexual dysfunction in terms
of conditioned fear responses.
– For example, in women with vaginismus, behavior
therapy views the conditioned fear response as
the spasm of the vagina.
Theory
– Therefore, in order to properly treat this disorder,
one would need to decondition the learned
response through gradual desensitization.
Psychoeducation

– In the 1980s, psychoeducation was developed as a composite of

numerous therapeutic elements to aid patients and their families in
developing a precursory understanding of their illness before
deciding on a long-term treatment. Since then, psychoeducation
has become a stand-alone treatment option with a focus on
didactic skillful communication of key information to help empower
patients and their families to understand and accept their illness in
a successful manner.
– In this view, psychoeducation for sexual dysfunction focuses on
disseminating information about physiological and
psychological changes that occur in the sexual response.
– The underlying rationale behind psychoeducation is that
a basic level of understanding of their illness will
enhance patients’ empowerment by decreasing anxiety
through providing knowledge. By gaining this
Theory
understanding, patients and their families tackle their
illness in the most optimal way, as an established
understanding of the illness allows patients to begin to
have insight into their ailment, thus improving
compliance and long-term successful cooperation
with treatment.
 Other Therapies

– Group mindfulness-based therapy has been researched as a therapeutic package in an

RCT by Brotto and Basson (2014). However, the theoretical base for it has not garnered
enough research. This type of theoretical model does seem convincing, as mindfulness-
based therapies have been increasingly being used and valued, with mindfulness-based
stress reduction having shown benefits for medical, psychological, and behavioral ailments
as well as physical parameters and epigenetic changes.
– Mindfulness-based cognitive therapy has been shown to alleviate anxiety and depression
and prevent depression relapse in preliminary studies (Brotto & Basson, 2014). The
proposed therapy teaches participants to attend to and accept the present moment and sexual
stimuli, thus lessening the tendency to self-criticize and to follow distracting thoughts, which in
turn not only increases awareness of sex responses but also lessens participants’ own
judgments that they are insufficient or substandard. This is all done in four 90-minute group
sessions that include mindfulness meditation, cognitive therapy, and psychoeducation.
Psychological Treatments
for Genitourinary and
Renal conditions
Problems Peculiar To Urinary
Conditions
– If strictly urinary conditions accentuate psychosexual and psychosocial
developmental vulnerabilities, broader urologic conditions (e.g.,
myelomeningocele, bladder exstrophy) create more global developmental
vulnerabilities.
– The genitourinary implications of these conditions appear to have a profound
impact on the child’s global developmental journey. For example, children with
myelomeningocele or exstrophy encounter significant psychological
repercussions of incontinence, sensorimotor dysfunction, and later issues of
sexual function, fertility, and the implications of these for sexual relationships.
– Adult studies imply that female patients may sometimes adapt better than males,
perhaps because genital issues are less problematic.
 Psychosocial factors

– Although urinary problems, in themselves, are not life threatening, the impact on
physical health, psychosocial functioning, daily life activities, and quality of life is
substantial.
– The seriousness of consequences may range from embarrassment over frequent
toilet going, actual leakage, declined performance in daily life activities to general
health issues such as sleep loss and daytime fatigue, and may cause
psychological and emotional distress.
– It may even discourage older men with urinary problems from leaving home and
exclude them socially. For men, urinary problems are stigmatizing and can
diminish their masculine identity, resulting in internalization of negative self-
worth and low self-esteem.
– The impact on spouses, such as affecting their sleep and reducing sexual and
marital satisfaction, has also been documented.
– However, the mention of one’s urinary problem in daily conversation is culturally
• Urinary problems have been found to be significantly associated with increased
depression or anxiety.

• Urinary problems as a stressor may reduce ones’ coping self-efficacy. Individuals with
urinary problems may limit their social activities outside of the home and develop a
restricted and isolated lifestyle.

• Embarrassment and shame related to incontinence can lead to a poor self-concept

and a lower sense of self-control. Thus, individuals distressed by urinary problems may
have poorer coping resources and coping capacity and thus, a lower coping self-
efficacy.

