TOPICAL
PAPERS:
Principles
of the
BY
WILLIAM
H.
Sex
New
MASTERS,
Therapy
Sex Therapy
M.D.,
AND
VIRGINIA
E.
The authors review the development oftheir rapid treatment dual-sex therapyfor sexual dysfunction. The basic tenets ofthe new sex therapy include 1) sound knowledge ofphysiology, endocrinology, and metabolicfunction, 2) institution of psychotherapy only when organicf’actors have been identified or ruled out, 3) treatment ofthe couple as a unit by dualsex therapy teams, 4) a short-term intensive program, and5) education in techniques ofverbal and nonverbal communication. Since its inception in 1958, the new therapy has been adopted, modified, and examined by clinicians and researchers all over the world. The authors suggest that professionals interested in effective treatmentfor sexual dysfunction should improve techniques, train personnel, and encourage sound research.
SINCE
THE
adequacy
(1)
of
PUBLICATION
in 1970,
there
Human been
have
many
Sexual Inattempts
by other health care professionals to interpret and extend the original concepts of dual-sex psychotherapy for the rapid treatment of sexual dysfunction. As part of the original research design, the Reproductive Biology Research Foundation has continued to reexamine its own philosophy and treatment methodology subsequent to further clinical experience, additional follow-up information, and constructive criticism from
Presented
at the
128th
annual
Association,
Anaheim,
The
are the Co-Directors
search
authors
Foundation,
Calif. 4910
Forest
,
meeting
of the
May 5-9,
1975.
American
of the Reproductive Park
Blvd.,
St. Louis,
Psychiatric
Biology Mo.
Re-
63108.
The papers in this section are Editor considers this material
grouped around a specific to constitute a comprehensive
548
May
Am J Psychiatry
133:5,
1976
JOHNSON
other sources. Although such an evaluation process might be expected to lead to broad changes in methodologies, the foundation’s basic conceptual framework for treating sexual problems has not substantially altered. In view of the increasing clinical interest in both the theory and practice of therapy for sexual dysfunction, a glance at the original treatment tenets from a current perspective may be of interest.
SEX
THERAPY
IN
1958
In 1958, as we began to make plans for a clinical research program in the psychotherapy of human sexual dysfunction, we conducted a detailed review of existing methods ly apparent
and findings in the field. that the available research
It was was
immediatefragmented
and unsystematic, with a marked dichotomy between biological and behavioral data that reflected the scientific bias of the times. Clinical techniques were both time-consuming and unreliable, and there were many indications that these methods derived more from the therapist’s personal investment in the psychotherapeutic
process
than
from
an objective
knowledge
of sexual function or a practical application of behavioral principles. Both published data and reports shared with us by people in the field clearly established the fact that health-cane professionals were essentially ignorant not only of human sexual physiology but of the potential clinical application of such knowledge. It seemed that sexually dysfunctional patients were being treated with professional insight drawn either from the psychotherapist’s own sexual experiencegood, bad, or indifferent as it may have been-or from anecdotal material provided by previous patients.
topic.
Publication analysis ofthe
here does topic.
not,
however,
imply
that
the
WILLIAM
This perspective was even bleaker when viewed within the constraints imposed by unrealistic dogma and prevailing modes of psychotherapy that peremptorily dismissed any nontraditional approach as worthless. Given this situation, innovation appeared to offer at least a realistic chance to improve treatment efficiency and efficacy. To assess this potential, we felt it necessary to document extensively the effectiveness of our experimental therapy model along at least two dimensions-the number and diversity of cases treated and the duration of therapy follow-up. Therefore, the research format that was implemented in 1959 included a plan to gather five-year follow-up data on treatment outcome. Simply stated, the research was designed to evaluate a two-week intensive psychotherapeutic appnoach to sexual dysfunction working in a format that examined the psychological and social components of sexual dysfunction along with the organic factors involved. This rationale was based on recognition of the fact that contemporary social values and pressures interact with individual sexual attitudes, experiences, and feelings derived from the past, and that no better microcosm of these elements could be found than a relationship in which one or both partners were sexually distressed. To ignore the relationship seemed not only to deny the importance of a partner’s potential positive or negative contribution but also to waste an opportunity to investigate the social laboratory provided by the relationship.
