Sex Therapy: Behavioral and cognitive Approach
Prepared By:
Fr. Immanuel, M.Phill
Clinical Psychology, KMC, Manipal, Manipal University
Date of last revision :
10-11-08
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Outline
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Two events in the late 1950s
marked the beginning of a new, direct approach to the treatment
of sexual dysfunctions. The first event was the publication of
an article by Semans (1956) describing a simple technique for
treating premature ejaculation. The second event was the
publication of Wolpe’s Psychotherapy by Reciprocal Inhibition
(1958), which described the application of conditioning
procedures to the treatment of various sexual dysfunctions.
These techniques did not receive widespread attention until
1970, when Masters and Johnson’s Human Sexual Inadequacy
expanded these direct approaches into a comprehensive therapy
program for sexual dysfunctions. Since then numerous articles
have been published on sex therapy, sex therapy clinics have
sprung up and many additional techniques have been added to the
repertoires of clinicians who treat sexual dysfunctions (Hogan,
1978).
Definition of Sexual Dysfunctions
Sexual dysfunctions are cognitive, affective, and/or behavioral
problems
that prevent an individual or couple from engaging in and/or
enjoying satisfactory intercourse and orgasm (Hogan, 1978).
Thus sexual dysfunctions are distinguished from sexual
variations, in which the individual may successfully engage in
intercourse in an unconventional way or with an unconventional
object choice (Kaplan, 1974b).Masters and Johnson (1966),
divided the common pattern of sexual response cycle in both
sexes into four specific phases such as a) Excitement phase, b)
Plateau phase, c) Orgasm phase and Resolution phase. Based on
these divisions
sexual
dysfunctions are also seen as disturbances in one or
more of the sexual response cycle's phases, or pain associated
with arousal or intercourse.
Classification of Sexual
Dysfunctions
Hogan (1978) classified
sexual dysfunctions in to male and female dysfunctions.
Male sexual dysfunctions can be subdivided into erectile
failure, retarded ejaculation, premature ejaculation, and
dyspareunia. The term impotence has been used in the
past to refer to the first three categories. However, the
importance of distinguishing among these three disorders is
emphasized both by Kaplan (1974b) and by Masters and Johnson
(1970), since the three differ both physiologically and in their
response to treatment.
Erectile failure (EF)
refers to the inability of the male to achieve or maintain an
erection to such an extent that he is unable to engage in
satisfactory intercourse.
Retarded ejaculation (RE),
also termed "ejaculatory incompetence" (Masters and Johnson,
1970) and "ejaculative impotence" (Cooper, 1968a), is a disorder
in which the male suffers from delayed intravaginal ejaculation
or the inability to ejaculate intravaginally.
Premature ejaculation (PE)
is topographically the opposite of RE: The patient suffering
from PE ejaculates prior to or soon after inserting his penis
into his partner's vagina. There are no objective criteria for
what constitutes premature ejaculation. However, data do
indicate that increasing ejaculatory latency beyond seven
minutes is not strongly associated with increased incidence of
coital orgasm for women, and that the median duration of
intercourse for men is somewhere between four and seven minutes
(Gebhard, 1966). Thus, one might suggest that a latency to
ejaculation of less than four minutes may be a tentative
indicator for treatment. Such a definition must be tempered by
several other factors: How much manual and oral foreplay
stimulation of his genitals can the male tolerate without
ejaculation; whether the male is unrestrained in intercourse or
can only delay ejaculation by slowing thrusting, thinking
unpleasant, antierotic thoughts, biting his tongue, or wearing a
condom; frequency of intercourse; age of the patient; and use
of alcohol, drugs, and even topical anesthetic creams to dull
sexual responsivity and delay ejaculation. It is therefore
easier to describe what not premature ejaculation is: both
husband and wife agree that the quality of their sexual
encounters is not influenced by efforts to delay ejaculation (LoPicolo,
1978).
The
final male dysfunction is dyspareunia, or painful
intercourse. ,This disorder is usually caused by organic
factors (Masters and Johnson, 1970).
