THEAMERICANJOURNALOF PSYCHOANALYSIS38:41-48 (1978)

PRINCIPLES IN SEX T H E R A P Y Jacqueline Rose H o t t

Sex therapy is a task-centered form of crisis intervention whose purpose is to remove specific obstacles to sexual functioning. Based on a psychodynamic framework, it is an integrated, synergistic combination of prescribed, systematically structured sexual tasks and experiences with psychotherapeutic intervention aimed primarily at bringing about symptomatic relief of a sexual dysfunction. It includes counseling about sexual techniques, dispelling myths, and educating about the psychological and physiological aspects of sexual functioning. The focus is on the here and now of the couple's sexual interaction. Suggestions are made for specific sexual activity and then these suggestions are followed by the couple in the privacy of their own home. The sex therapy is considered completed when the couple's sexual difficulty is relieved. Sex therapy is individualized and flexible. There is no standardized treatment routine that is applied mechanically to all sexual problems. The strategy of sex therapy, Kaplan expl ains, is to modify the couple's sexual transaction so as to eliminate fear, guilt, and anxiety and to maximize excitement and gratification. 2 The technique combines a number of different theoretical approaches. It includes medical-physiological research, intrapsychicdynamic psychology, interpersonal-dyadic psychology, and behavior learning theory2 Sex therapy uses a structured, step-by-step educational experience in functional sexual behavior where the patient is the couple and not the dysfunctional individual. Both members of the couple are treated as equal partners in the problem, even if only one of them is suffering from an explicit dysfunction. 4 The treatment methods are designed to modify their immediate obstacles to sexual functioning. Masters and Johnson called for an intensive two-week daily treatment regimen conducted at their center in St. Louis, necessitating separation from family, job, and community. In other programs, such as the highly regarded ones at New York Medical College and Long Island Jewish Medical Center, these fourteen to fifteen treatment sessions, for the purposes of practicality and economics, as well as therapeutic reasons, have been spread out over about four months in a once-a-week program. A contract for a fixed number of sessions is usually agreed upon before therapy begins. One of the therapeutic JacquelineRose Hott, R.N,, Ph.D., Professor,Parent-ChildNursing,Adelphi University; Director, Sex Therapy, Family ServiceAssociation,Hempstead, N.Y. 41

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advantages to this regimen is that it perm its an in vivo laboratory setting where all of the stresses and pressures with which the couple must cope and which impinge on their sexual and marital relationship can be dealt with realistically and with a truer perspective as to their relevance. Seeing the couple in their own community, compared to the Masters-Johnson isolation, also eases up follow-up visits and reinforcement. Masters and Johnson treat all couples by male-female cotherapists, of whom one is a physician. The programs at New York Medical College and Long Island Jewish Medical Center also use the dual therapist or conjoint approach. The therapist couple interviews the patient couple, employing the techniques of psychological interviewing. It is essential to understand that it is the couple's marital relationship which is considered to be the patient; the interpersonal relationship is the focus, and it is this relationship then which is dysfunctional, rather than an individual dysfunctional partner. The basic philosophical concept elaborated upon by Masters and Johnson is that there is no such thing as an uninvolved partner in any marriage in which there is some form of sexual inadequacy, s It is the quality of this couple's bonding in their relationship which is an important prognostic factor in the outcome of sex therapy. Do they love each other deeply and really want to function well together? Or is their relationship essentially hostile and fearful of increased intimacy and involvement? These feelings must be assessed to see whether they are resolvable and can be dealt with in sex therapy2 We look for love for each other and a commitment to their marriage as positive prognostic indicators. Frequently sex therapy will help resolve concomitant marital difficulties when the couple is motivated to do so. The cotherapists' most important role in the treatment and reversal of sexual dysfunctions is to act as catalytic agents to the couple's communication. Of course, the ultimate level of communication is sexual intercourse, even though much of the communication may be nonverbal. It is this failure to communicate in sexual intercourse which extends to every phase of communication in their marriage, s The cotherapists' ability to be open, flexible, inventive, warm, sensitive, and intuitive is a key factor in the four-way therapeutic situation. The therapeutic couple has to be really equal in their feelings of representing their sex. Each has to honor his or her own sexuality and the contribution of the other. The inference is that "it takes one to know one" and the conjoint team avoids the potential therapeutic disadvantage of interpreting the patients' complaints on the basis of male or female bias. The therapist of the same gender in conjoint therapy is considered to be an amicus curiae, a friend in court, s It is the major responsibility of each cotherapist to evaluate, translate, and represent fairly the views of the distressed marital partner of the same gender. Indeed, this may be the first time that these needs