H.
ASPECTS
OF
At the outset, ough knowledge
it seemed of male
endocrinology,
and
SEXUAL
DYSFUNCTION
logical to assume that a thorand female pelvic anatomy,
metabolic
function
would
be
a
strong asset in any approach to the treatment of sexual problems. This scientific background seemed essential for accurate evaluation of the organic aspects of sexual dysfunction; it also offered an opportunity for enhancing the psychotherapeutic process by providing a factual data base from which questions on sexual physiology could be answered objectively. It has become increasingly apparent that such expertise also provides therapists
with
objective
criteria
for
assessing
the
di-
mensions of clinical progress, both psychological and physiological, during the treatment process. Detailed knowledge of anatomy, physiology, and metabolic function will never replace the skills of a well-ordered and sensitive psychotherapeutic approach to sexual dysfunction, but neither can therapists realistically continue to ignore these areas in the psychotherapeutic
process.
It is important that prompt and thorough assessment of the organic aspects of sexual problems be carried out prior to treatment. Approximately 5% of all cases of sexual dysfunction are of physical origin and a higher but undetermined percentage are of metabolic origin; thus psychotherapy should not be instituted until
AND
VIRGINIA
E.
JOHNSON
the possibility of organic etiologies of sexual has been either eliminated or identified and when necessary. It is just as unconscionable sexual distress of metabolic on physiological exclusively with psychotherapy as it is totreat chosomatic illness directly with surgery. patients with complaints of sexual dysfunction rarely checked as thoroughly as possible, either cally or metabolically, before psychotherapy tiated. these
Unfortunately, factors before
ment
is still far from
LEARNING
AND
comprehensive a commitment
distress treated to treat etiology a psyIn 1958 were physiwas mi-
assessment to long-term
of treat-
routine.
INSTINCT
An original and continuing premise of our treatment model is that sexual response is a natural function. Human sexual behavior is clearly a complex set of learned and instinctive phenomena interacting with personality dynamics, hormonal factors, and cultural influences. Penile erection and vaginal lubrication are just as clearly inborn reflexes, responses. Just as the natural
not learned physiological
behavioral functions
of
respiration, digestion, and urination are not taught to the newborn infant, the reflex pathways of sexual response cannot be taught. Sexual functioning is influenced by psychosocial input, just as other natural physiological
functions
are,
and
can
be
disrupted
anxiety, depression, or physical stress. A major misconception that was at one by patients
ORGANIC
MASTERS
and
health
care
professionals
by
time was
shared that
sex-
ually dysfunctional individuals can be taught to respond effectively (i.e., the impotent male can be taught to achieve erections or the sexually dysfunctional woman can be taught vaginal lubrication). This is like believing that we can be taught how to sweat or to make our hearts beat. Certainly, we do learn the behavioral aspects of any natural function. Because sexual functioning involves social as well as psychophysiological components, we must emphasize learning as it relates
to sexual
behavior,
but
our
potential
to
respond to effective sexual stimulation is instinctual rather than learned. This does not mean that we cannot learn ways of facilitating our biological potential; unfortunately, it also implies that we can learn ways of disrupting
our
natural
physiological
processes.
Many individuals seek counseling on the assumption that there are reliable methods of teaching sexual response.
This
is not
quite
accurate.
