The treatment of male and female sexual dysfunctions is a multistage process with each stage important in determining the final success of therapy. Therapy proper starts with diagnosis and evaluation of the aetiology of the disorder which is usually complex. The need for an effective evaluation of medical, psychiatric, psychological, social and cultural influences is an essential element of proper therapy. Subsequent stages of therapy may use a variety of strategies The treatment of sexual dysfunction can take a psychodynamic psychotherapy approach, a brief focused eclectic psychotherapy approach, or a cognitive- behavioral approach, and hypnotic assistance to each of these is advantageous.
Treatment of Sexual Dysfunction : An Integrated Approach
Masters & Johnson proposed an approach to the treatment of sexual difficulties that took these problems out of the realm of long-term psychotherapy. Their investigation of sexual functioning, and focused therapy for sexual difficulties, was an important shift in treatment which created the specialty of `sex therapy'. Their approach was essentially behavioral in its focus and based around the in vivo desensitization, anxiety control and positive rehearsal of appropriate intimacy skills, all incorporated into the `sensate focus' technique.
Kaplan later extended the Masters & Johnson approach into a more comprehensive eclectic brief psychotherapy model. She proposed a model of brief therapy for sexual dysfunction starting from a psychotherapy base, but incorporating the cognitive-behavioral strategies available at that time, as an extension of their seminal works. While Kaplan does not discuss the potential role of hypnotically based therapies in her excellent work, she does offer an integrated approach into which hypnosis can be added.
Therapeutic intervention for sexual dysfunction involves at least five sequential components. Each builds on and is predicated by the previous stages and while early stages are seldom sufficient for a successful treatment outcome, not all will be necessary in a particular therapeutic intervention.
The first stage begins with the diagnostic evaluation of the dysfunction within one of the contemporary diagnostic frameworks. The process then begins with the development of a therapeutic intervention based on the aetiology, expectations and wishes of the patient concerned.
The second stage of treatment comes out of the developing rapport and the process of establishing the aetiology. It involves giving the patient and their partner permission to discuss openly in a non-judgemental way sexuality, sexual beliefs, sexual feelings and the general emotional context within which the sexual involvement occurs.
The third phase of treatment is an educative phase, which confirms the appropriate knowledge of the patient or couple, but most importantly corrects any misinformation the patient accepts about their own sexual functioning or responses or `normality'. Inappropriate beliefs and understanding, while becoming less common are still frequently implicated in the aetiology or maintenance of sexual difficulties.
The fourth component of treatment involves therapeutic interventions specifically targeting sexual behavior and learning, those most commonly thought of as `sex therapy'. A therapeutic agreement or contract is established with the patient or preferably the patient and partner, after an outline of the approach to be under-taken has been given. Once the therapeutic intervention is embarked upon through the cooperative effort of therapist and patient or couple, ongoing re-evaluation is essential to determine whether further information relevant to the aetiology has emerged in the process of therapy. Assessment of the outcome at each stage of treatment is a useful feedback mechanism to assist the therapist and patient or couple in refining the therapy focus. It is in this area that hypnosis may assist, incorporating its advantages with other therapy approaches.
Why is Hypnosis Useful In The Treatment Of Sexual Dysfunction?
Hypnosis, when added to traditional approaches to the treatment of sexual dysfunction in both males and females, facilitates treatment and extends treatment options. Hypnosis provides direct and indirect ways of effecting changes in negative thought processes at both the superficial and deeper schematic level. The involvement of thought, image and symbolism in sexual interest, arousal and behavior cannot be overemphasized. Changing the information, associations, symbols and images that contribute to dysfunction is a primary goal of therapy. Hypnosis provides a powerful means of influencing all these cognitive levels in treatment.
Hypnosis in Enhancing Anxiety Reduction
While relaxation is not a requirement of hypnosis, the use of hypnosis can facilitate relaxation and reduction in the anxiety which may directly or indirectly impair sexual functioning. Hypnotically cued relaxation may be utilized at the time of sexual intimacy, during self-stimulation or during the sensate focus or pleasuring technique, a process of in vivo desensitization. This use of cued relaxation may also overcome the anxiety accompanying sexual guilt.
Healthy Dissociation Away From the sexual Fears and Negative Cognitions
As a transitional part of therapy, during self-stimulation, the sensate focus or pleasuring experiences, and during actual sexual intimacy, the patient can be encouraged to use dissociation in a healthy and constructive way, to separate themselves from their sexual fears and negative cognitions about their sexual functioning.