Female
sexual dysfunctions have been divided into five categories:
general sexual dysfunction, primary and secondary orgasmic
dysfunction, dyspareunia, and vaginismus. General
sexual dysfunction consists of the inhibition of the
vasocongestive/ arousal stage of the sexual response, so that
vaginal lubrication and swelling develop minimally or not at
all. General sexual dysfunction is experienced subjectively by
the female as a lack of erotic feelings. This dysfunction was
first recognized as a discrete disorder in 1974 by Kaplan
(1974a,), and most investigators have not yet adopted the term.
Patients presenting with this disorder are classified by other
researchers as either inorgasmic or "frigid”.
Orgasmic
dysfunction consists of the inhibition of the orgasm
phase of the female sexual response. It is subdivided into
primary orgasmic dysfunction, which exists when the
patient has never experienced an orgasm in any way, and
secondary orgasmic dysfunction, a disorder in which the
client has had an orgasm at least once through some form of
sexual stimulation but currently experiences coital orgasms
rarely or not at all.
The
term frigidity is often used in the literature on sexual
dysfunctions as a catchall category for orgasmic dysfunction and
general sexual dysfunction. The term has little utility, since
it does not even inform one as to which of the two components of
the sexual response has been inhibited, let alone finer details
(e.g., whether the problem is primary or secondary).
Dyspareunia
(painful intercourse) in the female can range from postcoital
vaginal irritation to severe pain during penile thrusting. It is
far more common in the female than in the male (Masters and
Johnson, 1970), and female dyspareunia is more likely to involve
psychological factors than is male dyspareunia.
Vaginismus,
the final female dysfunction to be discussed, is a condition in
which the vaginal introitus closes tightly when intercourse is
attempted, thus preventing penetration. It is caused by an
involuntary spastic contraction of the sphincter vaginae and the
levator ani, the muscles surrounding the vagina.
ICD-10
classifies sexual dysfunctions, not caused by organic disorder
or disease under ten headings. These are lack or loss of sexual
desire, sexual aversion and lack of sexual enjoyment, failure of
genital response, orgasmic dysfunction, premature ejaculation,
nonorganic vaginismus, nonorganic dysparenunia, excessive sexual
drive, other sexual dysfunction, not caused by organic disorder
or disease, and unspecified sexual dysfunction, not caused by
organic disorder or disease.
Historical Overview
The history of sex therapy as a discipline is relatively brief (Leiblum
& Rosen, 1989). From the start of the twentieth century until
the late 1960s, sexual dysfunction was typically treated within
a psychoanalytic framework (Rosen & Weinstein, 1988), as were
most psychological problems (Comer, 1995). As such, treatment
consisted of long-term, individual psychotherapy to unmask the
underlying (and often unconscious) intrapsychic conflicts that
manifested themselves as disruption of "healthy" or "mature"
sexual functioning. In contrast to this dominant perspective, a
few clinicians (e.g., Lazarus, 1971; Obler, 1973; Wolpe, 1958)
explicitly applied behavioral principles in the treatment of
sexual dysfunction, but such approaches were not the norm prior
to the 1970s.
Sex therapy as it is known today
was essentially founded by Masters and Johnson (1970), whose
published report on a "new" therapeutic approach to sexual
problems revolutionized what health professionals saw as the
appropriate treatment for such difficulties. In contrast to
psychoanalytic approaches, the "new" sex therapy was relatively
brief, problem focused, directive, and behavioral with regard to
technique. Rather than intrapsychic factors, Masters and Johnson
(1970) emphasized social and cognitive causes of sexual
dysfunction; ultimately, the large majority of sexual
difficulties were seen as arising from a sexually restrictive or
religiously orthodox upbringing. On the heels of Masters and
Johnson, Helen Kaplan (1974, 1979) introduced and elaborated her
version of the "new" sex therapy. Potentially viewed as an
integration of, or bridge between, the traditional
psychoanalytic and more contemporary behavioral approaches, hers
included an initial emphasis on immediate symptoms. If the
direct approach to symptom treatment worked, the case was
closed. If, however, the "new" behavioral techniques met with
resistance, the therapist relied on psychodynamic theory, or
consideration of "deeper" issues, to understand the possible
intrapsychic and interpersonal roles the sexual dysfunction
might be serving.