What
does
exist
is
the possibility of identifying the obstacles to effective sexual functioning that have removed sex from its natunal context and suggesting ways to alleviate and/or circumvent these obstacles. Similarly, attitudes, behavior, and emotional environments conducive to mdividual sexual response can be identified and encouraged. When this is done, natural function usually takes over with surprising ease. This is one of the reasons why a briefbut highly concentrated form of psychotherapy can be very effective in treating sexual dysfunction. Am J Psychiatry
133:5,
May
/976
549
PRINCIPLES
THE
OF
SEX
COUPLE
Another
AS
THE
reason
intensive
for
the original
phasis on such thing relationship
relationship between effective sexual function and sexual identity. Earlier therapeutic techniques often failed to produce the desired return to effective sexual function be-
UNIT
for
therapy
among
THERAPY
the
effectiveness
sexual
dysfunction
that
tenets
from
treatment
the couple-the as an uninvolved where there
of short-term stems
contention partner is sexual
was
also
the em-
cause
that there is no in any committed dysfunction. This
partnership component of sexual functioning would seem obvious; however, the frequent use of individual psychotherapy indicated that the importance of mutual involvement in the problem was not always fully appreciated.
In our
nontraditional
methodology,
we
was imperative both partners
to direct treatment to the education simultaneously rather than focusing
clusively
the
on
sexual
distress
of
the
felt
site it
of ex-
chief
corn-
the
estab-
plainant. We
were
lished
concerned
particularly
practice
of sending
about
marital
partners
to separate
the
therapists
(most
of whom
were
sex
will
be
reduced.
However,
in 1958
distressed
patients.
The
dual-sex
therapy
theory, an excellent counterbalance nate therapeutic tendency. A primary
ties,
courage
and
levels
of interest
in and
knowledge
of the
field
This
principle
of involvement
of both
partners
has
widely misinterpreted. No implication of causality is necessarily intended-it is often apparent that the genesis of one partner’s sexual difficulties antedated his/her entrance into the relationship that presents for treatment. Alternatively, when sexual problems arise for the first time in a relationship where there had previously been satisfactory sexual interaction, the dysbeen
function often arises ly unrelated to the
from circumstances functional partner.
that are However,
functional partner is certainly involved to the extent that he/she may experience tion,
disruption
of other
reverberations patterns,
in and
self-
areas
or
partner
in the problem sexual fnustra-
in the
occupational
totalthe
relationship,
and
performance,
social
deprecation.
team is to acquire tern of each marital niques. The basic
DUAL-SEX
THERAPY
TEAM
A psychotherapeutic format using cothenapist team seemed particularly treatment of the sexually distressed.
pists’
ual
have
a limited
experiential
frame
of
reference
from
which to identify with female sexuality and have essentially no concept of the subjective aspects of female sexual function. Women often do not fully comprehend the subjective aspects of male sexual functioning or empathize with the depth of most men’s ego involvement with their sexuality. A man simply does not know what woman’s orgasmic episode feels like, and a woman will never experience the ejaculatory process. Neither
sex
finds
it easy
550
Am J Psychiatry
to evaluate /33:5,
Ma)’ 1976
for
the
other
the
knowledge partner therapeutic
we
had-
couple
to
can
first
achieve
attaining
their their rather
understood
is,
in
and
mutual
sexual
own concepts of than the thena-
or impressing their in the treatment. be
therapists and the committed
team
to this unfortufunction of the
of the sexual value sysby careful interview techapproach is then to en-
to identify and enjoy marital interaction
suggesting value system
goals
own social or sexIf each partner’s appreciated
by
the
can then be explained to both partners, couple will have a far better chance of
effective
functioning.
