This article was downloaded by: [University of Glasgow] On: 30 December 2014, At: 15:44 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Social skills training as an adjunct to sex therapy Bernie Zilbergeld
a b
& Carol Rinkleib Ellison
a b
a
Some of the work reported in this article was done at the Human Sexuality Program , University of California b
Drs. Zilbergeld and Ellison are now in private practice in Oakland , San Francisco Published online: 14 Jan 2008.
To cite this article: Bernie Zilbergeld & Carol Rinkleib Ellison (1979) Social skills training as an adjunct to sex therapy, Journal of Sex & Marital Therapy, 5:4, 340-350, DOI: 10.1080/00926237908407078 To link to this article: http://dx.doi.org/10.1080/00926237908407078
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Sex & Marital Therapy Vol. 5, No. 4, Winter 1979
Social Skills Training as an Adjunct to Sex Therapy
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Bernie Zilbergeld, PhD,and Carol Rinkleib Ellison, PhD
ABSTRACT: Many single men and women with sex problems lack the skills or confidence to meet potential partners and develop relationships. Social skills training is presented as a useful adjunct to sex therapy with such individuals. The relative strengths of group, workshop, and individual formats are discussed as well as screening procedures, important issues and methods in such training, and the results achieved by it. As more sex therapists break away from the couples model of treatment and work with men and women without partners, the need for social skills training will increase.
Although it is commonly assumed that the skills necessary for the initiation and development of sexual and romantic relationships are learned in adolescence, this assumption is frequently untrue. Many adult men and women have an inadequate repertoire of social skills or they experience so much anxiety in social situations that they are unable to use the skills they do have. These people are often labeled by themselves and others as shy or unassertive. And, whatever the labels, their discomfort and lack of skill make it difficult for them to meet others, to date, and to develop relationships. Obviously, many of them also have problems with sex. In recent years psychologists and other professionals have generated a small literature on social skills training.' However, this topic has received little attention from sex therapists. This is unfortunate since many of the single men and women seeking sex therapy cannot begin to resolve their sexual problems until they learn how to meet and get to know potential partners and how to develop the kinds of relationships in which they could have satisfying sexual experiences. As more sex therapists break away from the couples model of treatment and work with individuals who do not have partners, the need to deal with social skills will increase. Some of the work reported in this article was done at the Human Sexuality Program, University of California, San Francisco. Drs. Zilbergeld and Ellison are now in private practice in Oakland. Reprint queries should be directed to Dr. Bernie Zilbergeld, 6209 Buena Vista Avenue, Oakland, CA., 94618.
340 0092-623X179/1600-0340$00.95
@ 1979 Human Sciences Press
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Individuals particularly likely to need development or enhancement of social skills include the following: 1 . Those who have never felt very skillful or confident in this area who have generally shied away from social contact. This group includes many of those whom Zimbardo2 calls shy. 2. Those who have lost a partner through death or separation and believe that whatever social skills they had in the past are either rusty or irrelevant in today’s “liberated” world. 3. Men and women in relationships they are considering leaving who are afraid they will not know how to meet new partners. Gaining skill and confidence in the social area can enable them to concentrate on factors other than fear of loneliness in their decision making about leaving their relationships. 4. Those with physical handicaps. Many men and women with congenital defects have had few opportunities to develop personal relationships and have reached adulthood believing that they could not be regarded as potential partners. And many with noncongenital handicaps have felt undesirable since their illness or injury, even though they may once have been socially adept.
DEVELOPMENT OF SOCIAL SKILLS TRAINING A T THE HUMAN SEXUALITY PROGRAM In the first sex therapy groups for partnerless men held at our clinic, we found we were doing as much work on social skills as on sex therapy. To better meet the needs of the men in these groups, we developed social skills groups to bring together both men and women who wanted to practice and gain confidence in the use of rudimentary social skill^.^ Later we experimented with 2-day social skills workshops. As we started doing more individual therapy for both men and women, social skills training was incorporated into the work between clients and therapists. Screening of Applicants
Unlike many sex therapy clinics, ours screens out very few applicants. Many of the candidates for social skills groups or workshops are known to us because they are already being seen at the clinic for sex therapy. Others are accepted after a phone interview. If questions of suitability for the group arise during the phone interview, a personal interview is arranged. Of those who apply for social skills training, less than 5% are rejected. We turn down applicants whose contact with reality is so tenuous that it
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seems either they would be unable to learn in a group o r that they would significantly retard the progress of the other group members. Some are offered individual work, and those who need long-term treatment are referred elsewhere. Men and women who are so fearful of a group situation that it seems unlikely they would gain much from it are also offered individual treatment. Some people who apply are not appropriate candidates for social skills training at the time because they are not ready to meet others and initiate relationships. They think they should be meeting people o r having sex, but a careful appraisal indicates they are not ready or do not want to. People who have recently lost partners through death o r the breakup of relationships may fit into this category. Often it seems appropriate for them to take time to grieve and make peace with the end of their old relationships before starting to think about new ones. And men and women who are so busy with school, work, o r personal projects that they have neither the desire, time, nor energy to devote to developing relationships may need assurance that it is acceptable not to be interested in meeting others and dating. Formats
We use three different formats-group, workshop, and individual-for social skills training. Some of their relative strengths and weaknesses f0llOW.
