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Time-limited sex therapy for couples : a controlled evaluation of group and individual couple intervention Nemetz, Georgia Helen 1980

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TIME-LIMITED SEX THERAPY FOR COUPLES: A CONTROLLED EVALUATION OF GROUPS AND INDIVIDUAL COUPLE INTERVENTION by GEORGIA H. NEMETZ, M.A. The U n i v e r s i t y of B r i t i s h Columbia, 19 THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES Department of Psychology U n i v e r s i t y of B r i t i s h Columbia We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA October 1980 0 Georgia Helen Nemetz, 1980 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5 DE-6 (2/79) Ph.D. P s y c h o l o g y T i m e - L i m i t e d Sex Therapy f o r C o u p l e s : A C o n t r o l l e d E v a l u a t i o n o f Group and I n d i v i d u a l Couple I n t e r v e n t i o n G e o r g i a H. Nemetz, M.A. ABSTRACT The e f f e c t i v e n e s s o f a b e h a v i o u r a l l y based, broad band t h e r a p y f o r s e x u a l l y d y s f u n c t i o n a l c o u p l e s was examined. Twenty-four c o u p l e s were randomly a s s i g n e d t o e i t h e r i n d i v i d u a l o r group c o u p l e t r e a t m e n t . Treatment, i d e n t i c a l f o r b o t h c o n d i t i o n s , c o n s i s t e d o f : i n f o r m a t i o n and e d u c a t i o n ; emphasis on mutual r e s p o n s i b i l i t y ; a t t i t u d e change s k i l l s t r a i n i n g ; communication f a c i l i t a t i o n ; r e d u c t i o n of a l l forms of s e x u a l a n x i e t y and g r a d u a t e d b e h a v i o r a l homework ass i g n m e n t s . Measures of t r e a t m e n t e f f e c t i v e n e s s were r e p e a t e d l y t a k e n d u r i n g a two-week b a s e l i n e , f i v e weeks of t r e a t m e n t and a t the ends of the t h r e e week and t h r e e month f o l l o w - u p p e r i o d s . These measures i n c l u d e d the S e x u a l B e h a v i o r Index, the S e x u a l A r o u s a l I n v e n t o r y and the S e x u a l S a t i s f a c t i o n Index. The s i x c o u p l e s randomly a s s i g n e d t o the c o n t r o l c o n d i t i o n were s u b j e c t e d t o i d e n t i c a l measurement w i t h o u t the b e n e f i t of t r e a t m e n t . I n c r e a s e s i n a r o u s a l , s a t i s f a c t i o n and b e h a v i o r were e v i d e n c e d f o r both t r e a t m e n t groups; however a t r e n d towards i n c r e a s e d g e n e r a l i z a t i o n and maintenance o f improve-ment was e v i d e n c e d f o r those r e c e i v i n g group t r e a t m e n t . Improvement was m a i n t a i n e d t h r o u g h the t h r e e month f o l l o w -ups. C o n t r o l c l i e n t s showed no improvement and e v i d e n c e d t r e n d s towards d e t e r i o r a t i o n . The r e s u l t s o f the p r e s e n t s t u d y document the e f f i c a c y of the s h o r t term b e h a v i o r a l l y based program and i n d i c a t e the v i a b i l i t y o f the group format as a c o s t - e f f e c t i v e a l t e r n a t i v e t o i n d i v i d u a l i n t e r v e n t i o n . i v TABLE OF CONTENTS Page Abstract i i L i s t of Figures : v Acknowledgements and Dedication v i i Introduction 1 Method 32 Results 43 Discussion 71 Bibliography 92 Appendices 100 V 1 LIST OF FIGURES Page Figure 1: Mean scores over administrations for a l l subjects on the Sexual Arousal Inventory 45 Figure 2: Mean scores over administrations for a l l subjects on the "general s a t i s f a c t i o n " subscale of the Sexual S a t i s f a c t i o n Index 50 Figure 3: Mean scores over administrations for a l l subjects on the "communication s a t i s f a c t i o n " subscale of the Sexual S a t i s f a c t i o n Index 51 Figure 4: Mean scores over administrations for a l l subjects on the "orgasm s a t i s f a c t i o n " subscale of the Sexual S a t i s f a c t i o n Index 52 Figure 5: Mean scores over administrations for a l l subjects on the "sexuality s a t i s f a c t i o n " subscale of the Sexual S a t i s f a c t i o n Index . 53 Figure 6: Mean scores over administrations for a l l subjects on the "relationship s a t i s f a c t i o n " subscale of the Sexual S a t i s f a c t i o n Index 54 Figure 7: Mean scores over administrations for male subjects on "non-sexual massage" item of the Sexual Behavior Inventory 59 Figure 8: Mean scores over administrations for male subjects on "sensate focus female breast" item of the Sexual Behavior Inventory 60 Figure 9: Mean scores over administrations for male subjects on "sensate focus female g e n i t a l " item of the Sexual Behavior Inventory 61 v i Page F i g u r e 10: Mean scores over a d m i n i s t r a t i o n s f o r male s u b j e c t s on " i n t e r c o u r s e " item of the Sexual Behavior Inventory 62 F i g u r e 11: Mean scores over a d m i n i s t r a t i o n s f o r female su b j e c t s on "non-sexual massage"item of the Sexual Behavior Inventory 65 Fi g u r e 12: Mean scores over a d m i n i s t r a t i o n s f o r female s u b j e c t s on "sensate focus male g e n i t a l " item of the Sexual Behavior Inventory . . . . . . 66 Fi g u r e 13: Mean scores over a d m i n i s t r a t i o n s f o r female s u b j e c t s on "orgasm through masturbation" item of the Sexual Behavior Inventory . 67 Fi g u r e 14: Mean scores over a d m i n i s t r a t i o n s f o r female s u b j e c t s on "orgasm through f o r e p l a y " item of the Sexual Behavior Inventory . 68 F i g u r e 15: Mean scores over a d m i n i s t r a t i o n s f o r female s u b j e c t s on " i n t e r c o u r s e " item of the Sexual Behavior Inventory . 69 Fi g u r e 16: Mean scores over a d m i n i s t r a t i o n s f o r female s u b j e c t s on "orgasm through i n t e r c o u r s e " item of the Sexual Behavior Inventory . . . . . . 70 v i i ACKNOWLEDGEMENTS AND DEDICATION Many pe o p l e have c o n t r i b u t e d t o t h i s r e s e a r c h d u r i n g the p e r i o d of i t s development and e x e c u t i o n . I am d e e p l y i n d e b t e d t o my c o - t h e r a p i s t . Dr. W.K. C a i r d , w i t h o u t whom t h i s program c o u l d not have been r u n . I would a l s o l i k e t o e x p r e s s my deep a p p r e c i a t i o n t o Dr. D. Lawson and Dr. K. C r a i g f o r t h e i r many hours spent r e a d i n g and s u g g e s t i n g improvements f o r a l l s t a g e s of the p r e p a r a t i o n of t h i s m a n u s c r i p t . I would a l s o l i k e t o thank Dr. R. P o t a s h i n and Dr. R. H a k s t i a n f o r t h e i r c o n t r i b u t i o n s . I owe a s p e c i a l debt of g r a t i t u d e t o Mr. S. H o l i d a y and Mr. C. C l a r k f o r t h e i r h e l p w i t h the s t a t i s t i c a l a n a l y s e s . I n a d d i t i o n , I would l i k e t o thank Ms. J . D a v i s f o r her t y p i n g of the m a n u s c r i p t . Above a l l , my l o v e and g r a t i t u d e goes t o Dr. D. C r o c k e t t f o r h i s support and encouragement a t eve r y l e v e l of t h i s endeavour. T h i s work i s d e d i c a t e d t o . t h e memory of my b e l o v e d f a t h e r and the s u c c e s s f u l c o m p l e t i o n of h i s dream. 1 OVERVIEW The l a s t t h i r t y y e a r s has seen.a growing s c i e n t i f i c and p u b l i c c o n c e r n w i t h the n a t u r e o f human s e x u a l i t y . T h i s t r e n d has been m a n i f e s t e d i n the p r o l i f e r a t i o n o f , p u b l i c a t i o n s b o t h i n v e s t i g a t o r y and i n s t r u c t i v e and i n the e s t a b l i s h m e n t o f numerous c l i n i c s devoted to the study o f a l l f a c e t s of human s e x u a l i t y . In a d d i t i o n . , t h e r e have been numerous l a r g e s c a l e s u r v e y s and e v i d e n c e o f i n c r e a s e d i n d i v i d u a l s e l f - a p p r a i s a l ( L o P i c c o l o , 1978). Surveys have i n c l u d e d works by K i n s e y , Pomeroy, M a r t i n and Gebhard (1953)., K i n s e y , Pomeroy and M a r t i n (1948), Gebhard (1968), Shearer (1972), F i s h e r (1973), Hunt (1974) and H i t e (1976). These s t u d i e s , w h i l e p r i m a r i l y f o c u s s i n g on fr e q u e n c y o f s p e c i f i c s e x u a l a c t i v i t i e s such as pre and e x t r a m a r i t a l c o i t u s , a n a l i n t e r c o u r s e , e t c . , p r o v i d e l i t t l e i n f o r m a t i o n r e g a r d i n g the i n c i d e n c e of s e x u a l d i s s a t i s f a c t i o n s u f f i c i e n t t o cause c o u p l e s t o seek t r e a t m e n t . Perhaps more r e l e v a n t t o the e s t i m a t i o n of the p r e v a l e n c e o f s e x u a l d y s f u n c t i o n and d i s s a t i s f a c t i o n , S hearer (1972) found t h a t a p p r o x i m a t e l y 50% o f a l l m a r r i e d c o u p l e s e x p e r i e n c e a t l e a s t some form of s e x u a l d y s f u n c t i o n . Based on a sample o f one hundred c o u p l e s not a c t i v e l y s e e k i n g sex t h e r a p y , F r a n k , Anderson and R u b i n s t e i n (1978) r e p o r t t h a t 507o of the males and 77% of the females i n d i c a t e d a l a c k of s e x u a l i n t e r e s t which p r e c l u d e d s a t i s f a c t o r y s e x u a l a c t i v i t y . The au t h o r s s u g g e s t e d , moreover, t h a t the number of m a r i t a l d i f f i c u l t i e s r e p o r t e d was "more s t r o n g l y and. c o n s i s t e n t l y r e l a t e d , t o o v e r a l l s e x u a l d i s s a t i s f a c t i o n t h a n t o the number o f a c t u a l d y s f u n c t i o n s . " These d a t a are c l i n i c a l l y r e l e v a n t as they are based on s e l f - r e p o r t e d d i s s a t i s f a c t i o n , not merely on symptomatic accommodation to d i a g n o s t i c c r i t e r i a or on r e p o r t e d normative f r e q u e n c i e s of sexual behavior. P u b l i c a t i o n of r e p o r t s of both sexual p r a c t i c e and d i s s a t i s f a c t i o n has l e d many couples to s c r u t i n i z e t h e i r own s e x u a l i t y . Indeed, engaging i n robust sexual a c t i v i t y has become a " r e q u i r e d a b i l i t y " ( L o P i c c o l o and Heiman, 1977) almost necessary f o r s o c i a l acceptance. T h i s i n c r e a s e d p u b l i c awareness has c o n t r i b u t e d to the unprecedented number of couples seeking sex therapy. The nature of sex therapy has changed and must continue to change d r a m a t i c a l l y i n order to respond e f f e c t i v e l y to