EDUCATION
We presumed in 1958 on the basis rience in working with problems simple
and
education
of
physiology
patients
of human
of 13 years’ of infertility
in the
sexual
as separate
patients
more
individuals effectively.
factual
expethat
anatomy
response
some instances, relieve a significant dysfunction. Certainly, the practice ners in a distressed sexual relationship cate
a male and female indicated in the Men generally
the
goals and satisfying
er than THE
simply
and unfortunately we still have-no real concept of the depth ofgeneral ignorance ofthe sexuality and the sexual functioning of the opposite sex. Another advantage of the dual-sex team is related to the tendency of therapists to inadvertently impress their own social or sexual value systems on sexually
therapists, especially when husband and wife individually described separate sexual dysfunctions. When two marital partners, each with his or her own sexual dysfunction, are treated by different therapists with different professional orientations, professional capaciof sexual response, the chances of returning effective sexual response patterns to the marital partners mdividually or to the marital relationship are negligible.
men)
presumed expertise in both the sexual function and the sexuality of the opposite sex. As we gain knowledge of male and female sexuality and as our experience with the basic science aspects of human sexual function increases, it is to be hoped that specific gaps in our appreciation of the sexual response patterns of the oppo-
might,
in
amount of sexual of seeing the partas a couple nath-
has enabled In this
us to edu-
context,
when
a
couple is treated for sexual distress, the learning oppontunity becomes a combination of individual gain and mutual enrichment. Rather than just learning of self, a man and a woman treated together pontunity to consider the dynamics of ship. Man learns of woman as woman and vice versa. This mutual educational particularly effective as a therapeutic
dual-sex
therapy,
where
by modeling interactive preting material from
the cothenapists communication, both male and
have the optheir relationlearns of self opportunity is procedure in
can by female
educate interpen-
spectives, and by reinforcing therapeutic content in diifenent individual styles and contexts. An example of the use of simple education in treat-
WILLIAM
ing sexual problems is our approach premature ejaculation. It has long these two problems rarely respond rected psychotherapeutic approaches. ed developing the new sex therapy ual distresses were falsely aligned social
problems
as impotence
and
to vaginismus and been obvious that to specifically diWhen we startin 1958, these sexwith such psychononorgasmic
states.
In fact, some psychiatric textbooks listed and defined premature ejaculation as a form of impotence. The foundation took full exception to this concept. We felt that premature ejaculation and vaginismus would nespond far better to simple education of both marital partners and to the techniques of specific psychophysiological
reorientation
of
the
individual’s
non-
productive sexual response patterns with the partner’s cooperation. There is no doubt that conditioning of reflex response patterns, usually during initial opportunities for sexual interchange, plays a major role in both rapid ejaculation and vaginismus. Therefore, specific techniques to teach partners to help each dition these unfortunate reflex response
far more effective any known form
in reversing these of formal psychotherapy.
PERFORMANCE
FEARS
AND
THE
other reconpatterns are
distresses
than
SPECTATOR
ROLE
Education is only one component of psychotherapy, and it is far more valuable when combined with some degree of insight. In treating sexual dysfunction, insight often centers on the fears of sexual performance that are inextricably woven into the genesis of sexual problems. When fear of sexual performance dominates in a relationship,
spontaneity
either or both partners as they become spectators
sacrifice of their
their sexual
action. As spectators, they watch and measure their own or their partner’s sexual response patterns in an attempt to overcome their performance fears by noting obvious physical signs ofsexual excitation. The sexual experience ceases to be a mutually shared expression of feelings and needs and is reduced to individuals attempting to act out their expectations. The tragedy of the spectator role is that it often directly confirms the participant’s
worst fears-the individual or is slow to respond (or does not respond
partner which confirms adequacy. This text and usually Neither fears related spectator as a primary
the spectator’s feelings of role takes sexual response results in impaired function. of sexual performance nor role has been sufficiently
deterrent
to effective
sexual
his/her at all),
sexual inout of conthe closely recognized
functioning.
In addition, the depth ofmale performance fears usually is not fully understood even by committed female partners, since women have had little personal frame of reference from which to appreciate the devastating effect ofthese fears on the male ego. Too often, a woman’s well-intentioned attempt to help hen sexually apprehensive partner by masking her own sexual interest tends to prevent the sexual stimulation that he might
H.
MASTERS
AND
VIRGINIA
E.