• Urinary problems may increase fatigue symptoms. “Fatigue” has been defined as the
“sense of persistent tiredness or exhaustion that is often distressing to the individual”. It
is multidimensional and includes physical, mental, and emotional tiredness.

• Negative stereotypes deriving from social and cultural ideas of bodily self-control,
competence, social interruptions, urination as a private act, masculinity and femininity,
and sexuality becomes associated, resulting in stigmatizing effects that devalue and
discredit these older men.
• Stigmatized individuals also internalize the strict and harsh social ideals as a
code for their own self-evaluation and eventually result in the devaluation of
self, which is also known as self-stigma.

• People who internalize stigma related to urinary problems may be less likely to
seek professional help for such problems to avoid disclosing their identity and
being judged.

• Individuals distressed by urinary problems may be more likely to have negative

self-perceptions, particularly in sexual relationships.
Problems Peculiar To Genital
Conditions
– Anatomic deficiencies and surgical interventions can be constant reminders of inadequate
genitalia. This may seem obvious for affected males, yet surgical interventions for female
genital anomalies may impose a significant psychosexual developmental impact on these
patients as well.
– Reconstructive genital surgeries can have broad potential psychosexual implications if
performed in later childhood or adolescence, precisely because of an older child’s increased
awareness.
– Sex chromosomal and other genetic abnormalities often carry specific implications for
genital development. Poorly understood but important, these abnormalities may have
broader developmental ramifications as well. Children with disorders of sex development
(DSD), for example, may have primary or secondary hypoactive sexual desire resulting
from hypogonadism or from fear of sexual dysfunction, respectively. They may have
significant anxiety about a perceived lack of masculinity or femininity. They may
experience impotence, premature ejaculation, anorgasmia, or genital sensory deficits.
 Psychiatric Vulnerabilities

– Development of major anxiety or mood (affective) disorders in patients.

– In some cases, anxiety can be pervasive. Disruptive behavioral disorders, relationship disorders, and
insults to typical family relationships can also be problematic.
– The autonomic nervous system responds to pain, fear, touch, sound, and so on. Blood pressure and
pulse, for example, demonstrate obvious changes and effects. The HPA and HPG axes are also likely to
endure profound effects that can transform their basic functions.
– Disruptive behavior disorders can occur secondary to anxiety disorders, mood disorders, family
relationship problems, stress, or social upheaval.
– Personality factors and vulnerabilities and temperament all play a role in a person’s perceptions,
comprehension, and reactions.
– Any combination of these factors can produce effects in a given individual. Disruptive behaviors can
surface in home life, in academic situations, or in the hospital.
Psychological Interventions

– Cognitive behavioral therapy (CBT) can be very helpful as an

adjunct to treatment interventions for anxiety, mood problems,
self-esteem, sexual self-esteem, and sexual dysfunction.
– CBT can be useful as an intervention for specific psychiatric and
behavioral problems and as a preparatory adjunct to procedures.
– For adult patients who grew up with genitourinary problems, CBT
and insight-oriented therapy may be especially useful and
especially appreciated.
• For many genitourinary conditions, sex therapy and sex counseling can be very
therapeutic.

• Many of these individuals need to learn to be verbally intimate in order to adapt

to the sexual and psychosexual implications of their conditions. Similarly, verbal
intimacy can be vital to the ultimate development of sexual intimacy.

• Learning verbal intimacy as the initial step in sexual relationships can greatly aid
normal psychosexual development and may evolve to more near normal sexual
intimacy.

• When the urologist discusses with the individual their sexual situation, function,
and realities, openly and, preferably, alone, the individual will benefit clinically
and psychosexually and will learn important communication skills about intimate
subjects as well.

• Without such an intervention, many individuals may face a great obstacle to

sexual relationships.
• Similarly, children and adolescents with major genitourinary
conditions may have to be educated about the importance as well as
the function of their own genitalia.

