Until the mid 1960’s, the psychoanalytical approach was the most dominant form of therapy for most presentations of male and female sexual dysfunction. However, the interest in sexual dysfunction and its therapy has increased dramatically in the past three decades, which has stemmed from research, conducted by Masters and Johnson (1970). The findings of Masters and Johnson’s study, succeeded in providing the first empirical observations of human sexual functioning with an understanding of the physiological factors involved during sexual arousal and response. (Usser and Baker)
The therapies used for sexual dysfunction used by clinical psychologists today, are in the main, behavioural. Behavioural therapeutic approaches are based upon the work of Wolpe, (1958) which have been applied to the problems of sexual dysfunction. In clinical practice today, the approach that is used, is that of Masters and Johnson. (1970) which, is predominantly behavioural in approach, but has some elements of other approaches incorporated, that do not fall into the spectrum of behaviour therapy.
One of the main therapies used currently is that of Masters and Johnson. The Masters and Johnson’s research led to their treatment package, better known as Conjoint Therapy Approach. The aim of this therapy was provide a combination of therapies and make one, to investigate different aspects of the client’s relationship and where the problem of sexual dysfunction is located. However, this has since been modified by subsequent writers (e.g. Bancroft 1989; Gillian 1987; Hawton 1985; Spence 1991; Wincze and Carey 1991)
The main features of the Masters and Johnson’s conjoint therapy approach, was to enable the couple to treat the problem as a joint problem thus reducing the feelings of guilt or worry. One element of the conjoint therapy approach of Masters and Johnson uses the technique of sensate focus. Which includes non-genital intimacy during an agreed ban on sexual intercourse to alleviate anxiety about performance, and a stop start technique is used to improve ejaculatory control, however, this technique relies upon the couple to practice (‘homework’) between sessions. (Usser ; Baker)
The technique of sensate focus is still used today and has been adapted to a variety of sexual problems. (Usser and Baker) Studies have suggested that using the technique of sensate focus, only twenty five per cent of females with unresponsiveness and males with erectile dysfunction fail to improve. (Masters and Johnson 1970: Kaplan 1974)
Another technique that has importance in the Masters and Johnson’s approach is that of desensitisation. The anxiety that systematic desensitising the client to sexual situations reduces the client experience. The client is shown anxiety arousing situations, in an arrangement ranging from for example looking at a partner across a crowded room to sexually explicit situations, (such as being in bed with a partner, both nude). Thus producing high anxiety and low anxiety situations. The emphasis upon this technique is to condition the client to seeing ones partner naked and placing themselves in potentially sexually situations, without feeling anxious or to reduce the anxiety experienced. (P D Silva) This technique is entitled systematic desensitisation or vivo desensitisation as suggested by Masters and Johnson, although additional components are included to add to its overall effectiveness. (Davidson and Neale)
Employing sensory awareness procedures the client is ‘taught’ how to focus upon the physical contact and interaction without worries of failure alleviates sexual dysfunction. In this relaxed mutually pleasuring stage, they can acquire the confidence to move towards the more intimate body contact that is experienced during intercourse.
Involved in the therapy is the stop start technique, in which men learn ejaculatory control by learning to slow or halt stimulation just before ejaculatory inevitability. This process also involves the squeeze technique, in which the female is required to contract her muscles in order to help the man control his arousal level.
The factors mentioned above are in the main behavioural, combined with cognitive factors enables the therapist to address the particular sexual problems at the individual level. However, it can be adapted to the needs of couples needing therapy as well as a variety of clinical groups. Usser and Baker state at the behavioural level, the sex therapy package incorporates and makes use of existing techniques, which, deal directly with specific problems. Nevertheless, cognition’s are of equal importance, because these are the negative thoughts and beliefs that are the primary focus of the problem. The goal of therapy is to concentrate upon individual’s attitudes and faulty irrational thoughts about what is needed to acquire sexual fulfilment.
The underlying principle of cognitive/behaviour therapy is to challenge and restructure negative automatic thoughts that affect sexual fulfilment. A model that is used for depression studied by Beck (1974); Fennel (1991) is applied to outline the symptoms of sexual dysfunction. Beck (1979) summarises the cognitive model in six stages: early experiences: dysfunctional assumptions: critical events: assumptions activated: negative automatic thoughts: symptoms, this lays the foundations of the sexual difficulties presented. (Usser and Baker)
The negative automatic thoughts that inhibit sexual fulfilment are described as irrational thoughts processes, these occur when part-taking in sexual activity, thus preventing the sexual situation occurring. The therapist attempts to reduce the negative or irrational thought processes by using rational emotive therapy. In using this technique, the client is ‘taught’ how to challenge the irrational thoughts that inhibit sexual situations. Irrational thoughts for example, I ‘must’ have an orgasm, I ‘should’ perform a certain way or I am a ‘failure’ are challenged. (Bass & Walen)
Using this technique the therapist remains committed to the position that it is not the unfortunate events in life, but rather the individual’s perceptions and evaluations of those events that cause distress. In this regard, the distinction between sexual dysfunction (unfortunate life events) and sexual disturbance (exaggeratedly negative perceptions and evaluations of those events) is emphasised. (Journal of Rational Emotive Therapy)
An element as basic as education may attribute to sexual dysfunction; couples can be educated and counselled to discus the factors or issues that cause the client to have an sexual problem. Couple therapy enables the therapist to uncover issues that may affect the sexual relationship. In all forms of couple therapy each partner is trained to listen empathetically to the other and state clearly to the partner what he or she requires. If one partner is unsure of any sexual practices, this can lead to that partner experiencing irrational thoughts, and through ignorance or inhibitions, they may not be able to portray their lack of knowledge about anatomy, physiology and coital positions. The couple can be counselled through this learning process, in order for the problem to be reduced or eliminated.