The new sex therapy, as elaborated by Masters and
Johnson (1970), included short-term but intensive work with the
couple (conjoint therapy). Detailed information about relevant
human anatomy (structure) and physiology (functioning) was
provided, as was more general counseling as needed. The
therapists conducted their work as a male-female pair of
cotherapists; hence, traditional sex therapy involved four
individuals (the cotherapists and the client couple).
Additionally, the intervention consisted of direct behavioral
exercises, including prescription of nondemand pleasuring, or
"sensate focus," wherein the objective was to (re)experience
sexual pleasure in the absence of anxiety from perceptions of
performance demand or excessive self-monitoring of sexual
performance ("spectatoring").
Over the past decade or so, the types of cases commonly seen in
sex-therapy clinics have changed dramatically from the earliest
days of contemporary sex therapy (Leiblum & Rosen, 1995; Rosen &
Leiblum, 1995). As the proportion of clients who simply needed
education and direction dwindled, the proportion of clients with
more pervasive and chronic sexual problems increased.
Accordingly, instances of erectile failure (Rosen & Leiblum,
1992), low sexual desire (Beck, 1995; Kaplan, 1979; Leiblum &
Rosen, 1988), and compulsive sexual behavior (Coleman, 1991;
Goodman, 1993) have become an increasing part of sex therapists'
caseloads (Schover & Leiblum, 1994). These problems present a
greater challenge to clinicians and hence do not evidence the
high rates of improvement found among the earlier reports on the
success of sex therapy (Kilmann, Boland, Norton, Davidson, &
Caid, 1986; Rosen & Leiblum, 1995). Currently, sex therapists
appear to employ a broad range of treatment modalities,
including bibliotherapy and group therapy (Hawton, 1992; Shah,
1996). At the same time, sex therapists have witnessed a marked
"medicalization" of treatment for many sexual problems (Schover
& Leiblum, 1994; Tiefer, 1994).
Causes of sexual dysfunctions
Hogan (1978) summarizes the causes of sexual dysfunctions as
psychological, physical, interpersonal and socio-cultural.
Psychological causes can include:
-
stress or anxiety from work or
family responsibilities
-
concern about sexual performance
-
conflicts in the relationship with
your partner
-
depression/anxiety
-
unresolved sexual orientation
issues
-
previous traumatic sexual or
physical experience
-
body image and self-esteem
problems
Physical causes can include:
-
diabetes
-
heart disease
-
liver disease
-
kidney disease
-
pelvic surgery
-
pelvic injury or trauma
-
neurological disorders
-
medication side effects
-
hormonal changes, -related to
pregnancy and menopause
-
thyroid disease
-
alcohol or drug abuse
- fatigue
Interpersonal relationship causes may include:
-
partner performance and
technique
-
lack of a partner
-
relationship quality and
conflict
-
lack of privacy
Socio-cultural influence causes may include:
-
inadequate education
-
conflict with religious,
personal, or family values
-
societal taboos
Approaches Used in Sex Therapy
Masters and Johnson’s
Approach: Treatment begins with
assessment procedures, including a physical examination and
interviews with therapists who took medical and personal
histories. On the third day, the therapists met with the couple
to discuss their assessment of the nature, extent, and origin of
the sexual problem to recommend treatment procedures and to
answer any questions (Wiederman, 1998).
Kaplan’s Approach:
Assists the partners in achieving their sexual goals in as short
a time as possible. Sessions are usually held once or twice a
week while the partners continue to live at home.(Wiederman,
1998).
The PLISSIT Model
Approach (Annon,1976): The
model provides for four levels of approach, and each letter or
pair of letters designates a suggested method for handling
presenting sexual concerns. The four levels are:
Permission-Limited Information-Specific Suggestions-Intensive
Therapy.
The First Level of Treatment: Permission.
Sometimes, all that people want to know is that they are normal,
that they are okay, that they are not "perverted," "deviated,"
or "abnormal," and that there is nothing wrong with them.
Mostly, they would like to find this out from someone with a
professional background or from someone who is in a position of
authority to know. If permission giving is not sufficient to
resolve the client's concern,
then therapist can
combine their permission giving with the second level of
treatment.
