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,

Principles of the new sex therapy.

The authors review the development of their rapid treatment dual-sex therapy for sexual dysfunction. The basic tenets of the new sex therapy include 1...
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