Group and workshop. Social skills groups consisting of 8 to 16 members of both sexes meet for one 2-hour session a week for 8 weeks with two leaders, a male and a female. Social skills workshops meet for 2 full days (on consecutive Saturdays) with two leaders. T h e workshops usually have the same number of participants as the groups, although workshops have been done with as many as 24 clients. Both groups and workshops have the advantage of a reasonably large number of “real” people with whom participants can practice skills and from whom they can get feedback on how they present themselves. And both have two leaders whom clients can observe modeling various ways of dealing with social and relationship situations. Clients report they like being able to identify with a leader of their own sex. A problem in groups that does not arise much in workshops is a high attrition rate. Some members of each group heid in our program felt they had gotten what they wanted after a few sessions and then dropped out, sometimes causing problems for those who remained. T h e sense of belonging to a group, which often offers support and incentive, can be destroyed or damaged if too many people drop out. And remaining group members may respond with a sense of inadequacy: “I can’t even learn this stuff as fast as others do.”
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Groups (and individual work) have the important advantage of continuing opportunities for homework, whereas a 2-day workshop provides only a week for home assignments. Workshop members can and often do carry out exercises on their own after treatment, but they no longer have the opportunity to bring their results back to a group or therapist for feedback and assistance. For most people groups are probably the ideal format for developing social skills. However, groups are not always possible to organize. In addition, some people are more willing to come in for 2 Saturdays than to commit one night a week for 8 weeks. Also, those individuals who are too disturbed or too anxious to do well in any type of group situation need to see a therapist individually. Individual. We incorporate individual work on social skills into our sex therapy as needed. The client may have a therapist of the same or other sex and typically no time limit is set. Individual treatment, like group, allows continuing opportunities to practice in the real world what is learned in therapy. However, individual work does tend to be more expensive and to put a greater burden on the therapist, who, in the absence of other people, must do more modeling and role playing. Individual work also deprives clients of hearing from others who share problems and anxieties similar to their own. Compensating for these disadvantages is the fact that one-to-one work can provide a safer atmosphere than is possible in most groups. The therapist can devote all the sessions to focusing on one client, and the therapist and client can get to know and feel comfortable with each other. We usually achieve similar results whether we use workshops, groups, or individual therapy, but the latter, where there are not other “real” people present to practice with and where both the social and sexual aspects of a client’s life are dealt with in great detail, takes longer. Sexual issues are also covered in groups and workshops but not in as detailed or as individualized a way.
ISSUES AND TECHNIQUES IN SOCIAL SKILLS TRAINING Here we discuss some of the important issues and methods in our work. The examples come from our groups and workshops. Obviously, adaptations are required when doing individual therapy.
Fears of Rejection and Acceptance The fear of rejection is a powerful inhibitor. It can prevent approaching someone and saying “Hello” or asking for a date or for increased intimacy or for sex. It can also get in the way of rejecting the inconvenient or
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inappropriate requests of others. Often those who are unwilling to risk being rejected are also unwilling to say “No” to others, even when it would be in their own best interest. Since almost all our clients say that fear of rejection is their greatest obstacle, we usually begin with it. Clients talk about their fears and past experiences with rejection. Participants are usually surprised when the leaders say that there is no way of avoiding being rejected except by never asking for anything and, further, that there is no way of overcoming the disappointment and hurt that usually accompany rejection. Members are asked to weigh the pain of rejection against the possible advantages of taking some risks, e.g., saying “Hello” to someone they would like to meet. Invariably there is general agreement that the consequences of doing nothing are worse than the consequences of being rejected. Participants are given experiences in being rejected. Either in pairs or groups, each person has to make requests of others and be turned down. Afterward all have a chance to discuss their feelings about the experience. The lesson most people learn is that rejections, though not pleasant, are tolerable. Group members also get to see how they may sometimes set themselves up for rejection because of their style in making requests. For homework clients are usually asked to “collect some rejections.” They are to ask for things from people who they are certain will refuse them. Clients learn that they can indeed tolerate rejections, and many are surprised that, even with requests that seem unlikely or impossible to be fulfilled, they sometimes get what they ask for. Some clients discover that fear of rejection is a mask for an even greater fear, fear of being accepted. Doing nothing or being rejected, while not satisfying or pleasant, protects them from the even more uncomfortable prospect of getting together with a potential partner or getting into a relationship. Various sorts of fears surface: “If she goes out with me, I’ll have to have sex with her and I won’t be able to get it up.” “If he likes me and we go out, I’ll get into a relationship with him and I’ll be smothered just like I was in my marriage.” “If she accepts my advance we may get into a relationship which will take a lot of my attention and I’ll probably flunk out of school.” Most of the time fears can be dealt with as the clients learn new skills and attitudes. Clients learn that social events and relationships are not all-or-nothing affairs that will get out of control; they always have some control, and they can always terminate a date or relationship if necessary. Many of the skills taught in the group are directed precisely at how to get what one wants and not put u p with what one does not want. However, there are some cases where a client’s fears are so strong that individual treatment is needed to work through them. A recent example was a woman whose previous relationship had ended so badly that any possibility of getting into a new one set off feelings of panic.