Hypnotic Absorption in Fantasy
A great advantage of the use of hypnosis is that the sexual suggestions or fantasies created either by direct suggestion or indirectly by metaphor are responded to as though they were reality. As well as distracting the patient from negative self talk, this provides for effective sexual desensitization, sexual rehearsal of successful sexual functioning and attitude change.
Additionally the malleability of fantasy in the hypnotic state can result in shifting sexual arousal, from response to some unacceptable fantasy towards an acceptable fantasy. This reorientation towards a more appropriate sexual context can occur with the patient using fantasy in conjunction with sexual intimacy or in masturbatory changes in sexual focus.
Absorption in Pleasurable Sensations
Dissociation into sexual involvement rather than away from it can be used to heighten arousal and defeat affective and cognitive distractions. The use of the hypnotic focus and suggestion to encourage amplification of sexual arousal, through intense focusing on sexually pleasurable sensations, heightens sexual involvement, particularly in those disorders that require increased sexual arousal, such as the hypoactive sexual desire disorders, erectile dysfunction, dyspareunia, female orgasmic disorders and retarded ejaculation.
Reinterpretations of Past Experiences and Fantasies
Through the use of direct suggestion and metaphor past experiences may be reinterpreted and past problematic sexual fantasies changed. Fetish-based focuses may be shifted through such a process of reinterpretation, for example injury-dominated masochistic sexual fantasies may be reinterpreted progressively into a self-nurturing fantasy. Guilt over past sexual events may be lessened as the reinterpretation of the patient's part in former events is modified. Separation of the healthy and acceptable component of past experiences from the unacceptable and unhealthy aspects can be achieved through reinterpretation.
Distancing From Past Experiences
Using the techniques most commonly applied to dealing with traumatic experiences, patients can come to distance themselves from their past, and thereby the contemporary situation is not seen as an extension of that former disturbing experience. Theatre and television techniques and metaphors relating into the distant past can assist patients in leaving the emotional significance of former events out of current sexual involvement. These techniques may be particularly useful in dealing with earlier traumatic sexual experiences which are colouring contemporary sexual responses.
Metaphors and stories may also be employed to assist attitude change towards one of successful sexual functioning. Other metaphors including warmth, sweating, and so on, may also be used to enhance the sexual response. Cartoon or dramatic representations of the most erotic involvement have also been used to rehearse, give permission for and enhance involvement in sexual activity. Symbolic transformation of the parts of the anatomy which may be perceived negatively has also been used to remove anxiety-based inhibitory responses.
Time distortion may be used to deal with both delayed and premature ejaculation as well as anorgasmia or delayed female orgasm. Time may be expanded so that the time to reach orgasm appears long and satisfying or time may be truncated to bring the orgasmic response earlier in the arousal cycle. Such a distortion of perceived time is then generally carried over into an alteration of actual time in the sexual situation, most likely as a result of anxiety reduction, attitude, cognitive change and sexual rehearsal of effective functioning.
Age Regression and Age Progression
Age regression may be used to take the patient back to the first experience of the inhibiting or traumatic affect that is interfering with sexual functioning. Regression may also be used to take the patient back to a time of adequate sexual functioning, if such a time existed prior to the onset of the sexual dysfunction. Such an approach encourages expectation of successful sexual functioning, assists in systematic desensitization and in sexual rehearsal of successful intimacy. Lastly, regression techniques may assist in exploring the emotional basis of the sexual difficulties, with the understanding that information obtained may not represent a factual account of past events. Age progression of the patient beyond the current difficulties to successful sexual functioning is a similar method of producing satisfactory results.
Direct and indirect suggestions designed to elicit appropriate components of sexual arousal such as the warm healthy natural forces of life radiating throughout the body leading to vaginal muscle relaxation or lubrication at the early stages of arousal or waves of warmth and muscle tension at the later stages, can also be helpful in assisting sexual responsiveness.
Hypno-Analgesia and Anaesthesia
With sexual over arousal leading to premature ejaculation and in rare instances premature female orgasm, genital sensitivity to arousal may be reduced using suggestions of genital analgesia. Such suggestions may be given directly, may be transferred to the genital region from glove anaesthesia or via metaphor. Similarly with dyspareunia the oversensitivity may be reduced by these methods.
Hypno-Exploration And Hypno-Dynamic Therapies
Where there are deeper difficulties and the sexual dysfunction is symptomatic of more complex intrapsychic conflicts, hypnosis may be used in an exploratory fashion while the therapist must keep in mind the difference between the narrative truth of therapy and the factual truth of the court room.
Hypnosis plays an important role in the treatment of sexual dysfunctions and brings specific techniques not available to the non-hypnotically trained sex therapist. It is regrettable that the use of the hypnotic approaches is not more widely accepted within the therapies of sexual dysfunction.