the growing demand f o r s e r v i c e . The b a s i c changes i n format o r i g i n a t e d with Masters and Johnson (1970) who provided a b r i e f , t i m e - l i m i t e d i n t e r v e n t i o n which d e a l t d i r e c t l y with areas of d i s s a t i s f a c t i o n by way of e d u c a t i v e , d i r e c t i v e therapy. Since 1970, new short term broad band, problem s p e c i f i c t h e r a p i e s based on Masters and Johnson's work have p r o l i f e r a t e d . These t h e r a p i e s address themselves to the growing demand f o r sex therapy i n that they are time-l i m i t e d and c o n t a i n s u f f i c i e n t i n f o r m a t i o n f o r , and techniques o r i e n t e d towards, treatment g e n e r a l i z a t i o n . Although masquerading under v a r i o u s nomenclatures, the treatment components and goals are g e n e r a l l y s i m i l a r . The broad band approach i n c l u d e s : i n f o r m a t i o n and education; emphasis on mutual r e s p o n s i b i l i t y ; a t t i t u d e change; s k i l l s t r a i n i n g ; communication f a c i l i t a t i o n ; r e d u c t i o n of a l l forms of sexual a n x i e t y and graduated behavior homework assignments. While the a v a i l a b l e r e s e a r c h and c l i n i c a l case s t u d i e s based on v a r i o u s combination of these techniques i s most encouraging (Kaplan, 1974; L o b i t z and L o P i c c o l o , 1972 and Barbach, 1974) there i s l i t t l e experimental r e s e a r c h to document t h e i r e f f i c a c y ( S o t i l e and Kilmann, 1977). The f i r s t o b j e c t i v e of the present r e s e a r c h i s to document the e f f i c a c y of one such short term, broad band therapy w h i l e . a d d r e s s i n g many of the methodological flaws that have c h a r a c t e r i z e d p r e v i o u s r e s e a r c h ( S o t i l e and Kilmann, 1977). Given the i n c r e a s i n g demand f o r s e r v i c e i n the face of a l i m i t e d number of t h e r a p i s t s , a p p l i c a t i o n of group format to these broad band t h e r a p i e s would reduce c l i e n t c o s t s and i n c r e a s e the a v a i l a b i l i t y of treatment. U t i l i z a t i o n of the group format and d i r e c t comparison between i n d i v i d u a l and group treatment of sexual d y s f u n c t i o n i s v i r t u a l l y n o n e x i s t e n t (Golden, P r i c e , H e i n r i c h and L o b i t z , 1978) i n the a v a i l a b l e l i t e r a t u r e . I t i s , t h e r e f o r e , the second o b j e c t i v e of the present study to compare d i r e c t l y i n d i v i d u a l and group short term, broad based therapy to a s c e r t a i n the f e a s i b i l i t y of u t i l i z i n g the more economical group approach f o r the treatment of heterogeneous sexual d y s f u n c t i o n s . 4 REVIEW OF THE LITERATURE Although there are numerous p e r s p e c t i v e s from which to view the a v a i l a b l e l i t e r a t u r e on sex therapy, the d i s t i n c t i o n between i n d i v i d u a l and group therapy which i s c o n s i s t e n t with one of the o b j e c t i v e s of t h i s study and which a l s o a c c u r a t e l y r e f l e c t s the course of development i n t h i s area, w i l l be used as the o r g a n i z a t i o n a l framework f o r t h i s review. D i s c u s s i o n of each of these types of i n t e r v e n t i o n w i l l be d i v i d e d f u r t h e r i n terms of i t s a p p l i c a t i o n to males, females or couples. I n d i v i d u a l I n t e r v e n t i o n : Male and Female Despite i t s t h e r a p e u t i c f a i l i r i g s (Sherfey, 1972 ; Moore, 1961; Cooper, 1978 and Obler, 1973), Freudian p s y c h o a n a l y s i s was the f i r s t attempt to examine s y s t e m a t i c a l l y the nature of sexual d i f f i c u l t i e s and as such warrants d i s c u s s i o n . The key concepts of t h i s theory as i t a p p l i e s to sexual d y s f u n c t i o n are: unconscious con-f l i c t s which are presumed to mediate sexual d i f f i c u l t i e s ; r e p r e s s i o n and r e s i s t a n c e i n acknowledging sexual a t t i t u d e s and experiences; and i n f a n t i l e s e x u a l i t y which i s presumed to develop i n predetermined stages and to determine f u t u r e sexual potency (Freud, 1938). D y s f u n c t i o n i s seen as a symptom of u n d e r l y i n g unconscious motives or c o n f l i c t s and a m e l i o r a t i o n i s s a i d to take p l a c e only i f b a s i c changes i n p e r s o n a l i t y s t r u c t u r e are e f f e c t e d (Freud, 1938). In a d d i t i o n to t h e o r i z i n g about the e t i o l o g y and treatment of sexual d y s f u n c t i o n , Freud (1938) a l s o h e l d 5 s t r o n g b e l i e f s about the a p p r o p r i a t e e x p r e s s i o n of female s e x u a l i t y . Women who achieved c l i t o r a l r a t h e r than v a g i n a l orgasms were assumed to be immature and e m o t i o n a l l y d i s t u r b e d . T h i s assumption has not withstood experimental v e r i f i c a t i o n as Masters and Johnson (1970) and Sherfey (1972) c i t e anatomical and p h y s i o l o g i c a l data which i n d i c a t e that v a g i n a l orgasm i s a myth and that orgasm has to be mediated by a combination of sexual f a n t a s y and c l i t o r a l s t i m u l a t i o n . P s y c h o a n a l y t i c treatment of sexual d y s f u n c t i o n can be c r i t i c i z e d on t h e o r e t i c a l , p r a c t i c a l and methodological grounds. I t i s assumed f o r example that " e a r l y incestuous experiences are the only causes of sexual c o n f l i c t and that sexual d y s f u n c t i o n s are always caused by unconscious c o n f l i c t which i s the only e t i o l o g i c f a c t o r and that care must be p r e d i c a t e d on r e s o l u t i o n of these s p e c i f i c u n d e r l y i n g c o n f l i c t s " (Kaplan, 1974, p.144). The demonstrated e f f i c a c y of treatment u t i l i z i n g d i r e c t b e h a v i o r a l i n t e r v e n t i o n s (Nemetz, C r a i g and R e i t h , 1978 and Golden et a l . , 1978) p r o v i d e s evidence suggesting that i n t e r v e n t i o n on a p u r e l y b e h a v i o r a l l e v e l can provide p o s i t i v e t h e r a p e u t i c r e s u l t s . P r a c t i c a l l i m i t a t i o n s of p s y c h o a n a l y t i c therapy i n c l u d e : f a i l u r e to d e a l with both p a r t n e r s ; e x c e s s i v e l y long term involvement (Cooper, 1978); f i n a n c i a l burden and r e f u s a l to d e a l with the immediate sexual behavior while i n s i g h t i n t o p r e v i o u s l y unexplored c o n f l i c t o c c u r s . Moreover, the m a j o r i t y of r e p o r t s d e a l i n g with the use of 6 p s y c h o a n a l y s i s f o r sexual d y s f u n c t i o n s are s i n g l e subject case h i s t o r i e s u s i n g the s u b j e c t ' s v e r b a l r e p o r t as the outcome c r i t e r i o n ( S t a f f o r d - C l a r k , 1954). While no c o n t r o l l e d , outcome study has been done to evaluate the e f f e c t i v e n e s s of p s y c h o a n a l y s i s f o r these d i s o r d e r s , the approach i s c o n s i d e r e d to be i n e f f e c t i v e (Obler, 1973; Cooper, 1978). The f i r s t a l t e r n a t i v e to the p s y c h o a n a l y t i c approach to sexual d y s f u n c t i o n was the b e h a v i o r a l approach i n t r o d u c e d by Wolpe (1958). Wolpe (1958) viewed sexual d y s f u n c t i o n as a maladaptive behavior which c o u l d be i n f l u e n c e d by the a p p l i c a t i o n of e x p e r i m e n t a l l y v a l i d a t e d p r i n c i p l e s of l e a r n i n g . His theory of systematic d e s e n s i t i z a t i o n i s based on the p r i n c i p l e of r e c i p r o c a l i n h i b i t i o n which s t a t e s that " i f a response a n t a g o n i s t i c to a n x i e t y can be made to occur i n the presence of a n x i e t y - e v o k i n g s t i m u l i so that i t i s accompanied by a complete or p a r t i a l suppression of the a n x i e t y responses, the bond between the s t i m u l i and the a n x i e t y responses w i l l be weakened" (Wolpe, 1958, p.71). The major assumption supporting the a p p l i c a t i o n of systema-t i c d e s e n s i t i z a t i o n to sexual d y s f u n c t i o n i s that a n x i e t y i n i t i a t e s and maintains maladaptive behavior. T h i s technique i n v o l v e s p r o g r e s s i v e r e l a x a t i o n t r a i n i n g (Jacobson, 1938) and the c o n s t r u c t i o n of a h i e r a r c h y of s e x u a l l y - r e l a t e d , a n x i e t y - i n d u c i n g s t i m u l i which are presented one at a time, i n i m a g i n a t i o n while the c l i e n t i s i n a s t a t e of deep r e l a x a t i o n . 7 Wolpe (1958) r e p o r t e d two cases of female d y s f u n c t i o n , one d e s c r i b e d as " p a r t i a l f r i g i d i t y " and the other as "sexual a n x i e t y . " Although both cases were re p o r t e d to be s u c c e s s f u l l y t r e a t e d , the t h e r a p i s t ' s s u b j e c t i v e r e p o r t served as the o n l y outcome c r i t e r i o n . Despite t h i s methodological f a i l i n g and severe c r i t i c i s m of the t h e o r e t i c a l b a s i s f o r the c l i n i c a l techniques ( P a u l , 1969), Wolpe's work repr e s e n t s the f i r s t attempt to d e a l d i r e c t l y with problematic sexual behavior i n a r e l a t i v e l y short-term t h e r a p e u t i c program. Subsequently, numerous other c l i n i c i a n s have repo r t e d s u c c e s s f u l use of systematic d e s e n s i t i z a t i o n ( i n v i v o or imaginal) to a l l e v i a t e male and female sexual d y s f u n c t i o n (Cooper, 1968, 1969; Lazarus, 1961, 1963, 1965, 1968; L o P i c c o l o , Stewart and Watkins, 1972); K r a f t and A l - I s s a , 1964; Annon, 1974; Wincze, 1971 and Wolpe, 1953, 1958). Although the m a j o r i t y of these s t u d i e s used small samples and omitted c o n t r o l c o n d i t i o n s , the d i r e c t i o n of the f i n d i n g s i s c o n s i s t e n t l y p o s i t i v e . M o d i f i c a t i o n s of t h i s t h e r a p e u t i c technique which have been used e f f e c t i v e l y with sexual d y s f u n c t i o n have i n c l u d e d the use o f : chemical r e l a x a t i o n (Brady, 1966); hypnotic r e l a x a t i o n (Lazarus, 1973) and sexual a r o u s a l (Wolpin, 1969; Clopton and Risbrough, 1973; L o P i c c o l o and L o b i t z , 1973 and F r a