The
Second Level of Treatment: Limited Information. In
contrast to permission giving, which is basically telling the
client that it is all right to continue doing what he or she has
been doing, limited information is seen as providing the client
with specific factual information directly relevant to his or
her particular sexual concern. For example, providing
specific information for a young man concerned that his penis
may be somewhat smaller than average may be all that is
necessary to resolve his concern (e.g., the foreshortening
effect of viewing his own penis, that there is no correlation
between flaccid and erect penis size, that the average length of
the vagina is usually three to four inches, that there are very
few nerve endings inside the vagina, etc. Providing limited
information is also an excellent method of dispelling sexual
myths, whether they are specific ones such as those pertaining
to genital size, or more general ones such as that, on the
average, men and women differ markedly in their capacity to want
and to enjoy sexual relations and in their fundamental capacity
for responsiveness to sexual stimulation, or that men are more
quickly aroused than women, etc. If giving limited information
is not sufficient to resolve the client's sexual concern then
the therapist may proceed to the third level of treatment.
The Third Level of Treatment: Specific
Suggestions.
What the
clinician needs is a sexual problem history. This is not to be
confused with a sexual history. If clinicians begin to take a
sexual history, then they are heading into intensive therapy,
not brief therapy. It is an assumption of the model proposed
here that a comprehensive sexual history is not relevant or
necessary at this level. The application of the specific
suggestion approach may resolve a number of problems that
filtered through the first two levels of treatment; but,
needless to say, it is not expected that it will successfully
deal with all such problems. If the third level of approach is
not helpful to the client, then a complete sexual history may be
a necessary step for intensive therapy.
The Fourth Level of Treatment: Intensive Therapy.
Intensive therapy in the model proposed here does not mean an
extended standardized program of treatment. In the P-LI-SS-IT
model, intensive therapy is seen as highly individualized
treatment that is necessary because standardized treatment was
not successful in helping the client to reach his or her goals.
Many learning-oriented therapists have decried the restrictive
use of one or two standardized procedures and have advocated a
broad-spectrum approach to therapy.
The
Cognitive Therapy Approach:
Method based on exploring more positive ways
of viewing sex and sexuality to eliminate negative thoughts and
attitudes about sex that interfere with sexual interest,
pleasure, and performance (LoPicolo & LoPicolo,1978)
Cognitive
Behavior Therapy Approach: Because
positive sexual fantasies are associated with positive affect,
general physiological arousal, and sexual arousal, cognitive
behavior therapists encourage their use by asking the patient to
deliberately identify arousing sexual fantasies (LoPicolo &
LoPicolo,1978).
Basic
Principles of Direct Treatment of Sexual Dysfunction (LoPicolo,
1978)
Mutual Responsibility:
It must
be stressed that all sexual dysfunctions are shared disorders;
that is, the husband of an inorgasmic woman is partially
responsible for creating or maintaining her dysfunction, and he
is also a patient in need of help. Regardless of the cause of
the dysfunction, both partners are responsible for future change
and the solution of their problems.
Information and Education:
Most
patients suffering from sexual dysfunction are woefully
ignorant of both basic biology and effective sexual techniques.
Sometimes this ignorance can directly lead to the development of
anxiety, which in turn produces sexual dysfunction. For example,
a recent patient dated the onset of her aversion to sex as
beginning when she first noted that her clitoris “disappeared”
during manipulation. She interpreted this normal retraction of
the clitoral shaft during the plateau phase of arousal (Masters
and Johnson, 1966) as a pathological sign that she was not
becoming aroused. This anxiety led to a complete loss of her
arousal and enjoyment of sexuality. Similarly, many cases of
vaginismus seem to begin as a result of the husband's forceful
attempts to accomplish intromission in spite of his uncertainty
about the exact location of the vagina.
Attitude Change:
Negative
societal and parental attitudes toward sexual expression, past
traumatic experiences, and the current acute distress combine to
make the dysfunctional patients approach each sexual encounter
with anxiety or, in extreme cases, with revulsion and disgust.
Eliminating Performance Anxiety:
In
the culture of the 1970s, with its heavy emphasis on youth,
beauty, and sexual attractiveness, demands for sexual competence
and expertise seem to be assuming a larger role in the
development of sexual dysfunction. Accordingly, for therapy to
succeed, the dysfunctional patients must be freed from anxiety
about their sexual performance. Patients, regardless of
presenting complaint, are told to stop “keeping score,” to stop
being so goal-centered on erection, orgasm, or ejaculation, and
instead to focus on enjoying the process rather than trying for
a particular end result.