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have been expressed before, perhaps the first time listened to by the partner when this therapist isthe oneto explain, clarify, and amplify during the course of treatment. 4 7 Another aspect of the dual therapist role is to feel equal and comfortable in sharing the therapeutic situation with someone else and working out problems and countertransference. The dual therapists also offer a role model as accepting, permissive parents who say, "O.K., it's all right now to enjoy sex. We approve." Careful screening is an essential prerequisite for dual sex therapy. Some sexual difficulties may be too deeply rooted and inappropriate for this type of short-term, timedimited intervention. Screening establishes suitability and helps the couple to gain a realistic view of their mutual problem, the therapy, and the therapists. A complete diagnostic history, which includes a personal history, a history of the couple, and an in-depth sexual history of each partner is conducted prior to the start of therapy. Some programs, which follow the Masters and Johnson regimen, include a physical examination, usually conducted by the physician therapist with the cotherapist present, and sometimes with the marital partner present. Other therapists use the physical exam whenever they feel it is necessary or indicated by the couple's personal and medical history. Laboratory work-ups, hormonal studies, and psychological examinations may also be included before therapy begins. 7The significance of the medical history and pertinent medications which may affect sexual functioning cannot be underestimated. A distinctive aspect in the taking of a sexual history includes an emphasis on the positive and pleasurable aspects of what has been "good" and "right" in their relationship. Many times couples have focused so much on the dysfunction that they have not been able to focus positively on any aspect of functioning in their relationship which has been going right, makes them feel good, or gives them pleasure. This may be the therapists' first chance to point out family strengths, such as their acknowledgment that this is a mutual problem and that they, as a couple, want to do something about it? At the initial interview couples are told to refrain from overt sexual activity until directed otherwise. Then they are seen individually, first by the therapist of the same gender, and then, in the next interview, by the therapist of the opposite gender. These interviews tend to add depth and contemplation to the couples' histories and afford the cotherapists an opportunity to summarize their views of cause and effect of the sexual dysfunctions reflected in these histories. Again, it is the cotherapists' role as educators that is essential, clarifying and supporting the couples' understanding, and holding up an objective mirror, as it were, to better understand the marital unit. The first round4able discussion follows the screening interviews after the pertinent physical and other exams have ruled out physiological causes of dysfunction. At this round-table, the four principals--the marital partners and

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the cotherapists--have the opportunity to recapitulate and interpret the sexual history. Sometimes there is a question of inadmissable material produced by either partner in the individual sex histories. Confidentiality is respected at all times, with the marital relationship considered primary and the individual partner's problems secondary. For instance, a husband may function well in an extramarital affair which he has concealed from his wife and does not want to alter this out-of-wedlock illicit relationship, or a wife may be orgasmic with her lover but not with her husband and unwilling to give up the lover despite a wish to be sexually functioning in her marriage; these couples are n o t suitable for sex therapy. These patients may be referred for other psychotherapeutic treatments. Considering the patient to be an intact marital unit means that the couple must be committed to their marriage, in love with one another, and not involved with any extramarital relationships that they do not want to terminate. When a couple is accepted for therapy, they are reassured that they will n o t be observed, that this is n o t a laboratory setting, and that the sexual tasks they will be performing will be done in the privacy of their own homes. This t~kes place usually in their bedroom, although we did have a couple in treatment whose bed creaked and squeaked and whose bedroom was so cold that the only place they could find to do their "homework" was on a blanket on the kitchen floor in front of the open oven with all the burners on--literally and figuratively! Before going on to the specific tasks couples are assigned in therapy, it is important to review the kinds of dysfunctions suitable for this type of treatment. These are basically dysfunctions relating to the physiological stages of excitement and orgasm in both genders. In the male these are primary and secondary impotence and premature and retarded ejaculation. Female sexual dysfunctions are vaginismus, dyspareunia, and primary and secondary nonorgasmic response. A lack of libido and unconsummated marriage are clinical syndromes common to both sexes. In primary impotence the man has never been able to have an erection sufficient to achieve penetration or intromission in either homosexual or heterosexual relations. This syndrome is seen frequently in an unconsummated marriage. The overall success rate in therapy is about 49%. In secondary impotence the man has been successful before but cannot succeed in this situation or with this partner. There is tremendous pressure to perform and much self-fulfilling prophecy, particularly in the older man, the target of much societal folklore about advanced age and failing powers--physical, intellectual, and sexual. Fear of inadequacy is the greatest known deterrent to sexual functioning because it blocks reception of sexual stimuli. With many couples their real or imagined demands for performance perfection lead to humiliation and sexual dysfunction. A success rate of about 69% is predicted for the treatment of secondary impotence.