n k e l , 1979) to serve as a n x i e t y i n h i b i t o r s . Video-taped d e s e n s i t i z a t i o n has a l s o been employed s u c c e s s f u l l y , s p e c i f i c a l l y i n s t u d i e s of female sexual d y s f u n c t i o n ( C a i r d and Wincze, 1974; Woody and Schauble, 1969; 8 Nemetz et a l . , 1978). T h i s m o d i f i c a t i o n , i n which c l i e n t s view models engaging i n the d e s i r e d behavior without e x p e r i e n c i n g a d v e r s i v e consequences, i s based on Bandura and Walter's c o n c l u s i o n that " v i r t u a l l y a l l l e a r n i n g phenomena r e s u l t i n g from d i r e c t experiences can occur on a v i c a r i o u s b a s i s through o b s e r v a t i o n of other persons's behavior and i t s consequences f o r them" (Bandura, 1969, p.118). P o t e n t i a l e f f e c t s of modeling t h e r a p i e s p r e v i o u s l y i d e n t i f i e d (Bandura, 1969), i n c l u d e the a c q u i s i t i o n of p r e v i o u s l y n o n - e x i s t e n t p a t t e r n s of b e h a v i o r s , weakening response i n h i b i t i o n s and f a c i l i t a t i n g the occurrence of p r e e x i s t i n g responses i n the behavior r e p e r t o i r e . In terms of sex therapy, viewing a p r e v i o u s l y a n x i e t y - i n d u c i n g s i t u a t i o n as i t produces p o s i t i v e consequences, not only serves to e x t i n g u i s h the a n x i e t y and f a c i l i t a t e the response, but a l s o shows the c l i e n t the a p p r o p r i a t e s k i l l s to u t i l i z e i n h i s new behavior. S e v e r a l s t u d i e s have i n v e s t i g a t e d the r e l a t i v e e f f i c i e n c y of systematic d e s e n s i t i z a t i o n and i t s v a r i a t i o n s i n the treatment of sexual d y s f u n c t i o n s . Wincze (1971) compared the e f f e c t s of c o n v e n t i o n a l systematic d e s e n s i t i z a t i o n to v i c a r i o u s e x t i n c t i o n (Bandura, Grusec and Menlove, 1967) i n which the c l i e n t observes models performing a n x i e t y - p r o d u c i n g behaviors without e x p e r i e n c i n g adverse consequences. The s i n g l e s u b j e c t f o r the comparison was a female who r e p o r t e d numerous problem areas i n c l u d i n g sexual apathy and a n x i e t y . Wincze concluded t h a t systematic d e s e n s i t i z a t i o n was more e f f e c t i v e than v i c a r i o u s e x t i n c t i o n f o r that p a r t i c u l a r 9 case on the b a s i s of the s i n g l e s u b j e c t r e v e r s a l d e s i g n . U n f o r t u n a t e l y , he f a i l e d to c o n t r o l f o r p o s s i b l e sequence e f f e c t s of the t h e r a p e u t i c i n t e r v e n t i o n s u t i l i z e d . Wincze and C a i r d (1976) compared the r e l a t i v e e f f i c i e n c y of video-taped d e s e n s i t i z a t i o n / v i c a r i o u s e x t i n c t i o n and standard i m a g i n a l d e s e n s i t i z a t i o n u s i n g a sample of twenty-one women diagnosed i n Kaplan's nomenclature as having a "general sexual d y s f u n c t i o n . " The standard d e s e n s i t i z a t i o n c o n d i t i o n c o n s i s t e d of t h i r t y h i e r a r c h i c a l scenes presented i n imagina-t i o n . The video-taped c o n d i t i o n contained the above t h i r t y scenes presented v i s u a l l y . There were two or three weekly s e s s i o n s f o r each subject which were continued u n t i l the subject completed the t h i r t y h i e r a r c h y items. A c r o s s - o v e r c o n t r o l was i n c l u d e d i n which su b j e c t s were randomly assigned a f t e r a f o u r week de l a y to the two experimental c o n d i t i o n s . The r e s u l t s i n d i c a t e d that both treatment c o n d i t i o n s s i g -n i f i c a n t l y reduced sexual a n x i e t y by comparison to the c o n t r o l c o n d i t i o n although only the v i d e o - d e s e n s i t i z a t i o n produced s i g n i f i c a n t r e d u c t i o n of heterosexual a n x i e t y . Since the instrument u t i l i z e d to measure he t e r o s e x u a l a n x i e t y (The B e n t l e r Heterosexual Anxiety H i e r a r c h y , B e n t l e r , 1971) contained a number of novel sexual items not r e f e r r e d to d u r i n g the course of therapy, t h i s r e s u l t suggests t h a t the v i d e o - d e s e n s i t i z a t i o n showed g r e a t e r g e n e r a l i z a t i o n of treatment e f f e c t s . I t i s imperative that systematic d e s e n s i t i z a t i o n and i t s v a r i a t i o n s be evaluated with the a p p r o p r i a t e subject 10 sample. For example, v i c a r i o u s e x t i n c t i o n / v i d e o - t a p e de-s e n s i t i z a t i o n provides sex i n f o r m a t i o n , response f a c i l i t a t i o n and teaches the c l i e n t s new sexual s k i l l s , whereas i n v i v o d e s e n s i t i z a t i o n i n c l u d e s a c t u a l shaping of s k i l l s through p r a c t i c e with and feedback from the p a r t n e r . I f the c l i e n t has no p a r t n e r or i s e x p r e s s i n g extremely high l e v e l s of a n x i e t y , imaginal exposure coupled with v i c a r i o u s e x t i n c t i o n i s recommended (Kaplan, 1974; Lazarus, 1968). I f c l i e n t s are s e x u a l l y naive and u n s k i l l e d v i c a r i o u s e x t i n c t i o n would appear to be the most e f f i c i e n t method of t r a n s m i t t i n g i n f o r m a t i o n . Most sex t h e r a p i e s now use a combination of the three methods which provides both necessary i n f o r m a t i o n and the o p p o r t u n i t y f o r a c t u a l p r a c t i c e with p a r t n e r f e e d -back. One of the more recent developments i n the treatment of sexual d y s f u n c t i o n i s that of masturbation t r a i n i n g ( L o b i t z and L o P i c c o l o , 1972). The assumption u n d e r l y i n g the masturbation t r a i n i n g i s that masturbation i s the most probable method of producing an orgasm (Kinsey, 1953). There i s a l s o some evidence to suggest that an i n t e n s e orgasm which i s more f r e q u e n t l y produced by masturbation (Masters and Johnson, 1970) leads to i n c r e a s e d v a s c u l a r i t y i n the v a g i n a , l a b i a and c l i t o r i s and t h a t t h i s i n t u r n w i l l enhance orgasmic p o t e n t i a l (Bardwiek, 1971) . From a p r a c t i c a l standpoint t r a i n i n g i n masturbation techniques i s a p p r o p r i a t e f o r both male and female c l i e n t s who do not have par t n e r s (Annon, 1974); i t enables a c l i e n t to d i s c o v e r what types of s t i m u l a t i o n are a r o u s i n g which can then be communicated to a 11 p a r t n e r (Annon, 1973; L o P i c c o l o and L o b i t z , 1972); i t produces l e s s a n x i e t y than h e t e r o s e x u a l behaviors and thereby a l l o w i n g the c l i e n t to begin with a more r e l a x i n g assignment (Kaplan, 1974); and i t prov i d e s an o p p o r t u n i t y f o r males with the problem of premature e j a c u l a t i o n to p r a c t i c e the "squeeze" or "pause technique" without i n c u r r i n g performance demands from h i s pa r t n e r ( L o P i c c o l o and L o b i t z , 1973). L o P i c c o l o and L o b i t z (1972) have developed a nine step masturbation t r a i n i n g program f o r women i n which the c l i e n t s y s t e m a t i c a l l y explores her body v i s u a l l y and t a c t u a l l y , l o c a t e s areas of p o s i t i v e s e n s a t i o n , s t i m u l a t e s these areas manually and then with an e l e c t r i c v i b r a t o r , communicates these techniques to her par t n e r and then engages i n i n t e r -course with concurrent manual or v i b r a t o r s t i m u l a t i o n . U t i l i z i n g t h i s technique with eleven cases of primary orgasmic dys-f u n c t i o n , L o b i t z and L o P i c c o l o (1973) r e p o r t that a l l eleven women became orgasmic through masturbation and that nine of the eleven were orgasmic with t h e i r p a r t n e r (although a p p a r e n t l y r e q u i r i n g concurrent manual s t i m u l a t i o n ) . Given the l a c k of a c o n t r o l c o n d i t i o n t h i s study r e p r e s e n t s more of an i n i t i a l c l i n i c a l i n v e s t i g a t i o n than a r i g o r o u s attempt to evaluate the e f f i c a c y of masturbation t r a i n i n g . W i t h i n the i n d i v i d u a l treatment format, masturbation t r a i n i n g has a l s o been r e p o r t e d to be e f f e c t i v e with e r e c t i l e f a i l u r e (Annon, 1974), premature e j a c u l a t i o n ( L o P i c c o l o and L o b i t z , 1973), primary orgasmic d y s f u n c t i o n (Kaplan, 1974) and secondary orgasmic d y s f u n c t i o n (Annon, 1973). U n f o r t u n a t e l y , 12 these s t u d i e s have numerous methodological f a i l i n g s . They do, however, suggest f u r t h e r areas f o r more r i g o r o u s experimental i n v e s t i g a t i o n as to the e f f i c a c y of masturbation t r a i n i n g . I n d i v i d u a l I n t e r v e n t i o n : Couples Masters and Johnson (1970) were the f i r s t to emphasize the importance of t r e a t i n g both p a r t n e r s i n the sexual r e l a t i o n s h i p . They maintain that there i s no u n i n v o l v e d p a r t n e r s e i t h e r i n the e t i o l o g y or i n the treatment of sexual d y s f u n c t i o n : "sexual d y s f u n c t i o n i s indeed a m a r i t a l u n i t problem, c e r t a i n l y never only.a w i f e ' s or only a husband's pers o n a l concern" (Masters and Johnson, 1970, p.3). These authors d e s c r i b e an e x t e n s i v e r e t r a i n i n g program, e s s e n t i a l l y b e h a v i o r a l i n nature, whereby couples r e p o r t i n g any type or combination of sexual d y s f u n c t i o n p a r t i c i p a t e i n an i n t e n s i v e two week t h e r a p e u t i c program. In a d d i t i o n to d i s c u s s i o n , education and communication t r a i n i n g , two new techniques were i n c l u d e d i n t h e i r program. The f i r s t , sensate f o c u s , was designed to maximize p a r t n e r feedback r e g a r d i n g the e f f e c t s of sexual s t i m u l a t i o n and to give both p a r t n e r s an o p p o r t u n i t y to "give and r e c e i v e " s t i m u l a t i o n i n a non-t h r e a t e n i n g s i t u a t i o n . In c o n j u n c t i o n with t h i s e x e r c i s e , i n t e r c o u r s e i s p r o h i b i t e d i n i t i a l l y to remove performance a n