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Where and How to Meet People
Not knowing where to meet others is a vexing problem for those with few social graces. Their anxiety makes it difficult for them to see the obvious-that there are interesting people to be met almost everywhere. We ask them to look carefully at the people in places they frequent everyday-grocery stores, bus stops, classrooms, hallways, etc.-to see if they might want to meet any of them. Most clients quickly get the point. Even if those they encounter daily are not prime candidates for romance or sex, they still are people with whom they can practice their new skills. Of course, many group members are looking for someone with special qualifications-someone older or younger, a reasonably well-educated man, a divorced woman with children, someone who is involved in social and political activity, etc. T h e other group members are usually able to suggest appropriate places and situations. We recommend that the members not go to singles’ bars because our experience is that what usually goes on in them heightens rather than lowers anxiety, at least for the people in our groups. If there is an interest in singles’ bars-to see how the other half lives, so to speak-we suggest that several members go together to observe. We encourage clients to do the things they enjoy, go places where activities are going on they would like to be involved in. There they have the best chances of meeting potential partners with whom they have interests in common. Meetings, workshops, classes, sports activities, and special-interest singles’ groups are some possibilities. T h e next topic is, of course, how to make contact with a new person. This we break into a number of small steps. Clients practice making eye contact and maneuvering themselves close enough to someone they want to meet so they could say something if they wanted to. They also practice saying “Hello” to people they see on the street and in hallways; the instruction is to say “Hello” and no more. They quickly learn that such behavior is safer than they thought. A number of alternatives are presented to answer the question, “What do you say after you’ve said hello?”--e.g., compliments, questions (“Do you work here?” “How d o you like this class?”), and personal expressions (“This is the most interesting meeting I’ve attended all year.” “I’ve noticed you here before and wanted to meet you”). Clients practice these and other possibilities with other group members and receive feedback on their efforts. Those who use “lines,” i.e., say things that are not true or are not sincere, usually get negative feedback. Lots of practice is provided during group and workshop sessions in keeping conversations going. Initiating and maintaining conversations are also practiced outside the group with relatively “safe” people-friends, relatives, people at work. Meanwhile, clients are asked to pick out people they might want to meet
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and get physically close to them-sit next to them on the bus or in class, for example-and while thinking of what they might say to them, to be aware of all the reasons for not talking. This exercise often has results similar to the intercourse ban in sex therapy. As one woman said: “I saw the same guy at the meeting and managed to get a seat next to him. I really wanted to say something to him but held off and went over why I shouldn’t-he might just sneer at me, he might say he was married, he wouldn’t have time for someone as forward as me. T h e longer I did this, the stupider it got. The reasons all sounded crazy. So I just said, ‘Hi, I’ve wanted to meet you for a long time.’ It was so easy.” Getting to Know Others-A
Step-by-Step Approach
To deal with the concerns and fears attendant upon getting to know others, we teach a step-by-step or minimal-contact approach. We ask that instead of following the common routine of trying to rush someone they have just met into bed or a relationship, a pattern which often results in increased anxiety and feelings of obligation and being trapped, our clients go very, very slowly, always keeping within their level of comfort. We recommend that they spend only short periods of time with people they might be interested in. If interest continues and comfort increases, they can spend more time with them. Our main vehicle for implementing this approach is something we call a “coffee date.” A coffee date need not have anything to do with coffee. It is simply an encounter lasting no longer than 1 hour, during which time no physical contact other than a handshake or a hug is permitted. Examples include a walk, a ride, or the sharing of a drink or a meal. The date is informed of the time limit when the arrangement is made (“I have to be back at work at one but I wonder if you are interested in a quick lunch?”). The limit must be adhered to no matter what happens. T h e coffee dates, many of which are assigned as homework, allow clients time to get to know other people better, but not so much time that they feel at a loss for what to say, uncomfortable, or start wondering if they should do something sexual. Clients who try the coffee dates report feeling a great sense of relief when they are able to concentrate on being with another person without feeling pressured to fill u p vast amounts of time or deal with having to make or receive sexual advances. As one woman said: “The idea is wonderful. We used to do things like this in college, but I haven’t done anything similar since then. I’m much more relaxed when I’m out. I can just take my time and see how I feel about the guys I go out with. T h e time limit protects me from situations I don’t want to deal with. After a date I can think about the guy and determine if I want to see him again. If not, that can be the end of it.”
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Many clients report that without the structure they would have gotten more deeply embroiled with their dates than they did and would probably have had sex with them, even though on later reflection they were certain the people they were dating were not right for them. Minimal contact allowed them to take time to assess their feelings, make better decisions, and avoid embarrassment and hassle.
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Setting Limits In teaching clients how not to get overwhelmed by the dating game, we encourage them to pay attention to how they are feeling as they proceed and to use personal comfort as the clue to when artificial time limits and bans on sex are needed, or no longer needed. We recommend having coffee dates with many people and suggest that when there is someone they want to see more than once, they extend the time limit but still set a limit and observe it. Leaders continually stress the importance of proceeding slowly and not rushing into situations that may be difficult to handle. Many of our clients are hesitant to explore possible relationships because they fear being obligated or trapped. They often do not understand that a relationship can end anytime, after the first “Hello,” the first date, or any other time. They also do not see that they can exercise a lot of control over how the relationship develops and the directions it takes. Many come to us with a vague notion that once they go out with someone, they are committed, that the first date will lead automatically to a oneand-only situation, sex, or even marriage-probably a bad one. We discuss these fears and ways of setting limits and getting out of relationships. Clients practice turning down a date invitation from someone with whom they have already had a coffee date, asking someone out who asked them out before, expressing their desires and needs, setting limits with someone they are dating (limits usually involving sex, amount of commitment and intimacy, and amount of contact), and terminating relationships. After practicing expressing and asserting themselves with other group members, clients are encouraged to do the same when appropriate with people outside the group. At each step participants are given ample opportunity to explore and discuss their feelings about what they are doing. Pain and disappointment as well as the joy and satisfaction of relating to others come out, and some members deal with leftover feelings from past relationships that have been standing in the way of forming new ones. The negative aspects of relationships are not glossed over; the leaders point out their inevitability and ask participants to consider if negative aspects outweigh positive ones. Leaders point out that there are many options in relationships: one can
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date a person once and then decide to say “No” to future dates with that person; have more than one friendship, even with members of the other sex; date more than one person; have different friends and acquaintances for sharing different activities and with differing limits of intimacy and contact. Sex may become a part of none, one, or more than one of these relationships.