Increasing Communication and Effectiveness of
Sexual Technique:
Dysfunctional couples tend to be unable to clearly communicate
their sexual likes and dislikes to each other, due to
inhibitions about discussing sex openly, excessive sensitivity
to what is perceived as hostile criticism by the spouse,
inhibitions about trying new sexual techniques, and the
incorrect assumption that a person's sexual responsiveness is
unchanging, i.e., that an activity that is pleasurable on one
occasion will always be pleasurable. Accordingly, direct therapy
encourages sexual experimentation and open, effective
communication about technique and response. Procedures that are
used include having the patient couple share their sexual
fantasies with each other, read explicit erotic literature, and
see explicit sexual movies that model new techniques, and
training the couple to communicate during their sexual
interaction.
Changing Destructive Life-Styles and Sex Roles:
Direct
therapy for sexual dysfunction often involves the therapist's
stepping outside the usual therapeutic posture of responding to
the patient, and instead taking an active, directive, and
initiating role with the patient in regard to general life-style
and sex-role issues. For example, many dysfunctional patients
make sex the lowest priority item in their life. Sex occurs only
when all career, housework, child-rearing, home management,
friendship, and family responsibilities have been met. This
usually ensures that sex occurs infrequently, hurriedly, late at
night, and when both partners are physically and mentally
fatigued. In such a case, patients may be instructed to make
"dates" with each other for relaxing days or evenings (Annon,
1974).
Prescribing Changes in Behavior:
If there
is any one procedure that is the hallmark of direct treatment of
sexual dysfunction, it is the prescription by the therapist of a
series of gradual steps of specific sexual behaviors to be
performed by the patients in their own home. These behaviors are
often described as “sensate focus” or “pleasuring” exercises.
Typically, intercourse and, indeed, breast and genital touching
are initially prohibited, and the patients only examine,
discuss, and sensually massage each other's bodies. Forbidding
more intense sexual expression allows the patients to enjoy
kissing, hugging, body massage, and other sensual pleasures
without the disruption that would occur if the patient
anticipated these activities would be followed by intercourse or
other sexual behaviors that have not been pleasurable in the
past. The couple's sexual relationship is then rebuilt in a
graduated series of successive approximations to full sexual
intercourse. At each step, anxiety reduction, skill training,
elimination of performance demands, and the other components
described above are used to keep the couple's interactions
pleasurable and therapeutic experiences.
Treatment sexual dysfunctions
based on behavioral and cognitive approach
The Correction of Misconceptions:
Direct
advice, guidance, information, reassurance, or instruction may
suffice to overcome the milder, simpler, and more transient
cases of impotence and frigidity. The correction of faulty
attitudes and irrational beliefs is often an essential
forerunner to specific techniques of lovemaking. One should
endeavor to impart nonmoralistic insights into all matters
pertaining to sex. It is often helpful to prescribe nontechnical
but authoritative literature (Lazarus, 1978).
Graded Sexual Assignments:
Wolpe
(1958) evolved a simple but effective procedure for promoting
sexual adequacy and responsiveness in those cases where anxiety
partially inhibits sexual performance. A cooperative sexual
partner is indispensable to the successes of the technique. The
patient is instructed not to make any sexual responses that
engender feelings of tension or anxiety but to proceed only to
the point where pleasurable reactions predominate. The partner
is informed that she must never press him to go beyond this
point, and that she must be prepared for several amorous and
intimate encounters that will not culminate in coitus. The
theory is that by maintaining sexual arousal in the ascendant
over anxiety, the latter will decrease from one amorous session
to the next. Thus, positive sexual feelings and responses will
be facilitated and will, in turn, further inhibit residual
anxieties. In this manner, conditioned inhibition of anxiety is
presumed to increase until the anxiety reactions are completely
eliminated.