x i e t y and to allow couples to explore s a f e l y and to experience t h e i r i n t e n s i f i e d a r o u s a l . Secondly, Semans (1956) o r i g i n a l "pause" technique f o r premature e j a c u l a t i o n , which c o n s i s t e d of p e n i l e withdrawal immediately p r i o r to the 13 p o i n t of e j a c u l a t o r y i n e v i t a b i l i t y was m o d i f i e d to i n c l u d e the female's a p p l i c a t i o n of manual pressure to the frenulum to d i m i n i s h the e r e c t i o n and the urge to e j a c u l a t e . E v a l u a t i o n of t h e i r treatment program i s u n f o r t u n a t e l y complicated by u n c e r t a i n e x t e r n a l v a l i d i t y and imprecise outcome measures. The i n t e n s i v e two week r e s i d e n t i a l program was presumably a v a i l a b l e only to a h i g h l y s e l f -s e l e c t e d segment of the p o p u l a t i o n because of the d i s r u p t i v e and f i n a n c i a l l y burdensome nature of p a r t i c i p a t i o n . In a d d i t i o n , s e l e c t i o n c r i t e r i a f o r treatment were extremely r i g i d . These i n c l u d e d a h i s t o r y of at l e a s t s i x months of p r i o r symptomatic treatment, a w e l l - a d j u s t e d marriage and a h i g h l e v e l of m o t i v a t i o n f o r treatment. These c r i t e r i a , i n a d d i t i o n to the requirement of the two week commitment s e r i o u s l y c a l l i n t o q u e s t i o n the r e p r e s e n t a t i v e n e s s of t h e i r sample. Secondly, the outcome c r i t e r i o n , "symptom r e v e r s a l , " i s ambiguous e s p e c i a l l y i n terms of female sexual d y s f u n c t i o n as i t i s not c l e a r whether t h i s c r i t e r i o n i n c l u d e d only the a b i l i t y to achieve orgasm through c o i t u s or whether i t was extended to i n c l u d e the a b i l i t y to reach orgasm through other methods of s t i m u l a t i o n ( S o t i l e and Kilmann, 1977). In view of these l i m i t a t i o n s i t i s d i f f i c u l t to evaluate the r e p o r t e d 80% i n i t i a l success r a t e i n both the male and female samples. Despite these methodological c o n s i d e r a t i o n s , Masters and Johnson are c r e d i t e d with conducting a l a r g e s c a l e e v a l u a t i o n of t h e i r treatment, p o p u l a r i z i n g the concept of short term therapy, i n t r o d u c i n g the dual sex therapy 14 team and p r o v i d i n g the major impetus f o r subsequent i n v e s t i g a t i o n of couple i n t e r v e n t i o n . Hartmann and F i t h i a n (1972) and Kaplan (1974) have used sexual r e t r a i n i n g programs s i m i l a r to those of Masters and Johnson (1970). Hartmann and F i t h i a n ' s i n t e n s i v e two week r e t r a i n i n g program focused on a u d i o v i s u a l a i d s f o r sexual s k i l l s t r a i n i n g and the use of G e s t a l t techniques to examine both the c l i e n t ' s body image and the couple's method of i n t e r a c t i n g . Kaplan. (1974) i n c o r p o r a t e d both dynamic psychotherapy and b e h a v i o r a l l y o r i e n t e d r e t r a i n i n g methods i n an i n t e n s i v e program of v a r i a b l e l e n g t h . In a d d i t i o n , a l l c l i e n t s were seen i n i n d i v i d u a l psychotherapy s e s s i o n s which explored i n t r a p s y c h i c o b s t a c l e s assumed to impede sexual r e s p o n s i v e n e s s . N e i t h e r author, however, presented any e v a l u a t i v e data on t h e i r programs, i n s t e a d case h i s t o r i e s were o f f e r e d as a measure of program e f f e c t i v e n e s s . The new short term, broad band t h e r a p i e s have a l s o been a p p l i e d to i n d i v i d u a l couples. L o b i t z and L o P i c c o l o (1972), the o r i g i n a l proponents of t h i s form of i n t e r v e n t i o n , d e s c r i b e a f i f t e e n s e s s i o n treatment program which u t i l i z e d i n v i v o graded exposure tasks to reduce performance a n x i e t y , d a i l y s e l f - m o n i t o r i n g of sexual b e h a v i o r s , the "squeeze" technique (Masters and Johnson, 1970) to a m e l i o r a t e premature e j a c u l a t i o n , a c l a s s i c a l c o n d i t i o n i n g procedure to c o n d i t i o n sexual a r o u s a l , masturbatory s k i l l s t r a i n i n g combined with f a n t a s y and pornography to enhance sexual r e s p o n s i v e n e s s , modeling and r o l e - p l a y i n g to f a c i l i t a t e 15 the a c q u i s i t i o n of both i n t e r p e r s o n a l sexual and communication s k i l l s and c l i e n t p a r t i c i p a t i o n i n maintenance p l a n n i n g to f a c i l i t a t e treatment g a i n s . F o l l o w i n g Masters and Johnson's (1970) c r i t e r i o n t h a t the female p a r t n e r be s a t i s f i e d , t h a t i s reach orgasm " i n at l e a s t 50% of c o i t a l c o n n e c t i o n s , " (Masters and Johnson, 1970, p.92) they r e p o r t e d success with a l l t h i r t e e n cases of female primary orgasmic d y s f u n c t i o n and three of nine cases of secondary orgasmic d y s f u n c t i o n . In a d d i t i o n , s i x of s i x cases of premature e j a c u l a t i o n and f o u r of s i x cases of e r e c t i l e f a i l u r e were e f f e c t i v e l y t r e a t e d . Although these r e s u l t s remain to be r e p l i c a t e d i n a c o n t r o l l e d e v a l u a t i o n study, as an i n i t i a l i n v e s t i g a t i o n of a new short term, broad band therapy, they are promising. Although c l i n i c a l l y p romising, the l i t e r a t u r e on i n d i v i d u a l (male, female and couple) i n t e r v e n t i o n i n sex therapy i s r i f e with methodological d e f i c i e n c i e s ( S o t i l e and Kilmann, 1977). Stud i e s c o n s i s t e n t l y u t i l i z e small s u b j e c t samples with l i t t l e or no attempt to examine p r o g n o s t i c subject c h a r a c t e r i s t i c s . C o n t r o l groups and adequate follow-up are o f t e n n o n - e x i s t e n t . In cases of s i n g l e p a r t n e r involvement, very o f t e n no c o r r o b o r a t i v e data are s o l i c i t e d from the uninvolved p a r t n e r s . Data, when presented at a l l , too f r e q u e n t l y r e l y on s u b j e c t testimony about the e f f i c a c y of the i n t e r v e n t i o n . An u n q u a l i f i e d e v a l u a t i o n of the e f f e c t i v e n e s s of the sex t h e r a p i e s t h e r e f o r e w i l l not be p o s s i b l e u n t i l more c o n t r o l l e d and 16 m e t h o d o l o g i c a l l y sound r e s e a r c h has been conducted. Group I n t e r v e n t i o n Although extremely sparse, the e x i s t i n g l i t e r a t u r e On group i n t e r v e n t i o n i n sex therapy may be d i v i d e d on the b a s i s of gender and a l s o on the b a s i s of h e t e r o g e n e i t y or homogeneity of d i a g n o s i s . While not overcoming the numerous methodological d e f i c i e n c i e s c h a r a c t e r i s t i c of e a r l i e r r e s e a r c h ( S o t i l e and Kilmann, 1977) t h i s body of r e s e a r c h addresses the c u r r e n t d i f f i c u l t i e s of i n c r e a s e d cost and l i m i t e d v a r i a b i l i t y of treatment f o r sexual d y s f u n c t i o n . . Group I n t e r v e n t i o n : Female I n i t i a l work with female groups was done by Stone and Levine (1950) and Boas (1950). Stone and Levine (1950) ran e i g h t d i a g n o s t i c a l l y heterogeneous groups c o n s i s t i n g of nine women each. Treatment, f o c u s s i n g on sexual r e -education and group d i s c u s s i o n , c o n s i s t e d of three two-hour s e s s i o n s . Spouses were seen once i n a separate group to d i s c u s s t h e i r r o l e s i n t h e i r p a r t n e r s ' therapy. Although no o b j e c t i v e data were c o l l e c t e d , s o l i c i t e d s u b j e c t i v e r e p o r t s suggested that i n c r e a s e d communication and, i n some cases i n c r e a s e d female responsiveness had r e s u l t e d . B'oas (1950) saw twenty secondary inorgasmic females f o r f o u r t e e n f o r t y - f i v e minute s e s s i o n s . The purpose of the group s e s s i o n s was to provide i n s i g h t i n t o the p a t i e n t s ' c o n f l i c t s and to examine sexual a t t i t u d e s . Again, although no o b j e c t i v e or systematized data were obtained, the 17 author r e p o r t e d anecdotal f i n d i n g s of i n c r e a s e d understanding of s e x u a l i t y and decreased sexual a n x i e t y . Systematic d e s e n s i t i z a t i o n has been used i n group treatment of female sexual d y s f u n c t i o n by Lazarus (1968), Ob l e r , (1973), Husted (1975), S o t i l e and Kilmann (1978) and Nemetz, C r a i g and R e i t h (1978). Lazarus (1968) u t i l i z e d a group procedure with f o u r non-orgasmic women. Fourteen s e s s i o n s were devoted to a combination of r e l a x a t i o n and systematic d e s e n s i t i z a t i o n , r e - e d u c a t i o n and group d i s c u s s i o n At the t e r m i n a t i o n of treatment a l l women were e x p e r i e n c i n g orgasm (not f u r t h e r d e f i n e d ) i n at l e a s t 50% of t h e i r sexual encounters. Obler (1973) i n a r e l a t i v e l y w e l l - c o n t r o l l e d study compared a group r e c e i v i n g d e s e n s i t i z a t i o n and one r e c e i v i n g d y n a m i c a l l y - o r i e n t e d therapy, to a n o n - p a r t i c i p a t i n c o n t r o l group. S i x t y - f o u r women were randomly assigned to the three c o n d i t i o n s . Although the groups were matched f o r type and d u r a t i o n of d y s f u n c t i o n , no d e s c r i p t i o n of group composition was provided. Data i n d i c a t e d that s u b j e c t s r e c e i v i n g d e s e n s i t i z a t i o n r e p o r t e d s i g n i f i c a n t l y more r e d u c t i o n i n the p h y s i o l o g i c a l c o r r e l a t e s of an x i e t y than those i n e i t h e r of the other c o n d i t i o n s . Obler, however, used g r a p h i c a i d s and a s s e r t i v e t r a i n i n g i n c o n j u n c t i o n with the d e s e n s i t i z a t i o n and consequently i t i s d i f f i c u l t to i d e n t i f y the e f f e c t i v e treatment components. Husted (1975) compared the e f f e c t s of group imaginal systematic d e s e n s i t i z a t i o n to group imaginal systematic 18 d e s e n s i t i z a t i o n p l u s i n v i v o homework assignments i n a d i a g n o s