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Sex with a New Partner Receiving and making sexual advances is an important topic, since most group members have had or are having sexual problems. Members talk about the sexual pressures they feel and how these pressures scare them away from sex or from going out at all. T h e leaders contrast the usual performance model of sex (having sex on the first or second date because it is expected, to prove one’s masculinity or femininty, to show how liberated one is, etc.) with a more comfortable model of taking it easy, not pushing into anxiety, and getting comfortable with a partner before having sex by moving gradually into handholding, snuggling, perhaps massage, and even nonsexual sleeping together, before moving into sexual activity. T h e leaders model different ways of dealing with sexual situations, and the group members role play various approaches and statements. Important issues are rejecting sexual advances, expressing one’s sexual desires, talking about feelings that may be getting in the way of sexual arousal or function, and working out differences in style, practices, o r desire. Members are very interested in how their role-play partners respond to statements such as “I like you and am very turned on to you, but I don’t feel ready to have sex yet” and “This is going way too fast for me; I want to spend more time touching and caressing before getting to intercourse.” They are surprised to find that most of the time their group “partners” not only accept but welcome this kind of approach. It has become clear that for many single people resolving a sex problem is greatly dependent on how they get into a relationship and how they structure the first affectionate and sexual experiences therein.
Reading Material A number of good books touching on various aspects of social skills have been published recently and w e encourage our clients to read appropriate sections. T h e books that have been most helpful are It’s Up To YOU,^ Don’t Say Yes When You Want to Say NO,^ I Can If I Want TO,^ Male Sexuality,’ and Shyness.2 Not all clients like to read or get much from reading, but most have done some and have reported that it was beneficial. Assigning reading material is particularly helpful in individual
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therapy. Examples in the reading help clients to understand that they are not alone and also reinforce the ideas and skills they are learning in treatment.
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RESULTS OF SOCIAL SKILLS TRAINING Participants in social skills groups and workshops write evaluations of their training at the end of the last session. These evaluations are overwhelmingly positive, and most indicate a lessening of anxiety, greater confidence, and an acquisition of specific skills. Most participants report they have either exercised these skills in the “real world” or are willing to d o so. Since we view social skills training as an adjunct to sex therapy, however, we are even more interested in how those who receive the training do with their sexual problems. T h e therapists who are treating these clients either individually or in sex therapy groups generally agree with their clients’ evaluations and with few exceptions believe that the social skills training has made their own work much easier. During or following social skills training, clients either start going out on their own or after only minimal reinforcement from the therapists. And the training makes clients’ sex problems easier to resolve. This is not surprising because the principles of social skills training-a step-by-step approach always staying within the boundaries of individual comfort, taking charge of events instead of letting oneself be pushed or overwhelmed by them, expressing one’s likes and dislikes, and being able to stand u p for oneself-are the same principles we employ in our sex therapy ’ While preparing this article, w e received a letter from a man who 3 years ago participated concurrently in a sex therapy group and a social skills group. His report, while more spectacularly successful than most, suggests the power of social skills training. When he first came to o u r clinic, Martin was a 31-year-old virgin. He was a successful businessman but quite inadequate socially. He had never had a relationship with a woman and found it difficult to say more than one or two sentences to one. His social problems and virginity had bothered him for years, but several types of therapy, even sex therapy with a surrogate partner, had failed to help. In fact, the surrogate therapy had increased his anxieties and fears and made him feel more a failure. His situation was more difficult than most, and the leaders of his sex therapy group thought that nothing could be done for him unless he also participated in a social skills group. Martin reluctantly agreed to be in both groups. Since he had more problems than the other members of either group and no good experiences to give him hope, Martin had a rough time in treatment. At first he felt isolated and lonely because he thought that his problems were much worse than those of anyone else. But he gradually began to talk about his feelings and then about some of his experiences. It was a big step forward when he was able to tell about his humiliating experience with the surrogate. Apparently she had pushed him far beyond his limits, and
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he had been unable to stand u p to her: “ I can’t believe it. I failed with a pro. How can 1 make it with someone who isn’t trained and isn’t ready for all my problems?” Group members were supportive and Martin started to understand that others could understand and like him. He came out of his shell more and more and really put himself into the group sessions and the assignments. H e started talking to women outside the group and began to feel more comfortable with them. His fears of rejection, humiliation, and acceptance slowly diminished. He met a 50-year-old divorced woman and began an affair shortly after the groups ended. In his letter he said: “Such a pairing may not sound like an ideal situation, but it worked out really fine. I t was awkward at first, but there was really fine communication and I’m happy to say we’ve remained close friends.” He then dated other women and soon found one that was special. “Now we have been married 2 years and it’s still magic. Sex was a bit difficult at first, but now we’re really tuned to each other.” Martin closed his letter with the following: “The other day I told a woman friend I was a virgin 3 years ago as if I had been giving the weather report. To have all that charge gone off that issue is such a relief!”
Both of the leaders of Martin’s sex therapy group agreed that without the social skills training Martin’s progress would have been unlikely if not impossible, There simply was not time in the sex therapy group to devote to all of his social problems. REFERENCES 1 . Curran JP: Skills training as a n approach to the treatment of heterosexual anxiety: A review.
P,yychol Bull 84~140-157,1977. 2. Zirnhardo PG: Shyness. Reading, Mass., Addison-Wesley, 1977. 3. Zilbergeld B: Group treatment of sexual dysfunction in men without partners. J Sex Marital The7 1 :204-214, 1975. 4. Gambfill E, Richey C: I t s U p To You. Millbrae, Cal., Les Femrnes Publishing, 1976. 5. Festerheim H, Baer J : Don’t Say Yes When You Want to Say No. New York, McKay, 1975. 6. Lazarus A, Fay A: I Can If I Want T o . New Yo‘&, Morrow, 1975. 7. Zilbergeld B: Male Sexuality. New York, Bantam, 1978. 8. Barhach L: For YouneLf. New York, New American Library, 1975.