JOHNSON
experience in response to her obvious sexual involvement. Techniques of directly confronting fears of sexual performance and providing specific suggestions to help overcome these fears became an integral part of the new approach to sex therapy. For example, carefully structured exercises that present an opportunity to appreciate tactile sensations without any demand for overt sexual responsiveness provide one avenue for reducing cultural pressures to perform and concomitant fears of performance. Direct verbalization of these fears, both in the therapy interaction and between members of the sexually dysfunctional couple, provides another means of defusing the magnitude of anxiety because unspoken fear often looms larger than verbally acknowledged fear. Reducing the anxiety arising from self- or partner-imposed expectations for sexual performance, whether real or imagined, usually results in a move toward more spontaneous sexual interaction. Similarly, as fears dissipate, the need to be a spectator decreases and the sexual experience improves as it becomes one of involvement rather than performance. Once either on both marital partner’s fears of sexual performance have been reasonably neutralized, spectaton roles can generally be easily minimized. The technique of reversing sexual dysfunction by concentrating on neutralizing performance fears and minimizing spectator roles is based on the knowledge that sexual response patterns are natural phenomena and that dysfunction of these response patterns is reversed by nemoving psychogenic barriers to response, not by attempting to teach the individual how to function sexually. This technique also recognizes that patterns of behavioral interaction are learned aspects of a relationship
that
can
be modified
on the
basis
vation and cooperative Within this conceptual
effort. framework,
view
dysfunction
the
specific
sexual
of an intimate problem may wise arises
healthy from
of mutual
it was
relationship, hostility,
but poor
possible
within
interpersonal relationship. represent an isolated facet
moti-
the
to
context
A sexual of an other-
sexual distress communication,
usually main-
tenance of a double standard, unrealistic expectations, deception, differences in reproductive goals, on a host of other factors. Unless therapy focuses primarily on the relationship as a whole rather than being restricted to the sexual component, ics may be overlooked. system of communication
the relationship often that allows the couple ity
with
the
new
For
important treatment dynamexample, when a couple’s is improved, the status of
stabilizes. Then, in a time frame to develop reasonable familiar-
concepts,
dysfunction
can
often
be ne-
versed with simple educational techniques and a knowledge of the specifics of sexual physiology. Although sexual response cannot be taught, effective means of communication can be and the newly established state of effective communication often provides a direct catalyst to the pleasurable experience of satis,
fying,
responsive
sexual Am
interaction.
J Psychiatry
133:5,
May
1976
551
PRINCIPLES
NEW
OF
SEX
SEX
THERAPY
THERAPY
TRADITIONAL
COMPARED
evaluate
WITH
It is most important to emphasize that although psychothenapeutic dogma has been challenged in these new therapy techniques, traditional psychotherapeutic principles have not been obliterated. What has changed, of course, is the focus of therapy. Rapid treatment for sexual dysfunction emphasizes the pensonal interactions of men and women as they seek to enhance a total relationship rather than treatment of individuals concerned with their own sexual needs or inadequacies. Perhaps the most significant departure from past psychotherapeutic dogma was our contention that sexual dysfunction is not necessarily a symptom of underlying psychopathology. In 1958, it was almost universally believed that if underlying psychopathology could be identified and treated successfully, symptoms of sexual inadequacy would automatically be resolved, since they were only surface manifestations of a more deeply rooted neurotic or psychotic process. We have never denied that sexual dysfunction may be a symptom ofunderlying psychopathology, but we do believe most emphatically that sexual inadequacy is an entity all its own at least as often as it is a symptom of severe psychopathology. This marked departure from established psychotherapeutic concepts not only encouraged the development of the rapid treatment techniques but also stimulated dissemination of the concept of sexual response as a natural function. We also had a strong clinical feeling that when the sexual inadequacy was obviously a symptom of existmg psychopathology, real psychotherapeutic gain might result from a direct approach to symptom removal. This
position
is directly
antithetical
to
the
idea
that
symptoms should not be approached directly because their persistence serves the useful purpose of keeping the patient in therapy. The therapy program that we developed did not ignore individual psychodynamics. Rather, it recognized that identification of factors such as stress reactions, problems of self-esteem, psychopathology, and maladaptive defense mechanisms was essential to the efficiency and efficacy of therapy. Time
Frame
ofthe
We presumed cific
therapeutic
ofthe
new
sions
oven
New
that
Therapy
there which
a two-week
be a number
to the
usually period.