t i c a l l y heterogeneous sample of females. A f t e r f i f t e e n s e s s i o n s , a l l showed s i g n i f i c a n t i n c r e a s e s i n communication and orgasm. S i g n i f i c a n t decreases i n sexual a n x i e t y were a l s o evidenced. While both treatments were e q u a l l y e f f e c t i v e i n re d u c i n g sexual a n x i e t y , imaginal de-s e n s i t i z a t i o n alone was s i g n i f i c a n t l y more e f f i c i e n t i n terms of time needed to produce t h e r a p e u t i c b e n e f i t s . Husted suggests that t h i s was due.to the number of o b s t a c l e s that i n t e r f e r e d with the completion of homework assignments of the i n v i v o group. This o b s e r v a t i o n draws a t t e n t i o n to the l i m i t a t i o n s of homework assignments i n sex therapy. I f d a i l y events are not conducive to sexual a c t i v i t y any therapy dependent on the completion of sexual b e h a v i o r a l homework assignments i n j e o p a r d i z e d . S o t i l e and Kilmann (1978) u s i n g a d i a g n o s t i c a l l y heterogeneous sample, ran two groups of ten and twelve women r e s p e c t i v e l y f o r f i f t e e n biweekly s e s s i o n s . Each woman served as her own c o n t r o l . Group systematic d e s e n s i t i z a t i o n was conducted u s i n g f o u r common h i e r a r c h i e s of sexual scenes. Measures of sexual behavior and s a t i s f a c t i o n showed s i g n i f i c a n t i n c r e a s e s over b a s e l i n e which were found to be maintained s i x weeks l a t e r when follow-up assessments were done. 'This study c o n t r i b u t e s to the knowledge on group systematic d e s e n s i t i z a t i o n as i t i s one of the few to u t i l i z e a c o n t r o l measure and a follow-up p e r i o d . 19 Nemetz, C r a i g and R e i t h (1978) used a t t i t u d i n a l , b e h a v i o r a l and sexual a n x i e t y measures to assess the e f f e c t s of i n d i v i d u a l and group graduated symbolic modeling through videotapes with concurrent b e h a v i o r a l t a s k s . A l l twenty-two women had re p o r t e d severe sexual anxiety, which precluded sexual enjoyment or a c t i v i t y . S i x t e e n s u b j e c t s were randomly assigned to one of the two experimental c o n d i t i o n s and r e c e i v e d e i t h e r group or i n d i v i d u a l treatment. Treatment c o n s i s t e d of r e l a x a t i o n t r a i n i n g f o l l o w e d by viewing a h i e r a r c h y of f o r t y - f i v e video-taped v i g n e t t e s d e p i c t i n g graduated sexual b e h a v i o r s . F i v e s e s s i o n s were h e l d w i t h i n two and one-half weeks. The other s i x women c o n s t i t u t e d an assessment only c o n t r o l group. Decreased a n x i e t y , i n c r e a s e d sexual behavior, and improvement on a t t i t u d i n a l measures were evidenced i n both treatment c o n d i t i o n s i n c o n t r a s t to the c o n t r o l ; however, a tr e n d toward g r e a t e r improvement was observed f o r those who r e c e i v e d group treatment. Improve-ments i n both t r e a t e d groups remained s t a b l e through a one year follow-up p e r i o d . T h i s study, together with those r e p o r t e d by Obler (1973), Husted (1972) and S o t i l e and Kilmann (1978) c l e a r l y i n d i c a t e that group d e s e n s i t i z a t i o n i s an e f f e c t i v e procedure f o r r e d u c i n g sexual a n x i e t y and i n c r e a s i n g s e x u a l l y e f f e c t i v e b e h a v i o r s . The demonstrated e f f i c a c y of masturbation t r a i n i n g ( L o P i c c o l o and L o b i t z , 1973) f o r non-orgasmic women t r e a t e d i n d i v i d u a l l y has suggested i t s a d a p t a t i o n to group format. 20 Barbach (1974) saw e i g h t y - t h r e e primary inorgasmic women ( i n groups of f i v e to seven) twice a week f o r f i v e weeks. T r e a t -ment procedures i n c l u d e d masturbation t r a i n i n g , sexual r e -educat i o n through readings and d i s c u s s i o n , and an i n d i v i d u a l component designed to f a c i l i t a t e sexual communication with the woman's p a r t n e r . At the end of treatment Barbach found t h a t s e v e n t y - s i x of the e i g h t y - t h r e e women a t t a i n e d orgasm c o n s i s t e n t l y through masturbation. A f t e r e i g h t months only seventeen women were a v a i l a b l e f o r follow-up. assessment, a l l of whom continued to be orgasmic (Wallace and Barbach, 1974). Of these seventeen a l l but two women f a i l e d to r e p o r t orgasmic experiences with t h e i r . p a r t n e r s . Given the g r e a t l y reduced sample a v a i l a b l e f o r follow-up, no f i r m c o n c l u s i o n s r e g a r d i n g maintenance of. treatment e f f e c t s can be drawn. Schneidman and McGuire (1976) examined the e f f e c t s of masturbation t r a i n i n g i n c o n j u n c t i o n w i t h a m u l t i - f a c e t e d approach, on two groups each c o n s i s t i n g of ten primary inorgasmic women. One group i n c l u d e d women over t h i r t y - f i v e and the other i n c l u d e d women under t h i r t y - f i v e . The major components of the ten week program were r e - e d u c a t i o n , group d i s c u s s i o n , couple o r i e n t e d therapy and masturbation t r a i n i n g ( L o P i c c o l o and L o b i t z , 1972). The r e s u l t s i n d i c a t e d t hat the younger women became orgasmic e a r l i e r i n treatment and tha t a g r e a t e r percentage of t h i s group was orgasmic at the t e r m i n a t i o n of treatment. Only one woman became orgasmic d u r i n g c o i t u s . Although orgasm d u r i n g c o i t u s alone 21 should not be seen as the u l t i m a t e c r i t e r i o n f o r s u c c e s s f u l i n t e r v e n t i o n , i t appears that t h i s extremely low percentage i s due to the f a c t t h a t the pa r t n e r s were not c o n s i s t e n t l y i n v o l v e d i n the therapy. Although Barbach (1974) can be c r e d i t e d w i t h the i n t r o d u c t i o n of masturbation t r a i n i n g i n group format to preorgasmic women, the r e s e a r c h does not i n c l u d e adequate c o n t r o l or d i r e c t comparison to i n d i v i d u a l therapy. Leiblum and E r s n e r - H e r s h f i e l d (1977) d e a l t with three b a s i c i s s u e s concerning the implementation of women's groups: (1) t r a n s f e r of masturbatory s k i l l s t o he t e r o s e x u a l behavior; (2) p o s s i b l e b e n e f i t s of p a r t n e r i n c l u s i o n i n therapy; and (3) value of d i a g n o s t i c h e t e r o g e n e i t y versus homogeneity of group composition. Three groups of women were seen f o r one and one-half hours f o r e i g h t c o n s e c u t i v e weeks. Composition of the groups v a r i e d : Group 1 contained s i x women with heterogeneous diagnoses with no male p a r t i c i p a t i o n ; Group 2 contained f i v e women who r e p o r t e d primary orgasmic d y s f u n c t i o n , a l s o with no male p a r t i c i p a t i o n and Group 3 contained f i v e heterogenously diagnosed females with male p a r t i c i p a t i o n i n two s e s s i o n s . Treatment i n c l u d e d sexual r e - e d u c a t i o n and i n f o r m a t i o n , b e h a v i o r a l homework assignments and masturbation t r a i n i n g . Although ten of the eleven primary inorgasmic women became orgasmic with the masturbation t r a i n i n g , t r a n s f e r of orgasm to c o i t u s without a d d i t i o n a l g e n i t a l s t i m u l a t i o n , was not demonstrated. T h i s f i n d i n g which i s c o n s i s t e n t with other r e p o r t s 1 22 (Schneidman and McGuire, 1976; E r s n e r - H e r s h f i e l d and Kopel, 1979) s e r i o u s l y questions the l i k e l i h o o d of orgasm through c o i t u s alone. Although the authors s t r o n g l y recommend the p a r t i c i p a t i o n of male p a r t n e r s on the b a s i s of in c r e a s e d couple s a t i s f a c t i o n i n Group 3, as measured by the Locke Wallace M a r i t a l Adjustment Scale (Locke and Wallace, 1959) and the Sexual I n t e r a c t i o n Inventory ( L o P i c c o l o and Steger, 1974), i t must be noted that none of the u n i n v o l v e d p a r t n e r s i n the other groups were given these measures. Consequently, c o n c l u s i o n s about couple s a t i s f a c t i o n are unwarranted. H e r s h f i e l d and Kopel (1979) compared the e f f e c t of couples and women's group treatment f o r primary orgasmic d y s f u n c t i o n . The authors were p r i m a r i l y concerned about the r e l a t i o n s h i p of p a r t n e r - i n c l u d e d versus p a r t n e r - e x c l u d e d programs to the outcome c r i t e r i a or orgasm v i a couple a c t i v i t i e s , as opposed to orgasm through s e l f - s t i m u l a t i o n . In a d d i t i o n , the authors addressed the qu e s t i o n of massed versus d i s t r i b u t e d therapy s e s s i o n s . Twenty-four primary inorgasmic females were randomly assigned to one of fou r treatment groups: (1) women; or (2) couple massed s e s s i o n s (twice weekly f o r f i v e weeks); or (3) women; or (4) couple d i s t r i b u t e d s e s s i o n s (weekly f o r t en weeks). Treatment c o n s i s t e d of sexual e d u c a t i o n , communication and masturbation t r a i n i n g (Barbach, 1975; L o P i c c o l o and L o P i c c o l o , 1976). Subjects served as t h e i r own w a i t i n g l i s t c o n t r o l f o r an 23 u n s p e c i f i e d b a s e l i n e p e r i o d . Measures r e p e a t e d a t the i n i t i a l i n t e r v i e w , end of b a s e l i n e , i m m e d i a t e l y p o s t - t r e a t m e n t and f i v e and t e n weeks p o s t - t r e a t m e n t , i n c l u d e d the Locke W a l l a c e M a r i t a l Adjustment S c a l e (Locke and W a l l a c e , 1959) and a Survey o f S e x u a l A c t i v i t i e s ( E r s n e r - H e r s h f i e l d and K o p e l , 1979) which a s s e s s e d changes i n the f r e q u e n c y and p l e a s u r e r a t i n g s f o r s e l f and c o u p l e s e x u a l a c t i v i t i e s . A l l f o r m a t s of the t r e a t m e n t were e q u a l l y e f f e c t i v e f o r b o t h male and female p a r t i c i p a n t s i n terms of s e l f and c o u p l e s e x u a l i t y . At the two week f o l l o w - u p p e r i o d 917c of the women a c h i e v e d orgasm t h r o u g h s e l f - s t i m u l a t i o n and 82% e x p e r i e n c e d orgasm v i a c o u p l e a c t i v i t i e s , the g r e a t e s t f r e q u e n c y o c c u r r i n g v i a v i b r a t o r s t i m u l a t i o n u t i l i z e d i n a c o u p l e f o r m a t . C o n s i s t e n t w i t h p r e v i o u s r e s e a r c h (Schneidman and McGuire, 1976; L e i b l u m and E r s n e r - H e r s h f i e l d , 1977) orgasm through c o i t u s a l o n e was i n f r e q u e n t . No s i g n i f i c a n t d i f f e r e n c e was observed between the groups r e c e i v i n g massed or d i s t r i b u t e d s e s s i o n s . D e s p i t e the l a c k of adequate c o n t r o l s and d i r e c t comparison t o i n d i v i d u a l p r o c e d u r e s , the f i n d i n g s of the r e s e a r c h on group i n t e r v e n t i o n f o r female s e x u a l d y s f u n c t i o n suggest t h a t i t i s a p o t e n t i a l l y e f f e c t i v e form of i n t e r v e n t i o n . Group I n t e r v e n t i o n : Male L i t t l e r e s e a r c h has been done on male d y s f u n c t i o n i n g e n e r a l and t h e r e i s a p a r t i c u l a r d e a r t h o f l i t e r a t u r e r e p o r t i n g group p r o c e d u r e s w i t h males. 