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Social skills training as an adjunct to sex therapy Bernie Zilbergeld
a b
& Carol Rinkleib Ellison
a b
a
Some of the work reported in this article was done at the Human Sexuality Program , University of California b
Drs. Zilbergeld and Ellison are now in private practice in Oakland , San Francisco Published online: 14 Jan 2008.
To cite this article: Bernie Zilbergeld & Carol Rinkleib Ellison (1979) Social skills training as an adjunct to sex therapy, Journal of Sex & Marital Therapy, 5:4, 340-350, DOI: 10.1080/00926237908407078 To link to this article: http://dx.doi.org/10.1080/00926237908407078
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Sex & Marital Therapy Vol. 5, No. 4, Winter 1979
Social Skills Training as an Adjunct to Sex Therapy
Downloaded by [University of Glasgow] at 15:44 30 December 2014
Bernie Zilbergeld, PhD,and Carol Rinkleib Ellison, PhD
ABSTRACT: Many single men and women with sex problems lack the skills or confidence to meet potential partners and develop relationships. Social skills training is presented as a useful adjunct to sex therapy with such individuals. The relative strengths of group, workshop, and individual formats are discussed as well as screening procedures, important issues and methods in such training, and the results achieved by it. As more sex therapists break away from the couples model of treatment and work with men and women without partners, the need for social skills training will increase.
Although it is commonly assumed that the skills necessary for the initiation and development of sexual and romantic relationships are learned in adolescence, this assumption is frequently untrue. Many adult men and women have an inadequate repertoire of social skills or they experience so much anxiety in social situations that they are unable to use the skills they do have. These people are often labeled by themselves and others as shy or unassertive. And, whatever the labels, their discomfort and lack of skill make it difficult for them to meet others, to date, and to develop relationships. Obviously, many of them also have problems with sex. In recent years psychologists and other professionals have generated a small literature on social skills training.' However, this topic has received little attention from sex therapists. This is unfortunate since many of the single men and women seeking sex therapy cannot begin to resolve their sexual problems until they learn how to meet and get to know potential partners and how to develop the kinds of relationships in which they could have satisfying sexual experiences. As more sex therapists break away from the couples model of treatment and work with individuals who do not have partners, the need to deal with social skills will increase. Some of the work reported in this article was done at the Human Sexuality Program, University of California, San Francisco. Drs. Zilbergeld and Ellison are now in private practice in Oakland. Reprint queries should be directed to Dr. Bernie Zilbergeld, 6209 Buena Vista Avenue, Oakland, CA., 94618.
340 0092-623X179/1600-0340$00.95
@ 1979 Human Sciences Press
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Individuals particularly likely to need development or enhancement of social skills include the following: 1 . Those who have never felt very skillful or confident in this area who have generally shied away from social contact. This group includes many of those whom Zimbardo2 calls shy. 2. Those who have lost a partner through death or separation and believe that whatever social skills they had in the past are either rusty or irrelevant in today’s “liberated” world. 3. Men and women in relationships they are considering leaving who are afraid they will not know how to meet new partners. Gaining skill and confidence in the social area can enable them to concentrate on factors other than fear of loneliness in their decision making about leaving their relationships. 4. Those with physical handicaps. Many men and women with congenital defects have had few opportunities to develop personal relationships and have reached adulthood believing that they could not be regarded as potential partners. And many with noncongenital handicaps have felt undesirable since their illness or injury, even though they may once have been socially adept.
DEVELOPMENT OF SOCIAL SKILLS TRAINING A T THE HUMAN SEXUALITY PROGRAM In the first sex therapy groups for partnerless men held at our clinic, we found we were doing as much work on social skills as on sex therapy. To better meet the needs of the men in these groups, we developed social skills groups to bring together both men and women who wanted to practice and gain confidence in the use of rudimentary social skill^.^ Later we experimented with 2-day social skills workshops. As we started doing more individual therapy for both men and women, social skills training was incorporated into the work between clients and therapists. Screening of Applicants
Unlike many sex therapy clinics, ours screens out very few applicants. Many of the candidates for social skills groups or workshops are known to us because they are already being seen at the clinic for sex therapy. Others are accepted after a phone interview. If questions of suitability for the group arise during the phone interview, a personal interview is arranged. Of those who apply for social skills training, less than 5% are rejected. We turn down applicants whose contact with reality is so tenuous that it
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seems either they would be unable to learn in a group o r that they would significantly retard the progress of the other group members. Some are offered individual work, and those who need long-term treatment are referred elsewhere. Men and women who are so fearful of a group situation that it seems unlikely they would gain much from it are also offered individual treatment. Some people who apply are not appropriate candidates for social skills training at the time because they are not ready to meet others and initiate relationships. They think they should be meeting people o r having sex, but a careful appraisal indicates they are not ready or do not want to. People who have recently lost partners through death o r the breakup of relationships may fit into this category. Often it seems appropriate for them to take time to grieve and make peace with the end of their old relationships before starting to think about new ones. And men and women who are so busy with school, work, o r personal projects that they have neither the desire, time, nor energy to devote to developing relationships may need assurance that it is acceptable not to be interested in meeting others and dating. Formats
We use three different formats-group, workshop, and individual-for social skills training. Some of their relative strengths and weaknesses f0llOW.