The role of Desensitization Procedures in
Overcoming Frigidity:
Treatment of
chronic frigidity by systematic desensitization was first
reported Lazarus (1963). Desensitization has also been
successfully applied to groups of impotent men and frigid women
(Lazarus, 1969). The preferred size of desensitization groups
is between four and eight members. The sessions are conducted at
the pace of the slowest (most anxious) individual. If one group
member obviously delays the progress of the other patients, he
is given a few individual sessions to expedite matters. The
typical hierarchy applied to the frigid women consisted of the
following progression: embracing, kissing, being fondled, mild
petting, undressing, foreplay in the nude, awareness of
husband's erection, moving into position for insertion,
intromission, changing positions during coitus.
In
the treatment of vaginismus (as well as in those cases suffering
from generalized fears of penetration), desensitization, first
in imagination, followed at home by gradual dilation of the
vaginal orifice, has proved highly successful. The patient,
under conditions of deep relaxation, is asked to imagine her
inserting a graded series of objects into the vagina. When she
is no longer anxious about the imagined situation, she is asked
to use real objects. One might commence with the tip of a cotton
bud, or the tip of the patient's little finger, followed by the
gradual insertion of two or more fingers, internal sanitary
pads, various lubricated cylinders, and eventually by the
gradual introduction of the penis, culminating with vigorous
coital movement. Masters and Johnson (1970) consider it
necessary for husband and wife to cooperate in all phases of
dilatation therapy.
Assertive
Training for Impotent Men:
Many
impotent men appear to have servile attitudes toward women and
respond to them with undue deference and humility. Their sexual
passivity and timidity are often part of a generally
nonassertive outlook, and their attendant inhibitions are
usually not limited to their sex life. These men feel threatened
when required to assume dominance in a male-female relationship.
Therapy is aimed at augmenting a wide range of expressive
impulses, so that formerly inhibited sexual inclinations may
find overt expression. This is achieved first by explaining to
the patient how ineffectual forms of behavior produce many
negative emotional repercussions. The unattractive and
exceedingly distasteful features of obsequious behavior are also
emphasized. The patient is then told how to apply principles of
assertiveness to various interpersonal situations. For instance,
he is requested to "express his true feelings; stand up for his
rights," and to keep detailed notes of all his significant
attempts (whether successful or unsuccessful) at assertive
behavior. His feelings and responses are then fully discussed
with the therapist, who endeavors to shape the patient's
behavior by means of positive reinforcement and constructive
criticism (Lazarus, 1978).
Aversion- Relief Therapy in the Treatment of a
Sexually Unresponsive Woman:
Here patient is given
aversive stimuli such as electric shock. When the electrical
impulses became intolerable, she was required to turn her
attention toward several photographs of nude men on the desk in
front of her. Upon looking at the pictures, the shock is
immediately terminated (producing definite signs of relief). She
receives intermittent shocks when averting her gaze from the
pictures . A slightly modified method can be at a later stage.
The therapist says, "Shock!" and administered a very strong
burst of electricity to the patient's palm if she did not
proceed to look at the pictures within eight seconds. She is
told that she could avoid the shock by looking at the pictures
in good time.
(Lazarus, 1978).
The Treatment of Premature Ejaculation:
Premature ejaculation is sometimes a symptom of anxiety. The
amelioration of anxiety by such techniques as relaxation,
desensitization, and assertive training has therefore proved
helpful in certain instances. In general, however, it should be
noted that psychotherapeutic efforts have not proved especially
effective in altering the premature response pattern.
Nevertheless, some essentially simple tricks may occasionally
meet with gratifying success. For instance, some individuals
have managed to delay orgasm and ejaculation merely by dwelling
on nonerotic thoughts and images while engaged in sexual
intercourse. Others have found it more effective to indulge in
self-inflicted pain during coitus (e.g., pinching one's leg,
biting one's tongue). Masters and Johnson (1970), however, are
not in favor of distraction techniques. The use of depressant
drugs (e.g., alcohol or barbiturates) may also impede premature
ejaculation in some individuals. The reduction of tactile
stimulation (e.g., by wearing one or more condoms, or by
applying anesthetic ointments to the glans penis) is also often
recommended. All of the foregoing procedures are of limited
value (Lazarus, 1978).
Two
very effective techniques for the treatment of premature
ejaculation are the pause (Semans, 1956) and
the squeeze (Masters and Johnson, 1970) procedures.