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In premature ejaculation the man arrives at orgasm and ejaculation with loss of voluntary control over the ejaculatory reflex. He is dissatisfied with his performance, and this invariably relates to the fact that he has ejaculated and lost his erection before his partner has reached orgasm. The predicted success rates range from 97% to 100% with sex therapy. With retarded ejaculation the erection may be satisfactory but there is an inability to achieve orgasm within the vagina. The Masters-Johnson data gave this a success rate of about 72%. Among women, vaginismus, which can also be either primary or secondary, produces an involuntary muscle spasm of the muscles around the opening of the vagina, and these spasms prevent entrance of the pen is into the vagina. Secondary vaginismus may result from repeated episodes of vaginitis or a very tender mediolateral episiotomy scar, making intercourse impossible. 8Sexual trauma is another cause of secondary vaginismus. In vaginismus a physical exam is a vital part of sex therapy so that the husband can actually see the spasm of the muscles or the vaginitis. This tends to lessen his feelings of rejection and enables him to be more supportive and encouraging of his wife during therapy. ~ Dyspareunia is painful or difficult sexual intercourse. Here, a thorough gynecological examination is again necessary to rule out physical causes of the pain. Dyspareunia is frequently caused by insufficient lubrication and excitement in the woman, or it may be related to secondary vaginismus with psychological fears of penetration and the anticipation of pain increasing her perception of sexual sensations as painful ones. Vaginismus and dyspareunia can be reversed by sex therapy in almost all cases. The primary nonorgasmic response is the inability to achieve orgasm by any means, whether by masturbation or coitus. Masters-Johnson research revealed that 8 to 10% of American women have never had an orgasm by any means and 50% are coitally nonorgasmic. In secondary nonorgasmic response, the woman may have experienced orgasm with another partner or in another situation but be unable to under the current pressures. Success rates predicted for orgasmic dysfunctions in women range from 80% to 91%. The old terminology for nonorgasmic response was frigidity and more recent feminist literature describes nonorgasmic responses as preorgasmic, emphasizing a positive therapeutic prediction. Education to dispel the myth of the vaginal orgasm is essential when working with a couple where nonorgasmia is a presenting symptom. Teaching that the clitoris is sexually woman's most sensitive organ, equivalent to the man's penis, and that one-half to two-thirds of women require direct stimulation of the clitoris is basic to the couple's education. When couples present with a very low libido--or are sexually anorexic-they may have never consummated the marriage or have disparate wishes about the frequency of sexual intercourse. Their parallel-track marital rela-

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tionship may have been satisfactory to both, but when one partner begins to think that there's something wrong with this relationship then it begins to constitute a problem. Kaplan estimates that low libido and impotence are caused by medical and pharmacologic factors, at least in part, in 10 to 25% of cases. 2 Of couples seeking sexual therapy, in 50% each has a distress of some kind and in 50% one is involved in the problem of the other. The emphasis is always that it is the marital unit which is in treatment, and neither marital partner is made to feel culpable. Now let us briefly discuss the treatment methods that are designed to modify the immediate obstacles to sexual functioning. They are first essentially limited to relief of the sexual dysfunction. The tasks that are basically sexual and communicative are an integral part of therapy, but the primary objective is the relief of the sexual symptom. These tasks provide an opportunity for each of the partners to first give pleasure and then later to explore one's personal component in the pleasuring. One gives to get---on the other hand, the recipient of the pleasuring is permitted, indeed encouraged, to feel selfish about receiving it, without concern about whether it is something satisfying or gratifying to the partner, s Each learns to take responsibility for their own satisfaction in asking for what he or she wants. The sensate focus exercises mean exactly that--the focus of the experience is to heighten one's sexual sensory awareness. They start with the suggestion that there be no intercourse, but at least two sessions are set aside for sensory exploration of each other, including genitals. They are to explore what it feels like to the toucher. To facilitate this they are advised to use a body lotion. Masters and Johnson find that how the couple feels about the use of moisturizing lotions is significant and often predictable about their prognosis, s They are to tune in to their sensations, then reverse positions with the other partner as the doer. The couple are instructed never to getto the point of physical fatigue or procedural disenchantment and that although communication of these feelings is essential to their relationship, there is no requirement during the exercise to comment upon that which is pleasurable by word, or even by "body English" unless it is completely spontaneous and in terms of "1"--"1 like," "1 feel," "1 want"--making oneself open, vulnerable, and trusting so this can happen later in sex. Later this task becomes an educational exercise in which each one instructs the other. They proceed through these nondemanding tasks, in which they are encouraged to think and feel sensuously and leisurely, without demands for end-point release, until they are ready for intercourse. One of the beautiful points of sensate focus is that there are no "mistakes," because even the clumsiest couple can be confronted with the positive aspect that even their clumsiness is a means of communication. Another is the opportunity that presents to clarify the physiologic stages---excitement, plateau, orgasm, reso-