24 Kaplan, Kohl, Pomeroy, O f f i t and Hogan (1974) r e p o r t e d on f o u r couples whose major complaint was premature e j a c u l a t i o n . The couples were seen f o r s i x weekly f o r t y - f i v e minute s e s s i o n s . The o b j e c t i v e of the group s e s s i o n was to t r a i n the p a r t n e r s i n e j a c u l a t o r y c o n t r o l techniques and to d e a l with o b s t a c l e s to sexual f u n c t i o n i n g and r e s i s t a n c e to treatment. Success, maintained by a l l f o u r males at the end of the f o u r month follow-up p e r i o d , was d e f i n e d as the males' attainment of v o l u n t a r y e j a c u l a t o r y c o n t r o l with consequently prolonged c o i t u s . Z e i s s , C h r i s t e n s a n and Levine (1978) t r e a t e d s i x males without t h e i r p a r t n e r s f o r premature e j a c u l a t i o n d u r i n g s i x weekly s e s s i o n s . Treatment i n c l u d e d i n s t r u c t i o n i n the "squeeze" technique (Masters and Johnson, 1970), the "pause" technique (Semans, 1956) and i n communication s k i l l s . At the e i g h t month follow-up 50% of the s u b j e c t s had r e p o r t e d i n c r e a s e d e j a c u l a t o r y l a t e n c y . As i n the study by Kaplan et a l . , (1974), there was no c o n t r o l group with which these r e s u l t s c o u l d be compared. L o b i t z and Baker (1979) used group s e s s i o n s f o r males without r e g u l a r sexual p a r t n e r s i n the treatment of primary and secondary e r e c t i l e f a i l u r e and premature e j a c u l a t i o n . Treatment focussed on sexual e d u c a t i o n , p o s i t i v e sexual a t t i t u d e s , r e d u c t i o n of sexual a n x i e t y , development of communication s k i l l s and i n c r e a s e d s e n s i t i v i t y to p h y s i c a l s e n s a t i o n s and e r o t i c imagery. Two groups of s i x males each met f o r twelve weekly n i n e t y minute s e s s i o n s . Although 25 s e l f - r e p o r t e d data i n d i c a t e d that 66% of the men showed s i g n i f i c a n t improvements i n t h e i r a b i l i t y to o b t a i n and m a i n t a i n e r e c t i o n s , i n t e r p r e t a t i o n of t h i s f i n d i n g i s s e v e r e l y hampered by l a c k of a c o n t r o l group and r e l i a n c e on undefined s e l f - r e p o r t measures. None of the aforementioned s t u d i e s d e s c r i b e s the female p a r t n e r , or attempts to measure her c o - o p e r a t i o n or indeed her e x e c u t i o n of the t r a i n i n g procedures. T h i s i s a s i g n i f i c a n t omission i n view of the r e s e a r c h on u n i s e x u a l groups, both male and female, which suggests the importance of t r e a t i n g both p a r t n e r s i n the r e l a t i o n s h i p (Masters and Johnson, 1970; Leiblum et a l . , 1977). Advantages of dyadic involvement i n c l u d e : ease of communication of homework assignments; assessment of p a r t n e r s ' c o n t r i b u t i o n to p r e s e n t i n g problems and subsequent p a r t i c i p a t i o n i n therapy; assessment of p a r t n e r r e a c t i o n to t h e r a p e u t i c p r o g r e s s ; and c l a r i f i c a t i o n of t h e r a p e u t i c d i f f i c u l t i e s . However, where there i s no p a r t n e r a v a i l a b l e , the u n i s e x u a l group provides a s e t t i n g f o r t h e r a p e u t i c i n t e r v e n t i o n . Group I n t e r v e n t i o n : Couples Given the above mentioned d i f f i c u l t i e s of the u n i s e x u a l group, the recent development of couples' groups i n the treatment of sexual d y s f u n c t i o n merits s p e c i a l a t t e n t i o n . Although the s p e c i f i c d e t a i l s v a r y , treatment components g e n e r a l l y i n c l u d e i n f o r m a t i o n about s e x u a l i t y , r e l a x a t i o n techniques, communication s k i l l s , s p e c i f i c sexual technique t r a i n i n g and i n s t r u c t i o n s f o r maintenance. T h i s i n f o r m a t i o n 26 i s communicated through books, f i l m s , l e c t u r e s and group d i s c u s s i o n . Although the m a j o r i t y of these s t u d i e s have at l e a s t ' a two month follow-up, g e n e r a l i z a t i o n of t h e i r r e s u l t s i s l i m i t e d by small samples and l a c k of any s o r t of c o n t r o l c o n d i t i o n . Hartmann and F i t h i a n (1972) i n d i s c u s s i n g t h e i r b i o -p s y c h o - s o c i a l approach, mention the use of group workshops l a s t i n g one to s i x days. Data or e l a b o r a t i o n of the program was not i n c l u d e d . M i l l e r (1973) used a m o d i f i e d Masters and Johnson (1970) approach to t r e a t two groups of f o u r couples each. The p r e s e n t i n g problems i n c l u d e d primary and secondary orgasmic d y s f u n c t i o n and premature e j a c u l a t i o n . T h i r t e e n f o u r hour s e s s i o n s were h e l d w i t h i n three and one-h a l f weeks. Assessment was through a q u e s t i o n n a i r e about the presence or absence of v a r i o u s sexual d y s f u n c t i o n , c u r r e n t sex p r a c t i c e s and d e t e r r e n t s to sexual a c t i v i t y . Of the s i x t e e n i n d i v i d u a l s only two remained d y s f u n c t i o n a l at the s i x t y day follow-up. Although t h i s treatment outcome i s comparable to the r e s u l t s d e s c r i b e d by Masters and Johnson (1970), only a small sample was used and no c o n t r o l c o n d i t i o n was i n c l u d e d . McGovern, McMullen and L o P i c c o l o (1978) used a group format with four couples whose major complaints i n c l u d e d both premature e j a c u l a t i o n and primary inorgasmia. F i f t e e n three hour s e s s i o n s i n c l u d i n g warm-up e x e r c i s e s , r e l a x a t i o n t r a i n i n g , round t a b l e d i s c u s s i o n and b e h a v i o r a l r e h e a r s a l were g i v e n . The authors r e p o r t that at the end of treatment, a l l f o u r females were completely orgasmic by means of masturbation and that three of the f o u r males had succeeded i n i n c r e a s i n g t h e i r e j a c u l a t o r y l a t e n c y . At the s i x month follow-up assessment the Locke Wallace M a r i t a l Inventory (Locke and Wallace, 1959) showed an i n c r e a s e i n m a r i t a l s a t i s f a c t i o n , but some b e h a v i o r a l r e g r e s s i o n was noted. The authors suggest t h a t t h i s r e g r e s s i o n may be due to the withdrawal of support and encouragement experienced i n the group s e t t i n g . They f u r t h e r suggest t h a t the couples' changes i n a t t i t u d e s and behavior may have been a f f e c t e d more by the group involvement than by an improved dyadic r e l a t i o n s h i While t h i s may be the case, t h e i r f i n d i n g appears to argue more f o r programmed maintenance s t r a t e g i e s than f o r d e t r i m e n t a l e f f e c t s of group therapy. . Leiblum and Rosen (1979) u t i l i z e d a group format to conduct two weekend workshops f o r f i f t e e n d i v e r s e l y d y s f u n c t i o n a l c ouples. E i g h t couples p a r t i c i p a t e d i n the f i r s t workshop and seven p a r t i c i p a t e d i n the second. Each workshop i n c l u d e d sex r e - e d u c a t i o n , couple communication, a t t i t u d e change and the i n t r o d u c t i o n of s p e c i f i c s k i l l s aimed towards a m e l i o r a t i o n of s p e c i f i c d y s f u n c t i o n s . As treatment was only a v a i l a b l e f o r two days, a strong s e l f - h e l p component was i n t e g r a t e d i n t o the workshop. Pretreatment instruments i n c l u d e d the Lock Wallace Scale of M a r i t a l Adjustment (Locke and Wallace, 1959), the Sexual I n t e r a c t i o n Inventory ( L o P i c c o l o and Steger, 1974) and the Sexual 28 Assessment Inventory (Leiblum, 1973). The Sexual I n t e r a c t i o n Inventory and the Locke Wallace were both r e a d m i n i s t e r e d at the two month follow-up and the l a t t e r only at three months post-treatment. The r e s u l t s suggested t h a t the workshop format was s u c c e s s f u l i n i n c r e a s i n g m a r i t a l communication, s a t i s f a c t i o n with the r e l a t i o n s h i p and sexual i n t e r a c t i o n . Couples e x p e r i e n c i n g l o n g - s t a n d i n g sexual d y s f u n c t i o n , however, r e p o r t e d no improvement as a r e s u l t of group p a r t i c i p a t i o n and i n f o r m a t i o n on s e l f - h e l p methods. Given t h i s r e s u l t the authors suggest that group treatment on a continuous b a s i s would be the treatment of choice f o r those couples r e p o r t i n g long s t a n d i n g , s p e c i f i c sexual complaints. C l e a r l y , i d e n t i f i c a t i o n of those couples who would b e n e f i t from t h i s type of b r i e f i n t e r v e n t i o n would maximize t h e r a p e u t i c a c c e s s . Leiblum, Rosen and P e i r c e (1976) were concerned both w i t h the outcome and the s u b j e c t composition of group therapy. Six heterogeneous couples were seen f o r twelve weekly two hour s e s s i o n s . The s e s s i o n s focussed on education, a t t i t u d e change, communication and s k i l l s t r a i n i n g . Assessment techniques i n c l u d e d the Locke Wallace M a r i t a l