REDUCING PHOBIC REACTIONS. DESENSITIZATION
Fensterheim has used the classical desensitization (in imagery, with relaxation) for the treatment of ejaculatory incompetence. All of the men so treated were able to ejaculate in the presence of a woman but were unable to do so during intercourse.
The specific scenes used in the hierarchy were tailored to each individual, but all centered on these areas:
a. A series of pre-intercourse scenes in which the patient wondered whether or not he would be able to ejaculate.
b. A series of scenes depicting longer and longer periods of intercourse in which he was unable to ejaculate.
Ñ. A series of postcoital scenes in which the patient dwelt on the fact that he had been unable to ejaculate and in which his partner made various derogatory comments about it.
This method succeeded in bringing on ejaculatory competence about as often as it failed to do so. However, with several of the failures there was a considerable decrease in the anxiety over the problem. With one such failure, ejaculatory competence was attained in about months following cessation of treatment. With a second, the anxiety and frustration returned in full force in a short time. It must also be noted that only seven patients were involved over a period of six years. Hence, these findings are presented merely as an illustration of what may be attempted in a clinical practice.
At times, in vivo and imagery desensitization may be combined or used in tandem. An example of the hierarchies that may be used in such a combination is the case of a twenty- eight-year-old woman with a six-year unconsummated marriage and a fear of penetration. Her history included an episode of actual fainting when seeing female anatomy in a sex-education film shown in high school and an inability to have a gynecological examination (in her two attempts, she literary jumped off the examining table). When she attempted to put her finger in her vagina, she experienced feeling of nausea and faintness. Imagery desensitization with deliberate relaxation used the following hierarchy (in ascending order of anxiety):
1. Masturbating by rubbing against a pillow (her usual method)
2. Looking at a medical book diagram of male anatomy
3. Looking at her own genitals in a mirror
4. Putting her finger in her vagina
5. Husband putting his finger in her vagina
6. About to be examined by a gynecologist
7. Being examined by a gynecologist
8. Husband inserting his penis into her vagina
The in-vivo-hierarchy contained the following items (in ascending order of anxiety):
1. Masturbating against pillow followed by relaxation
2. Looking at her genitals in a mirror
a. Just looking
c. Looking at her finger placed on the mons
d. Looking at her finger slightly inside vagina
3. Guiding husband’s finger into vagina
4. Husband inserting finger without guidance
5. Same as steps 3 and 4 with two fingers
6. Inserting small vibrator into vagina
7. Guiding husband as he inserts vibrator
8. Husband inserting vibrator without guidance
9. Husband on back. She mounts and inserts his penis
a. Both remain motionless
b. She moves
ñ Both move
The imagery desensitization was carried out during office visits, and the in-vivo-desensitization was done at home. The latter was discussed during office visits with both husband and wife present. In all, it took fifteen visits over a period of four months for a successful treatment outcome.
The desensitization paradigm can be introduced into a variety of contexts in which other forces may also be operating. Sexual scenarios provide one such context which we have found to be especially useful with people who have only a mild degree of anxiety.
Sexual scenarios, as the term implies, are a sexual encounter planned as if it were a drama improvisation. Each partner acts out a role, and there is at least a vague outline of a plot. The scenario may be based on famous lovers of history or of the theater, on the fantasies of one of the partners, or on just a story acceptable to both. The attempts to remain within the role provide the elements to counter the phobia. We have found that couples who are able to do this often report rapid changes.
With a slight modification, the sexual scenario may be modified into a method called emotive imagery (Lazarus and Abramovitz). This method first provides a pleasant or an exciting context and then introduces the phobic stimulus (e.g., part of body or specific sexual act) for longer and longer periods of time. After each introduction, the couple immediately returns to the exciting part of the scenario role-playing. Fensterheim and Baer describe the use of such a scenario in removing a woman’s fear of performing oral sex.
It is important to recognize that we have made no attempt to cover all the behavioral methods available for reducing sexual phobias.
Even more important, we do not hold that all sexual disorders have a phobic core. Should the disorder stem from a blind habit, an irrational cognition, an assertive problem, or some other psychological process, other behavioral modes of intervention must be used.
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