John Köhl, Psychologist specializing in sex therapy

1.       Prostate cancer is an illness which has a major impact on a person’s sexuality and sexual health. When is the ideal time to refer a patient to a sex therapist?

John Köhl : The ideal time to refer a patient to a sex therapist is after the initial diagnosis and before the start of treatment. It is important to prepare the patient for side effects and the psychological impact of treatment and the rehabilitation process. Ideally the patient’s partner is included in this process. It is important to assess the patient’s sexual function prior to treatment as there may already be underlying sexual difficulties. Proper prior screening may also facilitate the correct post-treatment referral.

2.       Side effects of prostate cancer treatment may lead to erectile dysfunction (ED). How do you support the efforts of the medical team to treat these symptoms?

John Köhl : When supporting the medical team, I typically use a structured model known as Ex-PLISSIT. This intervention consists of four steps.

• The first step is P which stands for permission. Often, medical specialists focus on presenting the diagnosis and at the same time give further explanations about the consequences of the treatment. Sometimes all this life-changing information is difficult to absorb. Permission is about offering an open space where patients can talk about their concerns about sexuality, about the treatment and rehabilitation side effects. It is important to able to offer an open, non-judgmental and receptive space.
• The next level of the EXPLISSIT model is LI which stands for limited information. This level, which is also known as psychoeducation, has to do with making sure the patient fully understands the treatment and rehabilitation he will undergo. It is important to address any unrealistic expectations at this level.
• The next level SS, or specific suggestions, are post-treatment suggestions to help the patient in his rehabilitation. This includes pluridisciplinairy referrals to pelvic floor physiotherapists, homework for behavioral change, sexual activities, such as sensate focus and suggestions for pharmacological treatments.
• Finally if underlying psychological difficulties such as anxiety or resistant depression are stopping a patient from accessing an optimal rehabilitation then the final level of this model IT, intensive therapy, is appropriate for more comprehensive support and to address any barriers to therapeutic engagement.

In summary, I can assist the medical team with psychoeducation, interventions designed to facilitate the recovery of erectile function and more comprehensive therapy for underlying psychological difficulties, such as anxiety, depression or problematic grief processing. I also can assist the medical team in including the partner in the rehabilitation process and addressing any underlying communication issues in the relationship.

3.       What sort of obstacles or resistance do you encounter when treating this patient population?

John Köhl : When working with patients who have just gotten a cancer diagnosis, have come through treatment or face a long rehabilitation process, there are many aspects that are important to remember.

Patients will face first and foremost strong emotions. They may experience sadness and grief as they come to realize the losses. They may feel anger at being forced to make unwanted changes in their life. When these emotions are not processed and integrated, patients may not have the resources to focus on the treatment or the rehabilitation process.

Another source of emotional distress may come from erroneous perceptions of the past around sexual function. A patient may perceive a diagnosis or a treatment as causing the subsequent erectile dysfunction when in fact there had been prior to treatment a progressive diminished erectile function. There may also be prior couple difficulties that would lead to reduced frequency of intercourse. It is important to get an accurate picture of the past in order to have realistic expectations of the outcome.

Prior emotional functioning may also impede a full recovery. Patients who suffer from high anxiety levels or frequent depressive episodes may find that they are ill-equipped to deal with a cancer diagnosis, treatment and long rehabilitation. Performance anxiety, demanding self-monitoring, and failure anxiety are associated sympathetic nervous system activity which has an inhibitory effect on libido and genital arousal. Negative automatic thoughts or Catastrophisation, such as fear of the partner leaving, also lead to a vicious circle of anxiety, shame, avoidance and increased anxiety. Patients who have suffered from depression are more vulnerable to the lower levels of energy and lack of libido that this condition brings. They also suffer from negative thoughts and low self-confidence which can also affect the recovery process.

Awareness of these obstacles and others is primordial to supporting patients through this arduous process.

4.       What other interventions may be needed after prostate cancer treatment?

John Köhl : The main interventions, if we recall the EX-PLISSIT model (Permission, Limited Information, Specific Suggestions, and Intensive Therapy), are giving out science-based information, suggesting exercises to help the rehabilitation process, and working in intensive therapy for underlying difficulties with anxiety, depression or with a partner. Other psychotherapeutic interventions include coping with sadness and grief around loss, developing coping skills and cognitive flexibility.  Specific exercises that help the recovery process include Mindfulness meditation, non-judgmental present moment awareness and Sensate Focus, a technique emphasizing the pleasure of touch. Counseling and accompanying the patient in the use of pharmacological support such as phosphodiesterase 5 inhibitors or intra-cavernosal injections is also a useful intervention.

Finally, it is important to surround the patient with a skilled referral network that includes, for example, physiotherapists for pelvic floor therapy, biofeedback and relaxation techniques, and allow a tailor made rehabilitation process.

By Ashley Machen