Adjustment Scale (Locke and Wallace, 1959) and the Sexual I n t e r a c t i o n Inventory ( L o P i c c o l o and Steger, 1974) both of which were administered at the beginning and end of treatment. Although a s i x week follow-up was conducted, these q u e s t i o n n a i r e s were not r e a d m i n i s t e r e d . In a d d i t i o n to s i g n i f i c a n t improvements i n both the aforementioned 29 measures, f i v e of the s i x couples a l s o r e p o r t e d s i g n i f i c a n t a t t i t u d e change, i n c r e a s e d f a m i l i a r i t y with sexual techniques and i n c r e a s e d sexual knowledge. Although no c o n t r o l group was i n c l u d e d , the authors f e l t t h a t the s i g n i f i c a n t r e s u l t s warranted f u r t h e r i n v e s t i g a t i o n i n t o heterogeneous group composition. The only study found which attempts to compare i n d i v i d u a l and group sex therapy with c o u p l e s , was done by Golden, P r i c e , H e i n r i c h and L o b i t z (1978). Of seventeen^ couples complaining of both premature e j a c u l a t i o n and secondary orgasmic d y s f u n c t i o n , eleven were assigned to group s e s s i o n s and s i x to i n d i v i d u a l therapy. Couples were seen once a week f o r twelve weeks. As i n other s t u d i e s d i s c u s s e d p r e v i o u s l y , s k i l l s , t r a i n i n g , communication, i n f o r m a t i o n and homework assignments were the major treatment components. The Sexual I n t e r a c t i o n Inventory ( L o P i c c o l o and Steger, 1974), a background i n f o r m a t i o n q u e s t i o n n a i r e and the Goals f o r Sexual Therapy ( P r i c e and H e i n r i c h , 1975) were admin i s t e r e d at i n t a k e . The Sexual I n t e r a c t i o n Inventory and the Locke Wallace M a r i t a l Adjustment Scale were r e -administered at treatment t e r m i n a t i o n and at the two month follow-up. R e s u l t s i n d i c a t e s i g n i f i c a n t improvement i n c l i e n t s r e c e i v i n g both forms of treatment, with group treatment showing a n o n s i g n i f i c a n t tendency to be more e f f e c t i v e . U n f o r t u n a t e l y , the f i n d i n g s of t h i s study are l i m i t e d by the small sample and l a c k of c o n t r o l c o n d i t i o n . 30 In reviewing the e x i s t i n g l i t e r a t u r e on the a p p l i c a t i o n of group techniques to sexual d y s f u n c t i o n s , s e v e r a l i s s u e s become apparent. Given the e d u c a t i o n a l , s k i l l t r a i n i n g , communication b u i l d i n g nature of the promising, new, short-term sex t h e r a p i e s , t h e i r use i n group form would appear to maximize treatment a v a i l a b i l i t y without j e o p a r d i z i n g treatment e f f e c t i v e n e s s . Even though, as has been mentioned r e p e a t e d l y , s t u d i e s i n the area s u f f e r severe methodological d e f i c i e n c i e s such as l a c k of c o n t r o l , small samples and r e l i a n c e upon v e r b a l r e p o r t s ( S o t i l e and Kilmann, 1977) the m a j o r i t y suggest the value of the group approach. Only two s t u d i e s have compared group and i n d i v i d u a l therapy and i n both cases there was a n o n - s i g n i f i c a n t tendency f o r the group treatment to be more e f f e c t i v e (Nemetz et a l . , 1978; Golden et a l . , 1978). The elements i n group therapy which are thought to c o n t r i b u t e to i t s e f f e c t i v e n e s s i n c l u d e : support and encouragement from peers (Leiblum et a l . , 1976); atmosphere conducive to communication (Golden et a l . , 1978); modeling e f f e c t s (McGovern et a l . , 1978); and a b i l i t y to share other couples' coping s t r a t e g i e s (Nemetz and C a i r d , 1978). Although the i s s u e of group composition has not been examined s y s t e m a t i c a l l y , i t i s g e n e r a l l y recommended that both p a r t n e r s should be a c t i v e l y i n v o l v e d i n therapy wherever p o s s i b l e (Masters and Johnson, 1970; Leiblum and E r s n e r - H e r s h f i e l d , 1977). The d e s i r a b i l i t y of d i a g n o s t i c h e t e r o g e n e i t y or homogeneity has r e c e i v e d some a t t e n t i o n . 31 R e s u l t s suggest that mixed group format can be used e f f e c t i v e l y e s p e c i a l l y f o r the purpose of broadening sexual i n f o r m a t i o n and r e d u c i n g the tendency f o r couple competition that may occur i n homogeneous groups (Leiblum, Rosen and P e i r c e , 1976). Purpose of the Present Study Examination of the a v a i l a b l e l i t e r a t u r e on sex therapy r e v e a l s three important t r e n d s . F i r s t , i t i s g e n e r a l l y recommended t h a t both members of the dyad be i n v o l v e d i n therapy (Masters and Johnson, 1970; Leiblum and E r s n e r -H e r s h f i e l d , 1977). Second, the new broad band t h e r a p i e s which i n c o r p o r a t e a wide range of coping s k i l l s a p p l i c a b l e to a m a j o r i t y of c u r r e n t and p o t e n t i a l sexual d y s f u n c t i o n s i n c r e a s e the l i k e l i h o o d of e f f e c t i v e treatment d e s p i t e the continued use of the imprecise d i a g n o s t i c c l a s s i f i c a t i o n of sexual d y s f u n c t i o n s . T h i r d , the use of group format reduces c o s t and i n c r e a s e s the a v a i l a b i l i t y of treatment. The purpose of the present study i s to evaluate a broad band, short term therapy i n i t s a p p l i c a t i o n to both i n d i v i d u a l couples and groups of couples, while a v o i d i n g the methodological flaws which have c h a r a c t e r i z e d previous r e s e a r c h i n the area ( S o t i l e and Kilmann, 1977). I t was not the i n t e n t , nor would i t seem a p p r o p r i a t e at t h i s p o i n t i n the development of the area ( L o P i c c o l o , 1978) to evaluate the c o n t r i b u t i o n of i n d i v i d u a l treatment components. Rather the p r i n c i p a l o b j e c t i v e i s to examine the e f f i c a c y of the 32 program as a whole. The second objective i s to compare individual couple and group couple format. Although i t i s hypothesized that the experimental conditions w i l l result i n s i g n i f i c a n t l y greater improvement on a l l measures than the control condition, no prediction i s made regarding the r e l a t i v e e f f i c a c y of group as opposed to individual intervention. METHOD Subjects The subjects were t h i r t y sexually dysfunctional couples referred to the Human Sexuality C l i n i c i n the Health Sciences Center Hospital at the University of B r i t i s h Columbia. Twenty of these had been referred to the c l i n i c by p s y c h i a t r i s t s , general practitioners or gynecologists. Eight couples had heard about the program through friends, and two other couples responded to a brochure about the program di s t r i b u t e d by the Continuing Education Department of the University of B r i t i s h Columbia. Each couple's s u i t a b i l i t y for admission to the program was assessed at a standardized i n i t i a l interview (see Appendix I ) . Admission to the program was contingent on the presence of dysfunction defined as "cognitive, a f f e c t i v e and/or behavioral problems that prevent an ind i v i d u a l or couple from engaging i n and/or enjoying sat i s f a c t o r y intercourse and orgasm" (Hogan, 1978, p.58). Disqualifying factors included: lack of a steady and co-operative sexual 33 p a r t n e r ; r e c e n t d i a g n o s i s of a m e d i c a l c o n d i t i o n which w o u l d ' i m p a i r s e x u a l f u n c t i o n i n g ; presence of p s y c h o t i c symptomatology; presence of a severe m a r i t a l problem which would p r e c l u d e c o n j o i n t therapy.; presence of an a d d i c t i v e b e h a v i o r which would j e o p a r d i z e e f f e c t i v e i n t e r v e n t i o n ; and l a c k of commitment t o e i t h e r the partner, or the t h e r a -p e u t i c p r o c e s s . Nine c o u p l e s were d i s q u a l i f i e d from t r e a t m e n t on the b a s i s of the above c r i t e r i a . These c o u p l e s were s u b s e q u e n t l y r e f e r r e d t o the B e h a v i o r Therapy U n i t of S t . P a u l ' s H o s p i t a l , Vancouver, B.C. Of the q u a l i f y i n g s u b j e c t s , twenty-two c o u p l e s had one i d e n t i f i e d d y s f u n c t i o n a l p a r t n e r and i n e i g h t c o u p l e s b o t h p a r t n e r s r e p o r t e d d y s f u n c t i o n s . The sample c o n s i s t e d of t e n p r i m a r y i n o r g a s m i c and f i f t e e n secondary i n o r g a s m i c females and n i n e premature e j a c u l a t o r s . In a d d i t i o n , two females and two males were s e x u a l l y i n a c t i v e . The s u b j e c t s ranged i n age from e i g h t e e n t o f i f t y - s e v e n (X = 3 3 . 6 , SD = 5 .6 ) . T w e n t y - f i v e of the c o u p l e s were m a r r i e d and f i v e c o h a b i t i n g . The d u r a t i o n of the r e l a t i o n s h i p ranged from .3 t o t h i r t y - f i v e y e a r s (X = 8 .6 , SD = 4 . 