limited
consists First,
of spe-
time
ofdaily there
frame
ses-
is signifi-
cant cumulative return for patients who are exposed to sexual material on a day-by-day basis, since they become involved in mutual eroticism with increasing ease. Sexual thought and action seem to arrive at a healthy accord in a progressive manner that leads the distressed couple toward a sense of erotic well-being as a unit. Second, it is much easier to enhance communication skills when each day’s successes and problems can be freely recalled and analyzed during the next day’s visit. Third, it is far more clinically effective to 552
Am J Psychiatry
133:5,
Ma)’ 1976
develop
with
sexual
rather
than
problems
after
the
and
fact.
questions
Fourth,
daily
exposure to the therapists provides an ideal oppontunity to handle treatment-related crises that may develop. Such crises should be approached when they occur rather than after delays of days or even weeks. When two people are involved in a treatment crisis, any delay in dealing with their distress may be disastrous.
COUNTERTRANSFERENCE
ISSUES
Despite the obvious advantages of rapid treatment, we recognized that there were significant problems inherent in this mode of therapy. For example, a rapid treatment format does not allow time for the development of traditional transference interaction and insights.
However,
we
felt
that
therapeutic
emphasis
on
classical patterns of transference would obviously distract the focus of therapy from the marital relationship to the relationship between the individual and either on both cotherapists. Individuals with prior experience in analytically
oriented
psychotherapy
often
demand,
overtly or covertly, a chance to nurture and discuss transference dynamics. This frequently slows progress in
therapy
because
it diminishes
the
level
of
shared
feelings within the marital relationship. In general, the dual-sex therapy team minimizes importance of transference. By its very design, sex therapy tends to emphasize and encourage tional identification partners rather than
and commitment developing the
between patients’
the dualemo-
marital emotion-
al dependency on their therapists. It is important, however, to recognize the distinction between a full working through of transference and ways in which elements of transference phenomena can be used in particular situations. A good example of the use of transference in the new sex therapy is the psychotherapeutic approach to vaginismus, which includes education and instruction in use ofa series of vaginal dilators. It is usually necessary to foster an extraordinary degree of trust on the
part of the patient toward the therapist who is performing the pelvic examinations and introducing the dilators into use. For a day or two, as the woman is gaining
would
advantages
therapy,
and deal
as they
TECHNIQUES
confidence
in her
ability
to overcome
a painful
and frustrating problem, her partner’s participation in the use of the dilators is typically kept to a minimum. Deliberate development of this aspect of transference has been found to be highly effective, resulting in prompt reversal of the vaginismus so that the couple can focus on their sexual interaction without fear of interference from vaginal spasms. A bnieftnansition penod is then required to downplay the transference between patient and therapist; this is usually accomplished is
by repeatedly
the one
sizing
the
who catalytic
stressing
brought role
about played
Obviously, the therapist’s of major import. Acceptance
to the
woman
the change by
the
that
and
she
empha-
cotherapists.
authoritative of authority
position makes
is the
WILLIAM
process
the
infinitely
easier
necessary
is sometimes
used
effective
focus
less
say,
use
this
enables
Closely on their
it to progress
directed
to set the stage
a more to
and
rapidity.