• They may require education that it is safe to touch or handle their

genitalia and that masturbation is a normal activity.

• Males with significant penile anomalies may require education about

sexual positions that permit successful and satisfying sexual
intercourse.

• Some girls with vaginal anomalies may similarly require education.

• Written and pictorial materials can be very helpful.

• Adults who have endured congenital genitourinary anomalies may require
counseling before or during marriage.

• Interventions for adults may include education about sexual functioning,

sexual pleasure, satisfactory sexual intercourse, positions for intercourse,
masturbation, verbal intimacy, sexual intimacy, and the importance of
intimate activities other than intercourse—touching and sexual touching.

• Because of improved abilities to cope and to deal with embarrassing and

difficult material, adults are likely to require less education and fewer
intervention sessions in a given therapeutic approach than children or
adolescents.
Psychological treatments
for renal conditions
Therapeutic patient education

– Therapeutic patient education (TPE) is a type of education which aims to help

patients with a chronic illness acquires the skills necessary to manage their life
following the diagnosis of their illness in general and improve compliance with
treatment and quality of life in particular. The topics covered include
psychosocial support, hospital system, medical procedures, and health- and
illness-related behaviors such as compliance with treatment.
– Similarly, in randomized controlled studies therapeutic patient education (TPE)
programs improved levels of quality of life and decreased levels of emotional
problems including anxiety and depression. However, other studies showed
that TPE was not effective in improving quality of life or decreasing levels of
emotional problems.
Cognitive behavioral therapy
and Behaviour Modification
– A significant number of studies have shown their effectiveness in improving
adjustment including depression, quality of life, self-care behaviors, compliance
with vascular cleansing, and fluid and dietary restrictions in randomized
controlled studies, controlled studies, and quasi-experimental case studies. In
contrast, other studies found no effect of cognitive behavioral therapy on
adjustment or compliance as measured by interdialytic fluid gain.
Health beliefs model

– The Health beliefs model (HBM) aims to predict health-related behaviors such
as compliance with treatment and postulates five factors: perceived
susceptibility to illness; perceived severity of illness; perceived benefits of
treatment; perceived barriers to treatment; and cues to action. Accordingly,
patients tend to comply with treatment more if they perceive that their illness
is serious, if they feel susceptible to it, if they think that there are a high
number of benefits of treatment and low barriers of treatment. Perceived
benefits refer to perceptions about potential benefits or efficacy of a given
treatment and perceived barriers refer to perceptions about potential costs of a
given treatment. Cues to action refer to internal or external stimuli that
motivate people to engage in a given health-related behavior.
Social cognitive theory

– This theory postulates that a given behavior is the result of a self-regulatory

process which is characterized by the reciprocal interaction of environmental
factors with three cognitive factors.
– These include situation outcome expectancy; outcome expectancy and self-
efficacy.
– Situation outcome expectancy refers to the belief that a behavior is dangerous.
Outcome expectancy refers to the belief that a behavior will lead to some
positive outcomes. Self-efficacy refers to the belief of one’s confidence in
obtaining positive outcomes.
– Less but yet significant number of studies have examined the effect of interventions based on
the Health Beliefs Model and the Social Cognitive Theory and the findings have shown that the
intervention based on these theories improved compliance with fluid restrictions.
– However, a randomized control study found that an intervention guided by the Health Belief
Model combined with behavior modification did not lead to a change in health beliefs and
improvement in compliance with fluid restrictions. Similarly, one quasi-experimental study
found that an intervention based on the Self-Regulation Model had no effect on compliance
with fluid restrictions
Self-regulation model

– This model postulates that a patient evaluates his/her illness across a number
of dimensions. These include identity, cause, consequences, time line, and cure
or controllability of his/her illness. Identity refers to the label of the illness or
the nature of the illness including its signs and symptoms. Cause refers to
factors that lead to the illness. Consequences refer to perceptions about long-
and short-term physical, economic, social, and emotional effects of the illness.
Time line refers to whether an illness is perceived as acute, episodic or chronic.
Cure or controllability refers to beliefs about the ways in which patients
manage their illness.
Strategic self-presentation

