Running Head: Sex Therapy Biopsychosocial & Service Plan 1

Sex Therapy Biopsychosocial & Service Plan

Ariel Pliskin

Westfield State University

March 2018
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CLIENT INFO: Sam is a 42-year old white male. He works as a carpenter.

REASON FOR REFERRAL: A drug abuse treatment center referred Sam to sex therapy after a

recent relapse with alcohol included engaging a prostitute and admitting for the first time a

“20-year sex addiction” to his wife Jill.

CLIENT STRENGTHS:

 Resilience: Participation in recovery programs and maintenance of periods of sobriety,

most recently for two years.

 Commitment: Strong desire (shared by Jill) for marriage to succeed.

 Optimism: Belief that sex therapy could address his “core issue.”

CLIENT BARRIERS TO PROGRESS:

 Repetition of unwanted behavior: While his recent period of sobriety was two years,

Sam’s struggle with substance abuse and “sex addiction” has lasted for a very long time.

 Trauma: Sam has never received treatment for being molested by an uncle as a child.

 Sex negativity: Sam has negative ideas and feelings about sex.

 Spouse trauma: Jill’s father died of alcoholism and she has a history of abusive and

controlling boyfriends.

MEDICAL CONCERNS: Sam has a lengthy substance abuse history with alcohol, heroin, and

cocaine. Jill abused alcohol and heroin.

SUPPORT: Sam has participated in various 12-step groups though decided against a 12-step

addiction program because they encouraged a period of total abstinence. Sam and Jill feel that

abstaining from sex is not in line with the monogamous partnership they are trying to build.
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MARRIAGE DYNAMICS: Sam and Jill met four years ago in a recovery group. They married two

years ago. While he was honest with her about previous substance relapses, this is the first time

he has honestly shared with his wife about his violation of their monogamy agreement. He

describes their connection as intense and says he has “never felt this way,” though when asked

to what extent his marriage has the emotional intimacy he desires, he responds “not much.

We’re trying.”

THOUGHT CONTENT (THEMES/PATTERNS):

Dualism: Sam contrasts healthy and unhealthy sex. On the one hand, he says that “normal

people have a sex drive” and that “sex as intimacy and connection” is the “best thing in the

world.” On the other hand, he describes chronic masturbation as an adolescent, “obsessive”

searches for sexual partners over the course of his adulthood and his experience of “sex as a

drug.”

Fatalism: Sam says that once one crosses “the fatal line of intercourse” in extramarital sexual

activity (which he hasn’t done), “it’s all over”. He also says “sex is my core issue. If I don’t deal

with it, I’ll never stay clean.”

MENTAL STATUS:

Sam is a slightly overweight middle-aged man. His face has some wrinkles. He wore jeans and a

collared shirt to his first session. His clothes were neat and well-worn. He was well-kempt. He

sat with a slight hunch in his back. He alternated periods of sitting calmly and attentively with

moments of self-expression. When he talked about his problems, he gesticulated animatedly

and accelerated the pace and volume of his speech. He was generally respectful of balance in

the therapist-client exchange though sometimes blurted out ideas of concern to him. He usually
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made eye contact, though lost it when he got particularly excited. He had no trouble recalling

past events in detail. A tone of optimism and hope pervaded his mood though he also revealed

moments of anxious fear. He reports sleeping and eating well, though would prefer to eat less

fatty foods. There was no sign that he had any intention to harm himself or others. His thoughts

were coherent, clear and rational. His understanding of the problem seemed fairly helpful,

though at times rigid. He has a clear understanding of the harmful results of some of his past

choices.

SERVICE PLAN:

GOAL # 1 =

CLIENT (SAM) WILL: refrain from drugs and alcohol

BY: Immediately

AS EVIDENCED BY: Sam reports that he is sober.

INTERVENTIONS:

Continue attending treatment center

12-step program for drugs and alcohol

GOAL #2 =

CLIENT (SAM) WILL: “get comfortable with the idea that sex is not a bad thing.” client

statement

BY: three months

AS EVIDENCED BY: Sam reports that he feels more comfortable with sex

OBJECTIVE 1: Flesh out what Sam meant by chronic masturbation and “obsessive” searches for

partners both in terms of his subjective experience and the frequency and type of behaviors.
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Normalize and increase self-compassion for desires and past behaviors, regardless of whether

he chooses to continue those behaviors.