Practitioners, such as Woody (1992) take the view that relationship factors need to be considered, as they are an essential aspect of sex therapy, and she proposed an integrative systems approach. Relationship problems she suggests are an essential element in the aetiology of sexual problems; more often, they have a role in their maintenance. Issues in the relationship such as status, power and dominance, trust, jealousy and intimacy sometimes have a crucial role in the clinical picture. (P D Silva) (Usser and Baker)
The patient that presents himself or herself for therapy without a partner be that because they are single or the other partner does not want to attend the clinic for them there are options available. Clinical experience suggests that this is a less than ideal substitute for conjoint therapy, but it can be considered in the right circumstances. If the refusal of the partner to attend clinic suggests a poor relationship then this needs to be discussed. If the other partner refuses to attend clinic because they believe that the problem cannot be attributed to them then the possibility of therapy working are remote. Therapy can help if the refusal to attend is due to embarrassment or shyness. (Lindsay and Powell)
An approach that has been used and is recommended by some therapists is that of surrogate partners. Masters and Johnson used surrogates for some of their male patients, but later gave up this practice. However, there are serious legal and ethical issues to consider when applying this approach.
Therapy for sexual dysfunction has and can be adapted to be conducted in a group therapy session in which clients can discus their problems in an open session. The therapy that is conducted in groups use a variety of techniques, which include some of the techniques suggested by Masters and Johnson in their conjoint therapy. Other techniques are used also for example instructions on how to use masturbation and vibrators. This approach can have benefits (Bancroft, 1989) over and above the specific gain they make. (P. D. Silva)
Other Approaches, Non-behavioural.
The psychodynamic domain has a vast array of techniques within this approach, one of which is entitled psychotherapy. This technique can be used for couples or single clients to enable them to be assessed. This approach can help uncover unresolved unconscious conflict or repressed memories. By using this approach, the therapist is able to listen for clues of underlying causes of the problems, in what the client says, in the therapy sessions. The general psychodynamic view is that clients may be unable to express themselves freely and clearly to the therapist, in view of their problems. This enables the therapist to be able to plan the treatment necessary to alleviate the problem. (Davidson and Neale; Kaplan 1974)
The use of hypnosis in treating sexual dysfunction has been suggested by several writers (Cheek, 1976). The principles of this method is explore hidden sexual fears and memories and reduce tension and instigate relaxation in attempt to reduce the feeling of anxiety experienced when in a sexual setting. However the evidence of this method being a therapeutically intervention in its own right is not sufficient.
The medical profession can alleviate therapies that can be used for sexual dysfunction. Hormone therapy, which is used when there is a clear hormonal abnormality, and when used in this way, can be effective. (Davidson and Rosen, 1992; Bancroft, 1989) Biofeedback is used to enhance erectile dysfunction in males, the client is shown erotic or sexual material and then his penile changes are measured. However, its role in clinical practice is still in the infant stage. (P. D Silva)
Surgical methods, Mechanical aids, injections and drugs, such as Viagra can all help in the treatment of sexual dysfunction if the symptoms are caused by biological factors. However, The question is not ‘Is this problem physical or psychological?’ but how each kind of factor operates in this case. It is often the case that no definite biological cause can be found in a particular patient, and other mechanisms are presumed to operate. (P. D Silva)
Support in favour of the methods used by Masters and Johnson is not universal but considerable. Walter Everaerd, and Joost Dekker conducted a study entitled Treatment of male sexual dysfunction: Sex therapy compared with systematic desensitisation and rational emotive therapy. They compared two sets of couples using different techniques, one set of couples were treated with systematic desensitisation in its entirety. The second set of couples treated with an adaptation of the Masters and Johnson sex therapy. They found that all the couples in both conditions displayed an improvement in sexual functioning, but felt that there was no improvement in their relationship. However, the different between the conditions was not significant.
In the second study, two sets of couples were compared, set one used irrational emotive therapy, and set two, used sex therapy. They found that all couples again displayed an improvement in their sexual functioning, but, the couples that used rational emotive therapy stated that they were satisfied with the relationship as well. Significant differences between sex therapy and rational emotive therapy could not be demonstrated in a valid way. Thus supporting the findings of B Bass and S Walen (1986)
The success rates reported by Masters and Johnson (1970) have not been matched by other investigators, but there is, generally, evidence that the conjoint approach is beneficial to many patients (Bancroft, 1989; Spence, 1991). Nevertheless, the methodological is somewhat questionable, and are the findings credible? Masters and Johnson only impart with the information of their success rates, and not with their failure rates.
‘Currently Masters and Johnson’s techniques are still used today for a variety of sexual problems. Yet, whilst they are still very valuable to sex therapists, they have not yet been exchanged by more innovative and up to date techniques. This needs to be addressed in order to be able to deal with specifically with groups such as minority groups for example gay couples or drug addicts. Moreover, the Masters and Johnson’s technique excludes those who have no partners.’ (Usser and Baker)
Rosen and Leiblum (1995) state that although changes in formulation and treatment of sexual problems have changed in the past three decades, treatment outcome is less than satisfactory in several areas. They suggest that further research in needed on the aetiology and treatment of sexual problems.
Sexual dysfunction is described by J Golden (1993) as a rapidly developing field, for which text books are always somewhat out of date. While we understand that sexual dysfunction’s are more complicated than first thought, and that interest and support for sexuality research has shrunk. There are still as many suffering patients, or more, than there ever were. There is still a need for sex therapists and more in-depth up to date sexual research for therapy of sexual dysfunction.
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