– During this intervention, patients are asked to present themselves as successful

copers, ostensibly as part of a project which aim to develop a videotape for new
dialysis patients. In that they are asked to generate positive coping skills that
they appraise as helpful by focusing on their strengths rather than their
weaknesses. This intervention is based on the postulation that public self
portrayals such as independence, emotional stability, sociability influence
actual appraisals of self. This in turn influences future behaviors.
Other therapies

– Some studies have shown the effectiveness of other interventions. These

included nutritional counselling, exercise therapy, psychosocial techniques,
strategic self-presentation, technology enabled peer-mentoring program, music
therapy, supportive individual or group therapy, insight therapy, motivational
interviewing, and mindfulness meditation.
Technology-enabled peer-
mentoring program
– This is a peer-mentoring program to support young adults who are receiving
dialysis treatment and the renal staff providing treatment for them. This
consists of two DVDs of interviews carried with peer mentors and renal staff
who have considerable professional experience of young adults on dialysis
treatment. The DVD covered information on the ways in which end-stage renal
disease affects patients’ lives including their relationships, body image,
sexuality, education, and careers.
Supportive group therapy

– During this form of psychological therapy, the therapist uses a number of

techniques such as active listening techniques. This can be offered in individual
or group format. The supportive therapist deals more with the individuals’ daily
events and appeals to the individuals’ conscious mind.
Imagery techniques

– These techniques are also referred to as positive visualization. They consist of a

number of techniques such as special place imagery, descent imagery, and
counting, Special place imagery usually consists of suggestions for helping the
individuals to build a mental picture of a pleasant, safe, peaceful, and relaxing
place such as a garden or a beach. Descent imagery usually consists of
suggestions for helping the individuals to build a mental picture of a set of steps
to go to the other side of the pleasant, safe, and relaxing place. Counting
usually consists of counting from 1 to 5 together with suggestions of deep
relaxation. Imagery techniques can also target specific symptoms such as pain
or medical procedures (e.g., dialysis treatment), and involve suggestions to
improve coping with symptoms and medical procedures.
Progressive muscular relaxation

– This is a technique which helps the individuals to relax. There are two types of
progressive muscular relaxation. First one consists of progressive muscle
relaxation by suggestions of warmth, comfort and relaxation while at the same
time encouraging a given individual to imagine himself/herself saying the word
“relax” under his/her breath, each time he/she breathes out. Second one
involves tensing and relaxation cycles. The training usually starts with legs,
proceeds to the muscles of the back, shoulders, neck, head, forehead, and ends
with concentrating on the whole body.
Rational emotive therapy

– This form of psychological therapy is based on the notion that situations

themselves do not determine the ways in which people feel and behave, and
emotions and behaviors are the result of ways of thinking. This therefore aims
to help individuals to modify their ways of thinking to achieve more positive
emotions and behaviors.
Mindfulness meditation

– This aims to help individuals to develop a nonjudgmental, moment-tomoment

awareness of their experience. This nonjudgmental awareness is postulated to
help the individuals to notice, understand, and integrate their perceptions of
self and environment to bring insight into their cognitions both positive or
negative, and to observe rather than react to or change their thoughts and
emotions.
References

– Krespi, M. R. (2017). Psychosocial interventions to improve outcomes among dialysis

patients. Seminars in Dialysis, 31(1), 65–71.
– Emanu, J. C., Avildsen, I., & Nelson, C. J. (2018). Psychotherapeutic Treatments for Male
and Female Sexual Dysfunction Disorders. In: D. David, S. J. Lynn, and G. H. Montgomery
(Eds.), Evidence-Based Psychotherapy (pp- 253-270). John Wiley & Sons, Inc.
– Reiner, W. G. (2010). Psychological and Psychiatric Aspects of Genitourinary Conditions.
In: G. H. Mouriquand, Paediatric Urology (pp- 512-518). Elsevier.