INTERVENTIONS:

PLISSIT model of sex therapy: Permission, Limited Information, Specific

Suggestions and Intensive Therapy.

Limited Information: normalcy of stigmatized desires and behaviors

Permission: having sexual thoughts and feelings, engaging in healthy

behaviors.

OBJECTIVE 2: Sam will grow to understand the factors (trauma history, religious, cultural) that

led him to believe sex is a bad thing. Sam will reassess those beliefs.

INTERVENTIONS:

Trauma-informed Cognitive Behavioral Therapy

OBJECTIVE 3: Sam will learn how to better manage the impacts of childhood trauma on his

current functioning. (I recommend that Jill receive counseling to do the same)

INTERVENTIONS:

Mindfulness-Based Stress Reduction

Somatic Experiencing

OBJECTIVE 4: Sam will develop a vision of sexual health, including unwanted and wanted

behaviors.

INTERVENTIONS:

Out of Control Sexual Behavior (OCSB) group for men.

Writing personal vision of sexual health

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GOAL # 3 (shared by wife Jill)

CLIENT (SAM) WILL = Increase sexual and emotional intimacy with wife and develop a lasting

monogamous relationship

BY: six months

AS EVIDENCED BY: Sam and Jill report that they feel closer. Sam will report that he has honored

their relationship agreements.

OBJECTIVE 1: Sam and Jill will develop a shared vision of sexual health, identifying unwanted

and wanted behaviors.

INTERVENTIONS:

Writing shared vision of sexual health

OBJECTIVE 2: Sam and Jill will bond with each other.

INTERVENTIONS:

Emotionally Focused Couples Therapy

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Critique

Before writing my service plan, I read the introduction and description of a first session of a

case in the book Quickies. I did not read the intervention and results from the case study in

order to avoid bias. This critique will both draw from The Practice of Generalist Social Work

(Birkenmaier, & Berg-Weger, 2014) and the intervention described in the case study (Flemons

& Green, 2007).

With the loose sexual health model as a center-piece, my service plan draws from

several psychotherapeutic orientations. The elements aligned with the Sexual Health Model are

the focus on developing a vision of desired sexuality within the OCSB model. Interventions I

mention include 12-steps, drug treatment center, sex therapy (including sexual health, Out of

Control Sexual Behavior model and PLISSIT), Cognitive Behavioral Therapy, Mindfulness Based

Stress Reduction, Somatic Experiencing and Emotionally Focused Couples Therapy. The

treatment described in the actual case was much simpler. The therapist largely responded to

and reinforced progress achieved through the innate wisdom of the clients. The therapist

provided empathy and affirmed client strength and progress. The therapist provided context to

frame the couple’s journey; she normalized Jill’s fearful hesitation and reminded the couple

that it takes time to build trust while balancing caution and intimacy.

As recommended by Birkenmaier and Berg-Weger (2014), my service plan details a

sequence of manageable achievable steps which work towards a “preferred reality” identified

by the client (p. 131). As Birkenmaier and Berg-Weger (2014), recommend, I propose realistic

language to replace client framing that I judge to be overly grandiose or unrealistic.

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Identifying what I called “fatalistic” and “dualistic” thinking reflects elements of diagnosis and

intervention more thoroughly described by Birkenmaier and Berg-Weger and also illustrated in

the case. Birkenmaier and Berg-Weger explain that social workers could help “thicken” a

narrative that is overly simple (p. 113). The therapists in the case pointed out that Sam’s talking

with Jill about moments of avoiding temptation to engage prostitutes served to rewrite his

story to include her (Flemons & Green, 2007). The therapist encouraged Sam to see resisting

unwanted compulsions as a “continuous” instead of “discrete” goal (Birkenmaier, & Berg-

Weger, 2014, p. 133) While it will get easier with time, it is never fully accomplished.

References

Birkenmaier, J. & Berg-Weger, M. (2014) The practice of generalist social work. New York, NY:

Routeledge. 978-0-415-51989-2

Flemons, D. & Green, S. Just between us: a relational approach to sex therapy. In Flemons, D. &

Green, S. (2007) Quickies: The Handbook of Brief Sex Therapy . New York: Norton, W. W.

& Company, Inc.