for a couple
own
of transference
with
transference to develop
interaction. must
Needbe
individ-
ualized. The concept ofcontnolling on channeling transference during rapid treatment for sexual dysfunction should be seen as unique to this method; it in no sense reflects denial of the importance of the objective use of transference phenomena in other therapeutic programs. We thought that if patients’ emotional identification with
the
therapists
(beyond
that
necessary
to establish
the authority figure) was to be discouraged, it was necessary that the cothenapist team take particular care to avoid problems arising from countertransference The sexually dysfunctional man or woman is incredibly vulnerable to any suggestion of sexual connotation from the authority figure. Sexual seduction, whether actual on fantasized by either patient or therapist, clouds any therapeutically encouraged trend toward emotional identification within the sexually dysfunctional mantal unit. Overt evidence of countertransference can create a distraction of such magnitude that the rapid treatment technique can easily be prejudiced. We have seen direct evidence of the ultimate in countertransference many, many times in histories of patients who had other types of psychotherapy for sexual dysfunction before considering dual-sex rapid treatment techniques. The ultimate in countertransference .
is, of course,
a therapist
seducing
a patient
into
overt
sexual activity. We feel that this approach to the extremely vulnerable patient with a dysfunction is professionally and personally inexcusable. The use of dualsex teams provides a significant degree of built-in protection against any extensive devlopment of countertransference,
much
less
seduction
of patients.
We feel that when sexual seduction of patients can be firmly established by due legal process, regardless of whether the seduction was initiated by the patient or the therapist, the therapist should initially be sued for rape rather than for malpractice, i.e.,the legal process should be criminal rather than civil. Few psychotherapists would be willing to appear in court on behalf of a colleague and testify that the sexually dysfunctional patient’s facility for decision making could be considened normally objective when he or she accepts sexual submission after developing extreme emotional dependence on the therapist.
care.
There
evitably,
it is the
VIRGINIA
less
would While
patient
that
vide a built-in tinuing peer
peer
E.
JOHNSON
review
of
profes-
who
suffers.
a dual-sex
therapy
opportunity review, since
team
for a modest the members
would
pro-
degree of conof the team
be immediately accountable to we did not consider this approach
each other. to peer re-
view completely satisfactory, and did not feel it should be employed to the exclusion of formalized peer review programs, we did think that objective criticism from a co-therapist was fan better than any self-review technique imaginable.
IMPROVING
COMMUNICATION
WITHIN
THE
COUPLE
Satisfying a
sexual
mutually
interaction
enhancing
has always
means
of
represented
communication
be-
tween man and woman. When sexual interaction is not initiated merely for the release of accumulated sexual tensions, what is its potential? As a means of communication, its sion, sexual
potential is vast. communication
um or opportunity ity.
interaction
vulnerable both
In one important dimencan be viewed as the medi-
for exchanging
Sexual
occasion
a physical
for
and
trust
and vulnerabil-
represents
a
committed
an
uniquely
participants
emotional
level.
on
Within
this
framework of sex as a form of communication, we decided to concentrate much attention on developing techniques to improve intimate communication skills. We presumed that if effective communication were established outside the bedroom and sexual anxieties were reduced, sexual functioning would often improve. This presumption has certainly been supported by our
clinical
Sensate
Focus
Our
original
aspects is most
experiences
of the
approach
ofcommunication. identified with
last
was to focus
18 years.
on the nonverbal
Because the sense nonverbal communication
of touch and is
the special sense used most often in sexual interaction, we developed the concept of sensate focus. In order to achieve optimum effect, sensate focus be
used
partner
solely
citation
Peer review is an integral part of patient care, and self-regulation certainly has been established and supported by the medical fraternity. There is, however, a lack of peer review for psychotherapists of any pensuasion in the private practice of their ant; not only has this been a major handicap to the therapist pnofessionally but also an obvious obstacle to good patient
AND
is currently
We believed
the REVIEW
MASTERS
sional productivity in psychiatry than in any other majon discipline in medicine. Once a psychotherapist has completed training, his or her work is rarely if even subjected to peer review. This clinical tragedy slows and may prevent professional growth and maturity. In-
should PEER
H.