Group and workshop. Social skills groups consisting of 8 to 16 members of both sexes meet for one 2-hour session a week for 8 weeks with two leaders, a male and a female. Social skills workshops meet for 2 full days (on consecutive Saturdays) with two leaders. T h e workshops usually have the same number of participants as the groups, although workshops have been done with as many as 24 clients. Both groups and workshops have the advantage of a reasonably large number of “real” people with whom participants can practice skills and from whom they can get feedback on how they present themselves. And both have two leaders whom clients can observe modeling various ways of dealing with social and relationship situations. Clients report they like being able to identify with a leader of their own sex. A problem in groups that does not arise much in workshops is a high attrition rate. Some members of each group heid in our program felt they had gotten what they wanted after a few sessions and then dropped out, sometimes causing problems for those who remained. T h e sense of belonging to a group, which often offers support and incentive, can be destroyed or damaged if too many people drop out. And remaining group members may respond with a sense of inadequacy: “I can’t even learn this stuff as fast as others do.”
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Groups (and individual work) have the important advantage of continuing opportunities for homework, whereas a 2-day workshop provides only a week for home assignments. Workshop members can and often do carry out exercises on their own after treatment, but they no longer have the opportunity to bring their results back to a group or therapist for feedback and assistance. For most people groups are probably the ideal format for developing social skills. However, groups are not always possible to organize. In addition, some people are more willing to come in for 2 Saturdays than to commit one night a week for 8 weeks. Also, those individuals who are too disturbed or too anxious to do well in any type of group situation need to see a therapist individually. Individual. We incorporate individual work on social skills into our sex therapy as needed. The client may have a therapist of the same or other sex and typically no time limit is set. Individual treatment, like group, allows continuing opportunities to practice in the real world what is learned in therapy. However, individual work does tend to be more expensive and to put a greater burden on the therapist, who, in the absence of other people, must do more modeling and role playing. Individual work also deprives clients of hearing from others who share problems and anxieties similar to their own. Compensating for these disadvantages is the fact that one-to-one work can provide a safer atmosphere than is possible in most groups. The therapist can devote all the sessions to focusing on one client, and the therapist and client can get to know and feel comfortable with each other. We usually achieve similar results whether we use workshops, groups, or individual therapy, but the latter, where there are not other “real” people present to practice with and where both the social and sexual aspects of a client’s life are dealt with in great detail, takes longer. Sexual issues are also covered in groups and workshops but not in as detailed or as individualized a way.
ISSUES AND TECHNIQUES IN SOCIAL SKILLS TRAINING Here we discuss some of the important issues and methods in our work. The examples come from our groups and workshops. Obviously, adaptations are required when doing individual therapy.
Fears of Rejection and Acceptance The fear of rejection is a powerful inhibitor. It can prevent approaching someone and saying “Hello” or asking for a date or for increased intimacy or for sex. It can also get in the way of rejecting the inconvenient or
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inappropriate requests of others. Often those who are unwilling to risk being rejected are also unwilling to say “No” to others, even when it would be in their own best interest. Since almost all our clients say that fear of rejection is their greatest obstacle, we usually begin with it. Clients talk about their fears and past experiences with rejection. Participants are usually surprised when the leaders say that there is no way of avoiding being rejected except by never asking for anything and, further, that there is no way of overcoming the disappointment and hurt that usually accompany rejection. Members are asked to weigh the pain of rejection against the possible advantages of taking some risks, e.g., saying “Hello” to someone they would like to meet. Invariably there is general agreement that the consequences of doing nothing are worse than the consequences of being rejected. Participants are given experiences in being rejected. Either in pairs or groups, each person has to make requests of others and be turned down. Afterward all have a chance to discuss their feelings about the experience. The lesson most people learn is that rejections, though not pleasant, are tolerable. Group members also get to see how they may sometimes set themselves up for rejection because of their style in making requests. For homework clients are usually asked to “collect some rejections.” They are to ask for things from people who they are certain will refuse them. Clients learn that they can indeed tolerate rejections, and many are surprised that, even with requests that seem unlikely or impossible to be fulfilled, they sometimes get what they ask for. Some clients discover that fear of rejection is a mask for an even greater fear, fear of being accepted. Doing nothing or being rejected, while not satisfying or pleasant, protects them from the even more uncomfortable prospect of getting together with a potential partner or getting into a relationship. Various sorts of fears surface: “If she goes out with me, I’ll have to have sex with her and I won’t be able to get it up.” “If he likes me and we go out, I’ll get into a relationship with him and I’ll be smothered just like I was in my marriage.” “If she accepts my advance we may get into a relationship which will take a lot of my attention and I’ll probably flunk out of school.” Most of the time fears can be dealt with as the clients learn new skills and attitudes. Clients learn that social events and relationships are not all-or-nothing affairs that will get out of control; they always have some control, and they can always terminate a date or relationship if necessary. Many of the skills taught in the group are directed precisely at how to get what one wants and not put u p with what one does not want. However, there are some cases where a client’s fears are so strong that individual treatment is needed to work through them. A recent example was a woman whose previous relationship had ended so badly that any possibility of getting into a new one set off feelings of panic.
