Tuesday, April 7, 2009 4:57

Having identified the target phobic reactions, the therapeutic task now centers on organized attempts to reduce these reactions. As the phobia disappears, we expect normal sexual behavior (desire, arousal, and orgasm) spontaneously to emerge. There are a number of methods available for this purpose.

The most commonly used methods for the reduction of sexual phobias stem from the de-sensitization paradigm (Salter; Wolpe). This method is a series of controlled exposures to the phobic stimuli and attempts to change the phobic reaction either by reducing its intensity or by increasing the self-control behaviors. With each such exposure, the power of the phobic reaction diminishes until it completely disappears.

Although the efficacy of this procedure has been well demonstrated experimentally and clinically, the theory underlying it is not so clear. It has been explained in terms of counter-conditioning, self-control concepts, extinction, cognitive variables, and in still other terms. The issue is far from resolved. Indeed, Goldfried and Davison opine that in this area greater confusion exists today than it did years ago. Rather than discussing this, we will present the methods specifically involved.

In its most classical form, systematic desensitization has certain characteristics:

1. The disturbing situation must be approached in a gradual, step-by-step manner. The aim is to keep the elicited disturbance at each step sufficiently low so that the person may learn to counter it. The series of graded situations used in this approach is called a “hierarchy.” The situations used may be imagined, may be simulated or may be actual life situations.

2. A counter-anxiety behavior must be applied at each step of the hierarchy. Although deliberate muscle relaxation is probably the most widely used behavior for this purpose, many others are available. Brady has used medication to counter the tension. Bass has used the feeling of sexual excitement to counter the anxiety. The aversion relief method has already been mentioned. Wolpe states that any response-inhibiting anxiety, including assertive responses, can be used in desensitization.

The patient is first presented with the lowest (least anxiety-provoking) item of the hierarchy. When he or she experiences any disturbance, the item is removed and the counter-anxiety element (e.g., relaxation) is introduced. The item is repeated until it no longer elicits any disturbance whatever. At this point, the next item of the hierarchy is introduced.

The self-control method of desensitization (Goldfried) also utilizes hierarchies and relaxation. Here relaxation is thought of as a coping technique, as self-control of the physiological reactions of anxiety (Goldfried and Merbaum). Instead of removing the hierarchy item when an anxiety response is elicited, the person is kept in the situation and is encouraged to cope until the anxiety diminishes.

We have tried both the classical and the self-control methods with the in-vivo-desensitization treatment of vaginismus. Here the hierarchy consists of objects of various sizes to be placed in the vagina. In the classical method, the patient removes the object at the first indication of discomfort and then relaxes. With the self-control method, the patient allows the object to remain while learning to cope with the anxiety. The number of patients involved was far too low to indicate whether one method was superior to the other. However, when both procedures were presented, several of the patients had definite preferences for one or the other.

Desensitization using imagined stimuli has the advantages of convenience, flexibility, and greater control of the stimuli. The stimulus scenes used in imagery desensitization may be very creative, and professional literature abounds with examples. A rather typical hierarchy that we have found useful is the one reported by Lazarus for the group desensitization of women with the common complaint of frigidity. The items he used were: embracing, kissing, being fondled, undressing, and foreplay in the nude, awareness of the husband’s erection, intromission, and changing positions during coitus.


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