The pause technique consists of the female stimulating the male
manually until he feels the physical sensations immediately
preceding orgasm. At this point, the wife stops stimulating him
until the sensations subside, then begins stimulating the penis
again, and stops just before ejaculation. As this procedure is
repeated, the male begins to develop ejaculatory control. The
next step consists of repeating the procedure with the penis
lubricated, so that the intravaginal environment is more closely
approximated.
Masters and Johnson (1970) have developed a modification of
this procedure in which the wife manually stimulates the penis
until it becomes erect. She then squeezes the penis at the
coronal ridge for three to four seconds, which causes the man to
lose the urge to ejaculate and to lose 10-30% of his erection.
The wife waits fifteen to thirty seconds, then repeats the
procedure. After practicing for a few days, the couple repeats
the procedure with intravaginal containment of the penis, but no
thrusting, to produce stimulation. The next steps are
intravaginal containment with slow movement, and than fast
movement, using the squeeze as before.
Co-therapy and Conjoint Therapy
Masters
and Johnson (1970) write: "Definitive laboratory experience
supports the concept that a more successful clinical approach to
the problems of sexual dysfunction can be made by the dual-sex
teams of therapists than by an individual male or female
therapist. Certainly, controlled laboratory experimentation in
human physiology has supported unequivocally the initial
investigative premise that no man will ever fully understand a
woman's sexual function or dysfunction. . . . The exact converse
applies to any woman."
Conjoint
Therapy: Another Masters and Johnson (1970) dictum is
that the relationship, rather than either of the partners, is
the patient. Because of this, they treat couples and not
individual patients. Kaplan (1974b) and LoPiccolo (1975) echo
this view. LoPiccolo (1975) emphasizes to the husband and wife
that they are both responsible for future change, and Kaplan
(1974b) believes that conjoint therapy is more effective than
individual therapy because the shared sexual experiences are the
crucial factor in therapy.
Research Outcomes: problems and
issues
More than a decade after Masters
and Johnson (1970), LoPiccolo (1983) noted that sound empirical
evidence about the relative efficacy of sex therapy compared to
other types of interventions was lacking. What is conspicuously
missing from the sex-therapy literature are large, well-done
studies involving adequate comparisons among specified treatment
and control groups (Rosen & Leiblum, 1995; Schover & Leiblum,
1994).
In
general, conducting outcome research in psychotherapy is a
daunting enterprise (Bergin & Garfield, 17994), and conducting
outcome research in sex therapy may be even more difficult,
given the variety of physical and psychological etiological
factors that may be relevant to a group of individuals, all of
whom evidence the same manifest sexual dysfunction. This issue
may partially explain the apparent decrease in outcome studies
in sex therapy (see Schover & Leiblum, 1994, for discussion of
other factors). As the clinical presentation of sexual
difficulties has become more complex, the idea of applying the
same therapeutic approach to all cases may seem increasingly
absurd (LoPiccolo, 1992, 1994; Rosen & Leiblum, 1995). Still, in
an era of increasingly complex clinical presentations, it is
even more important to determine empirically the active
ingredients in sex therapy, especially as matched with
particular types of clients, dysfunctions, and etiological
factors. In other words, we are lacking the necessary data to
answer the question, "What type of sex-therapy approaches, with
what type of sexual problems, what type of clients, and what
type of sex therapist is most likely to result in a positive
outcome?" (McCarthy, 1995).
Conclusion
In
a broad sense, the future of sex therapy is dependent on the
future of sexual science. Advances in theory and research on the
components of, and factors related to, human sexual experience
allow for further growth regarding interventions to alleviate
sexual dysfunction. However, it is also incumbent on those who
actually perform sex therapy to elaborate their theoretical
assumptions and test the relative efficacy of their
interventions through empirical study. The current nature of the
complex cases with which the sex therapist is faced makes such
research both more difficult and more needed than was true two
decades ago (Wiederman, 1998).
References
Annon, Jack
S. & Robinson, Craig H. (1978).
The use of vicarious learning in the treatment of sexual
concerns. In LoPicolo, Joseph & LoPicolo, Leslie
(Eds.), Handbook of sex therapy (pp. 35-56). New York: Plenum
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