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Where and How to Meet People
Not knowing where to meet others is a vexing problem for those with few social graces. Their anxiety makes it difficult for them to see the obvious-that there are interesting people to be met almost everywhere. We ask them to look carefully at the people in places they frequent everyday-grocery stores, bus stops, classrooms, hallways, etc.-to see if they might want to meet any of them. Most clients quickly get the point. Even if those they encounter daily are not prime candidates for romance or sex, they still are people with whom they can practice their new skills. Of course, many group members are looking for someone with special qualifications-someone older or younger, a reasonably well-educated man, a divorced woman with children, someone who is involved in social and political activity, etc. T h e other group members are usually able to suggest appropriate places and situations. We recommend that the members not go to singles’ bars because our experience is that what usually goes on in them heightens rather than lowers anxiety, at least for the people in our groups. If there is an interest in singles’ bars-to see how the other half lives, so to speak-we suggest that several members go together to observe. We encourage clients to do the things they enjoy, go places where activities are going on they would like to be involved in. There they have the best chances of meeting potential partners with whom they have interests in common. Meetings, workshops, classes, sports activities, and special-interest singles’ groups are some possibilities. T h e next topic is, of course, how to make contact with a new person. This we break into a number of small steps. Clients practice making eye contact and maneuvering themselves close enough to someone they want to meet so they could say something if they wanted to. They also practice saying “Hello” to people they see on the street and in hallways; the instruction is to say “Hello” and no more. They quickly learn that such behavior is safer than they thought. A number of alternatives are presented to answer the question, “What do you say after you’ve said hello?”--e.g., compliments, questions (“Do you work here?” “How d o you like this class?”), and personal expressions (“This is the most interesting meeting I’ve attended all year.” “I’ve noticed you here before and wanted to meet you”). Clients practice these and other possibilities with other group members and receive feedback on their efforts. Those who use “lines,” i.e., say things that are not true or are not sincere, usually get negative feedback. Lots of practice is provided during group and workshop sessions in keeping conversations going. Initiating and maintaining conversations are also practiced outside the group with relatively “safe” people-friends, relatives, people at work. Meanwhile, clients are asked to pick out people they might want to meet
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and get physically close to them-sit next to them on the bus or in class, for example-and while thinking of what they might say to them, to be aware of all the reasons for not talking. This exercise often has results similar to the intercourse ban in sex therapy. As one woman said: “I saw the same guy at the meeting and managed to get a seat next to him. I really wanted to say something to him but held off and went over why I shouldn’t-he might just sneer at me, he might say he was married, he wouldn’t have time for someone as forward as me. T h e longer I did this, the stupider it got. The reasons all sounded crazy. So I just said, ‘Hi, I’ve wanted to meet you for a long time.’ It was so easy.” Getting to Know Others-A
Step-by-Step Approach
To deal with the concerns and fears attendant upon getting to know others, we teach a step-by-step or minimal-contact approach. We ask that instead of following the common routine of trying to rush someone they have just met into bed or a relationship, a pattern which often results in increased anxiety and feelings of obligation and being trapped, our clients go very, very slowly, always keeping within their level of comfort. We recommend that they spend only short periods of time with people they might be interested in. If interest continues and comfort increases, they can spend more time with them. Our main vehicle for implementing this approach is something we call a “coffee date.” A coffee date need not have anything to do with coffee. It is simply an encounter lasting no longer than 1 hour, during which time no physical contact other than a handshake or a hug is permitted. Examples include a walk, a ride, or the sharing of a drink or a meal. The date is informed of the time limit when the arrangement is made (“I have to be back at work at one but I wonder if you are interested in a quick lunch?”). The limit must be adhered to no matter what happens. T h e coffee dates, many of which are assigned as homework, allow clients time to get to know other people better, but not so much time that they feel at a loss for what to say, uncomfortable, or start wondering if they should do something sexual. Clients who try the coffee dates report feeling a great sense of relief when they are able to concentrate on being with another person without feeling pressured to fill u p vast amounts of time or deal with having to make or receive sexual advances. As one woman said: “The idea is wonderful. We used to do things like this in college, but I haven’t done anything similar since then. I’m much more relaxed when I’m out. I can just take my time and see how I feel about the guys I go out with. T h e time limit protects me from situations I don’t want to deal with. After a date I can think about the guy and determine if I want to see him again. If not, that can be the end of it.”
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Many clients report that without the structure they would have gotten more deeply embroiled with their dates than they did and would probably have had sex with them, even though on later reflection they were certain the people they were dating were not right for them. Minimal contact allowed them to take time to assess their feelings, make better decisions, and avoid embarrassment and hassle.
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Setting Limits In teaching clients how not to get overwhelmed by the dating game, we encourage them to pay attention to how they are feeling as they proceed and to use personal comfort as the clue to when artificial time limits and bans on sex are needed, or no longer needed. We recommend having coffee dates with many people and suggest that when there is someone they want to see more than once, they extend the time limit but still set a limit and observe it. Leaders continually stress the importance of proceeding slowly and not rushing into situations that may be difficult to handle. Many of our clients are hesitant to explore possible relationships because they fear being obligated or trapped. They often do not understand that a relationship can end anytime, after the first “Hello,” the first date, or any other time. They also do not see that they can exercise a lot of control over how the relationship develops and the directions it takes. Many come to us with a vague notion that once they go out with someone, they are committed, that the first date will lead automatically to a oneand-only situation, sex, or even marriage-probably a bad one. We discuss these fears and ways of setting limits and getting out of relationships. Clients practice turning down a date invitation from someone with whom they have already had a coffee date, asking someone out who asked them out before, expressing their desires and needs, setting limits with someone they are dating (limits usually involving sex, amount of commitment and intimacy, and amount of contact), and terminating relationships. After practicing expressing and asserting themselves with other group members, clients are encouraged to do the same when appropriate with people outside the group. At each step participants are given ample opportunity to explore and discuss their feelings about what they are doing. Pain and disappointment as well as the joy and satisfaction of relating to others come out, and some members deal with leftover feelings from past relationships that have been standing in the way of forming new ones. The negative aspects of relationships are not glossed over; the leaders point out their inevitability and ask participants to consider if negative aspects outweigh positive ones. Leaders point out that there are many options in relationships: one can
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date a person once and then decide to say “No” to future dates with that person; have more than one friendship, even with members of the other sex; date more than one person; have different friends and acquaintances for sharing different activities and with differing limits of intimacy and contact. Sex may become a part of none, one, or more than one of these relationships.