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lution, and refractory--as they relate to the couples' experiences. They learn that education about sex is a continuous life-long process. They are taught about the entire process of sensuality that can cause excitement--that looking, smelling, listening, touching and being touched, caressing and kissing all parts of the body that are pleasing to oneself and to one's partner are as essential as the orgasm itself. Approaches differ with various presenting complaints. Where nondemand pleasuring is most effective in the treatment of impotence, concentration on the preorgasmic sensations in the excitement stage is particularly helpful in the treatment of premature ejaculation. Here couples are taught the techniques specific to gaining this awareness and control. With problems of retarded eajaculation, where there is an excess of control, the couple learns gradually how to associate letting go with vaginal containment. Orgastic dysfunctions in the female respond to nondemand prolonged stimulation and frequently manual self-stimulation or vibrator stimulation, leading to partner stimulation and then bridging these maneuvers to coitus. Desensitization methods which may include dilators and finger and dildo insertion are helpful in the treatment of vaginismus and dyspareunia. For problems.of lowered libido the whole panoply of sensual arousal may be necessary along with getting to the root causes. There is no "recipe" or "plumber's manual" approach in the assignment of the sexual tasks. They are always related to their interaction as a couple and are tied in psychotherapeutically by the dual therapists in the office sessions by active interpretation, support, clarification and integration. Often psychotherapy is needed to deal with the couples' resistances to the therapeutic exercises, and in many sessions most of the therapy relates to these psychodynamics. In this brief period I have defined dual sex therapy, explained the unique role of the conjoint therapists, described the process of patient selection, the various clinical syndromes usually suitable for treatment, and touched upon sensate focus exercises. I have not told you how reward ing working with these couples can be, but I think Kaplan sums it up well in the concluding paragraph of The New Sex Therapy: Sometimes, in the course of therapy--in the processof touching and pleasuring each other and expressing authentic feelings~a couple will discover love. The emergenceof love which had been buried under tons of defensesand weapons and armors is a rare but magnificent reward of therapy.3 References

1. Charlton, R. S. Principles of conjoint sex therapy. WeeklyPsychiatryUpdateSeries 4. Princeton: Biomedia, Inc., 1976.

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2. Kaplan, H. S. The Illustrated Manual of Sex Therapy. New York: A. & W. Visual Library, 1975. 3. _ _ . The New Sex Therapy. New York: Brunner-Mazel, 1974. 4. Levay, A. N. Concurrent sex therapy and psychoanalytic psychotherapy: effectiveness and implications. J. Sex Education and Therapy 2: 25-33, 1976. 5. Masters, W., and Johnson, V. Human Sexual Inadequacy. Boston: Little, Brown, 1970. "6. Moulton, R. Some effects of the new feminism. The Am. J. Psychiatry 134: 1-6, 1977. 7. Sadock, V., and Sadock, B. Dual-sex therapy. In The Sexual Experience (B. Sadock, H. Kaplan, and A. Freedman, Eds.). Baltimore: Williams & Wilkins, 1976. 8. Wabrek, A. J., and Wabrek C. J. Vaginismus. J. Sex Education and Therapy 2:21-24, 1976. Address reprint requests to 301 East 62nd Street, Apt. 14 B, New York, N.Y. 10021.

Principles in sex therapy.

THEAMERICANJOURNALOF PSYCHOANALYSIS38:41-48 (1978) PRINCIPLES IN SEX T H E R A P Y Jacqueline Rose H o t t Sex therapy is a task-centered form of cr...
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