for
as
doing the
of the
a means
the sensual
partner
of physical
touching
and
pleasure
being
not or
touched.
awareness
by
specifically
or ex-
even
sexual
Sensate
focus
in
the early stages of therapy tends to dissipate anxieties related to sexual performance on the pant of either on both spouses. Thus, in nonverbal communication, the therapeutic emphasis is on touching as a personal sensual
experience
and
ual opportunity. The ploring the textures, Am
only
secondarily,
ifat
all,
as a sex-
sensual experience consists of excontours, temperatures, and conJ Psychiatry
133:5,
May
1976
553
PRINCIPLES
OF
trasts
partner’s
of the
SEX
THERAPY
body
in a manner
and
at a pace
chosen by the individual doing the touching. By specifically structuring the sensate focus opportunities at the onset of therapy, it is usually possible to significantly reduce the constraints imposed by old habit patterns of sexual interaction. Concomitantly, removing stereotyped expectations of what sexual interaction “should be” often leads to an awakening of spontaneous natunal response that has long been forgotten and sometimes never recognized. We have noted with regret that the technique of sensate focus has been introduced out of context countless
times
by therapists
nately
as a means
settings
where
little opportunity related needs. function
and
of sexual the
means is lost.
Verbal
Techniques
been
used
stimulation,
individual’s
even
sexual
in the
of initiating
use
in public
response
of touch
nonverbal
has
as an ex-
communication
During
new
concept;
learning
new
Therapy
AmfPsychiatry
in fact,
theory.
skills
maintain
May
1976
the
is mastered,
long-proven
intense
briefer these
tenets
phase
exposure
of
of
learning
will suffice
to
skills.
CONCLUSIONS
In this paper, we have briefly described the original principles of treatment that were the foundation of the new therapy techniques for sexual dysfunction. Of course, there has been both significant modification of these principles and expansion of concepts of treatment as the clinical therapy program has been closely observed during its 18 years ofexistence, first at WashUniversity Reproductive
Obviously,
School of Medicine Biology Research
there
have
concept,
format,
throughout represented ens have
the United significant been poorly
ducted.
even mand
All
of
distortions
tive
treatment
been
and
and since Foundation.
further
technique
various
point
alterations,
to the immense
professional
support
in this
of
centers
abroad. Some and additions, and casually
improvements,
simply
1964
modifications
in
States and innovations conceived
these
for adequate
ignored health been scratched,
cal
133:5,
it follows
Once
or improve
have othconand
public
de-
hitherto
care field. Now that the surface has it remains for those interested in effecprograms
personnel,
We felt that a period of uninterrupted attention to the relationship was necessary to allow the couples to integrate the new techniques of verbal and nonverbal communication into the existing patterns of their lifestyle. It was anticipated that the quality of this time would be enhanced by social isolation, which would
554
couples children, bilities
ington at the
Verbal communication, although often emotionally charged in a couple with sexual problems, is more familiar and thus more comfortable than nonverbal communication for many individuals. Because ofthis, a significant focus of the new therapy was education in more effective verbal communication. Many couples are surprised that the majority of time in therapy is devoted to this area. It is indeed dramatic to find how often improvement in verbal communication skills releases a couple’s sexual feelings toward one another and thereby enhances their sexual relationship. Isolation
interference from the exigencies ofdaily life. a decided therapeutic advantage when are temporarily freed from the demands of friends, relatives, work, and other responsiin a therapeutic program. This is certainly not a is
indiscnimi-
of being supported by fulfillment of In these cases, the specifically designed
of self-awareness
cellent usually
has
minimize
There
to
and encourage
improve
both
basic
techniques,
science
train
and clini-
investigation.
We all have
such
a long
way
to go.
REFERENCE 1. Masters Little,
WH, Brown
Johnson & Co.
VE: Human 1970
Sexual
Inadequacy.
Boston,