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Sex with a New Partner Receiving and making sexual advances is an important topic, since most group members have had or are having sexual problems. Members talk about the sexual pressures they feel and how these pressures scare them away from sex or from going out at all. T h e leaders contrast the usual performance model of sex (having sex on the first or second date because it is expected, to prove one’s masculinity or femininty, to show how liberated one is, etc.) with a more comfortable model of taking it easy, not pushing into anxiety, and getting comfortable with a partner before having sex by moving gradually into handholding, snuggling, perhaps massage, and even nonsexual sleeping together, before moving into sexual activity. T h e leaders model different ways of dealing with sexual situations, and the group members role play various approaches and statements. Important issues are rejecting sexual advances, expressing one’s sexual desires, talking about feelings that may be getting in the way of sexual arousal or function, and working out differences in style, practices, o r desire. Members are very interested in how their role-play partners respond to statements such as “I like you and am very turned on to you, but I don’t feel ready to have sex yet” and “This is going way too fast for me; I want to spend more time touching and caressing before getting to intercourse.” They are surprised to find that most of the time their group “partners” not only accept but welcome this kind of approach. It has become clear that for many single people resolving a sex problem is greatly dependent on how they get into a relationship and how they structure the first affectionate and sexual experiences therein.
Reading Material A number of good books touching on various aspects of social skills have been published recently and w e encourage our clients to read appropriate sections. T h e books that have been most helpful are It’s Up To YOU,^ Don’t Say Yes When You Want to Say NO,^ I Can If I Want TO,^ Male Sexuality,’ and Shyness.2 Not all clients like to read or get much from reading, but most have done some and have reported that it was beneficial. Assigning reading material is particularly helpful in individual
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therapy. Examples in the reading help clients to understand that they are not alone and also reinforce the ideas and skills they are learning in treatment.
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RESULTS OF SOCIAL SKILLS TRAINING Participants in social skills groups and workshops write evaluations of their training at the end of the last session. These evaluations are overwhelmingly positive, and most indicate a lessening of anxiety, greater confidence, and an acquisition of specific skills. Most participants report they have either exercised these skills in the “real world” or are willing to d o so. Since we view social skills training as an adjunct to sex therapy, however, we are even more interested in how those who receive the training do with their sexual problems. T h e therapists who are treating these clients either individually or in sex therapy groups generally agree with their clients’ evaluations and with few exceptions believe that the social skills training has made their own work much easier. During or following social skills training, clients either start going out on their own or after only minimal reinforcement from the therapists. And the training makes clients’ sex problems easier to resolve. This is not surprising because the principles of social skills training-a step-by-step approach always staying within the boundaries of individual comfort, taking charge of events instead of letting oneself be pushed or overwhelmed by them, expressing one’s likes and dislikes, and being able to stand u p for oneself-are the same principles we employ in our sex therapy ’ While preparing this article, w e received a letter from a man who 3 years ago participated concurrently in a sex therapy group and a social skills group. His report, while more spectacularly successful than most, suggests the power of social skills training. When he first came to o u r clinic, Martin was a 31-year-old virgin. He was a successful businessman but quite inadequate socially. He had never had a relationship with a woman and found it difficult to say more than one or two sentences to one. His social problems and virginity had bothered him for years, but several types of therapy, even sex therapy with a surrogate partner, had failed to help. In fact, the surrogate therapy had increased his anxieties and fears and made him feel more a failure. His situation was more difficult than most, and the leaders of his sex therapy group thought that nothing could be done for him unless he also participated in a social skills group. Martin reluctantly agreed to be in both groups. Since he had more problems than the other members of either group and no good experiences to give him hope, Martin had a rough time in treatment. At first he felt isolated and lonely because he thought that his problems were much worse than those of anyone else. But he gradually began to talk about his feelings and then about some of his experiences. It was a big step forward when he was able to tell about his humiliating experience with the surrogate. Apparently she had pushed him far beyond his limits, and
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he had been unable to stand u p to her: “ I can’t believe it. I failed with a pro. How can 1 make it with someone who isn’t trained and isn’t ready for all my problems?” Group members were supportive and Martin started to understand that others could understand and like him. He came out of his shell more and more and really put himself into the group sessions and the assignments. H e started talking to women outside the group and began to feel more comfortable with them. His fears of rejection, humiliation, and acceptance slowly diminished. He met a 50-year-old divorced woman and began an affair shortly after the groups ended. In his letter he said: “Such a pairing may not sound like an ideal situation, but it worked out really fine. I t was awkward at first, but there was really fine communication and I’m happy to say we’ve remained close friends.” He then dated other women and soon found one that was special. “Now we have been married 2 years and it’s still magic. Sex was a bit difficult at first, but now we’re really tuned to each other.” Martin closed his letter with the following: “The other day I told a woman friend I was a virgin 3 years ago as if I had been giving the weather report. To have all that charge gone off that issue is such a relief!”
Both of the leaders of Martin’s sex therapy group agreed that without the social skills training Martin’s progress would have been unlikely if not impossible, There simply was not time in the sex therapy group to devote to all of his social problems. REFERENCES 1 . Curran JP: Skills training as a n approach to the treatment of heterosexual anxiety: A review.
P,yychol Bull 84~140-157,1977. 2. Zirnhardo PG: Shyness. Reading, Mass., Addison-Wesley, 1977. 3. Zilbergeld B: Group treatment of sexual dysfunction in men without partners. J Sex Marital The7 1 :204-214, 1975. 4. Gambfill E, Richey C: I t s U p To You. Millbrae, Cal., Les Femrnes Publishing, 1976. 5. Festerheim H, Baer J : Don’t Say Yes When You Want to Say No. New York, McKay, 1975. 6. Lazarus A, Fay A: I Can If I Want T o . New Yo‘&, Morrow, 1975. 7. Zilbergeld B: Male Sexuality. New York, Bantam, 1978. 8. Barhach L: For YouneLf. New York, New American Library, 1975.