3 ) . D e s i g n A combined b e t w e e n / w i t h i n s u b j e c t s d e s i g n was employed i n which c o u p l e s , who were a s s i g n e d t o t h r e e d i f f e r e n t groups were r e p e a t e d l y a s s e s s e d b e f o r e , d u r i n g and a f t e r t r e a t m e n t . Twelve c o u p l e s were o r i g i n a l l y a s s i g n e d t o the i n d i v i d u a l group t r e a t m e n t c o n d i t i o n ; two groups of s i x c o u p l e s each comprised the group c o u p l e c o n d i t i o n and s i x 34 couples were assigned.to the c o n t r o l c o n d i t i o n . Random assignment to the three experimental c o n d i t i o n s was c a r r i e d out with the exc e p t i o n of two couples. As Golden et a l . , (1978) p o i n t s out, e t h i c a l c o n s i d e r a t i o n s demand a departure from random assignment when couples enter therapy over an extended p e r i o d of time. The exception was made i n the present study when fo u r couples had been w a i t i n g f o r over nine weeks f o r the formation of a group. Because of t h i s long d e l a y , the next two couples were s p e c i f i c a l l y assigned to group treatment. Dependent V a r i a b l e s The Sexual Behavior Inventory was designed by the author and c o l l e a g u e s (Nemetz, C r a i g and R e i t h , 1978) to measure s p e c i f i c sexual behaviors (see Appendix I I ) . This instrument r e q u i r e s both p a r t n e r s to r e c o r d the d a i l y frequency of f o u r t e e n separate sexual b e h a v i o r s . A l l items were o p e r a t i o n a l l y d e f i n e d f o r the couple at the i n i t i a l i n t e r v i e w . A l l s u b j e c t s were asked to complete t h i s measure f o r two weeks p r i o r to treatment, d u r i n g the f i v e weeks of treatment and f o r three weeks a f t e r treatment. During each week of treatment and follow-up records were c o l l e c t e d and examined to ensure that s u b j e c t s were completing them c o r r e c t l y . The Sexual S a t i s f a c t i o n Index (Nemetz and C a i r d , 1978) c o n s i s t s of twenty-two statements about v a r i o u s aspects of both s e x u a l i t y and communication (see Appendix I I I ) . Subjects were asked to r a t e these statements on a zero to s i x 35 s c a l e w i t h zero being e n t i r e l y d i s s a t i s f i e d with the subject of the statement and s i x being extremely s a t i s f i e d . T h i s s c a l e was designed to assess the p o t e n t i a l e f f e c t s of sexual d y s f u n c t i o n not only on couples' sexual behavior and r e l a t i o n s h i p , but a l s o on the i n d i v i d u a l p a r t n e r s p e r c e p t i o n of h i s or her own s e x u a l i t y . This q u e s t i o n n a i r e was completed independently by. both p a r t n e r s at the i n i t i a l i n t e r v i e w , at the f i r s t and l a s t treatment s e s s i o n and at the three week and three month fo l l o w - u p s , again with responses being monitored to ensure that the su b j e c t s were complying with i n s t r u c t i o n s . Responses from eighty-one people, i n c l u d i n g both the s u b j e c t s i n the present study and pr e v i o u s c l i e n t s at the Human S e x u a l i t y C l i n i c were analyzed to evaluate the i n t e r n a l c o n s i s t e n c y of t h i s measure. When the Sexual S a t i s f a c t i o n . Inventory was d i v i d e d i n t o c o n c e p t u a l l y i n t e r -r e l a t e d s u b t e s t s , no subtest r e c e i v e d an alpha or Hoyt c o e f f i c i e n t of l e s s than .73 (see Table 1 ) . The Sexual A r o u s a l Inventory (Hoon, Hoon and Wincze, 1976) (see Appendix IV) c o n s i s t s of twenty-eight statements d e s c r i b i n g p o t e n t i a l l y a r o u s i n g s i t u a t i o n s . The su b j e c t s were asked to r a t e each s i t u a t i o n on a s c a l e from -1 i n d i c a t i n g a d v e r s e l y e f f e c t s a r o u s a l through to +5 i n d i c a t i n g always causes a r o u s a l . The s c a l e has been u t i l i z e d i n previous r e s e a r c h (Hoon et a l . , 1976) with good t e s t - r e t e s t r e l i a b i l i t y and h i g h concurrent v a l i d i t y . 36 P r o c e d u r e Telephone c o n t a c t was made w i t h a l l p r o s p e c t i v e s u b j e c t s t o a r r a n g e a time f o r the i n i t i a l i n t e r v i e w . The o n l y i n f o r m a t i o n g a t h e r e d a t t h i s p o i n t was the a v a i l a b i l i t y of a p a r t n e r and w i l l i n g n e s s t o arrange an i n i t i a l appointment. No q u e s t i o n s c o n c e r n i n g the program were answered over the t e l e p h o n e . I t was e x p l a i n e d t o the c l i e n t s t h a t b o t h the d e t a i l s o f t h e i r problems and the t h e r a p e u t i c s t r a t e g y would b e s t be d i s c u s s e d i n the presence o f b o t h p a r t n e r s at the i n i t i a l i n t e r v i e w . The s u b j e c t was a s s u r e d however, t h a t the c o u p l e ' s presence a t the i n t e r v i e w i n no way committed them t o a c c e p t t h e r a p y . The i n i t i a l i n t e r v i e w , conducted by b o t h t h e r a p i s t s , was s t a n d a r d i z e d (see Appendix I ) and l a s t e d a p p r o x i m a t e l y one hour. At t h i s time d e t a i l e d s e x u a l h i s t o r i e s were t a k e n ; s u i t a b i l i t y f o r t r e a t m e n t was a s s e s s e d ; and the d e t a i l s o f the program were e x p l a i n e d . I f the c o u p l e f a i l e d t o meet t h e s e l e c t i o n c r i t e r i a , a l t e r n a t e s o u r c e s of t h e r a p e u t i c i n t e r v e n t i o n were suggested. I f the c l i e n t s were s u i t a b l e f o r the program they were a d v i s e d t h a t t h e r a p y was o f f e r e d i n b o t h group and i n d i v i d u a l c o u p l e s e t t i n g s and t h a t t h e y would be i n f o r m e d as soon as a p o s i t i o n i n e i t h e r format became a v a i l a b l e . Couples were c l e a r l y i n f o r m e d t h a t t h e y were f r e e t o d e c l i n e assignment t o the group t r e a t m e n t c o n d i t i o n w i t h o u t j e o p a r d i z i n g t h e i r o p p o r t u n i t y t o r e c e i v e i n d i v i d u a l 37 t r e a t m e n t . No c o u p l e s r e f u s e d the group t r e a t m e n t assignment. In the case of c o n t r o l c l i e n t s , c o u p l e s were a d v i s e d t h a t t h e r a p y would not be a v a i l a b l e f o r t e n weeks due t o a sh o r t a g e o f t h e r a p i s t s . A l l o f these s u b j e c t s v o l u n t e e r e d t o p a r t i c i p a t e i n p r e - t r e a t m e n t i n v e s t i g a t i o n s which i n c l u d e d c o m p l e t i n g the Sexual S a t i s f a c t i o n Index, the S e x u a l B e h a v i o r I n v e n t o r y and the S e x u a l A r o u s a l I n v e n t o r y a t the same i n t e r v a l s as those c u r r e n t l y r e c e i v i n g t h e r a p y . S u b j e c t s who were s e l e c t e d f o r the st u d y were r e g i s t e r e d as o u t p a t i e n t s o f the H e a l t h S c i e n c e s Center H o s p i t a l P s y c h o l o g y U n i t and, t h e r e f o r e , p a i d one d o l l a r p e r s e s s i o n . In o r d e r t o ensure i n f o r m e d c o n s e n t , c o u p l e s were c l e a r l y and r e p e a t e d l y a d v i s e d o f the uses of t h e i r d a t a and t h e i r r i g h t t o withdraw from t h e r a p y (see Informed Consent Form, Appendix V ) . A f t e r s i g n i n g the consent form, t h e y were asked t o complete the S e x u a l A r o u s a l I n v e n t o r y and the S e x u a l S a t i s f a c t i o n Index. They were a l s o i n s t r u c t e d t o m o n i t o r t h e i r s e x u a l a c t i v i t i e s u s i n g the S e x u a l B e h a v i o r I n v e n t o r y f o r the f o l l o w i n g two weeks. Due t o the s p o r a d i c r e f e r r a l r a t e , the i n t e r v a l from the end o f the s e l f -m o n i t o r i n g p e r i o d t o the b e g i n n i n g o f t r e a t m e n t was not f i x e d , but averaged a p p r o x i m a t e l y t h r e e weeks. There were s i x weekly t r e a t m e n t s e s s i o n s l a s t i n g a p p r o x i m a t e l y two hours each. The s t r u c t u r e of a l l s e s s i o n s was the same. For the f i r s t hour of each s e s s i o n the f e m a l e ( s ) were w i t h the female t h e r a p i s t and the m a l e ( s ) were 38 with the male t h e r a p i s t . For the second hour p a r t n e r s were •k together with the two t h e r a p i s t s . The procedure o u t l i n e d below (and d e s c r i b e d i n d e t a i l i n Appendix I) was the same f o r both group and i n d i v i d u a l c o n d i t i o n s . Session 1: The f i r s t s e s s i o n was devoted to making the subj e c t s f e e l as comfortable as p o s s i b l e i n the new s i t u a t i o n and i n c l u d e d d i s c u s s i o n of t h e i r p r e s e n t i n g problems i n d e t a i l and an o u t l i n e of the program. Subjects were a l s o given a w r i t t e n o u t l i n e of the program (Appendix V I ) , a t e n s i o n management pamphlet (Appendix.VII) and a re a d i n g l i s t (Appendix V I I I ) . During the second h a l f of the s e s s i o n the cou p l e ( s ) saw a f i l m e n t i t l e d Human Sexual Response (Szasz, 1974) and were given the r a t i o n a l e f o r r e f r a i n i n g from i n t e r c o u r s e f o r four weeks. They were i n s t r u c t e d about the use of the r e l a x a t i o n e x e r c i s e s (modified from B e r n s t e i n and Borkovec, 1973) and were given the Sexual S a t i s f a c t i o n Index and the Sexual Ar o u s a l Inventory to complete f o r the second time. Homework f o r t h i s s e s s i o n i n c l u d e d : p r a c t i c e of the r e l a x a t i o n e x e r c i s e s at l e a s t once a day; readi n g and d i s c u s s i n g the f i r s t three chapters of Our Bodies.Ourselves (Boston Women's Heal t h C o l l e c t i v e , 1971) and i n c r e a s i n g non-sexual p h y s i c a l contact such as hugging, k i s s i n g and massage. *Both t h e r a p i s t s are members of the B r i t i s h Columbia P s y c h o l o g i c a l A s s o c i a t i o n 39 Sess i o n 2: During the second s e s s i o n , the t o p i c of masturbation f o r both males and females was reviewed. In the f i r s t h a l f of the s e s s i o n , a t t i t u d e s towards and experiences with masturbation were d i s c u s s e d by both the male and female subgroups. The f i l m shown d u r i n g the second h a l f of the s e s s i o n , The S e x o l o g i c a l Examination (Sutton, 1973), p o r t r a y e d a systematized method of g i v i n g feedback to the pa r t n e r r e g a r d i n g the s u b j e c t i v e e f f e c t s of sexual s t i m u l a t i o n . D i s c u s s i o n i n c l u d e d masturbation f o r both sexes, progress made i n response to the r e l a x a t i o n e x e r c i s e s and compliance with the request f o r i n c r e a s e d non-sexual p h y s i c a l c o n t a c t s . Homework i n c l u d e d : attempting the S e x o l o g i c a l Examination at l e a s t twice ( i n s t r u c t i o n s f o r couples who a n t i c i p a t e d d i f f i c u l t y with t h i s e x e r c i s e are contained i n Appendix I ) ; c o n t i n u i n g the r e l a x a t i o n e x e r c i s e s ; and j o i n t l y r e a d i n g chapters one through three of For Y o u r s e l f (Barbach, 1975). Females were i n s t r u c t e d to explore t h e i r g e n i t a l s v i s u a l l y and to l i s t the p o s i t i v e / n e g a tive aspects of t h e i r b o dies. Males were i n s t r u c t e d to monitor the frequency of masturbation and to r e c o r d t h e i r p o s i t i v e and negative a t t i t u d e s to t h i s a c t i v i t y . Session 3: During the t h i r d s e s s i o n , women were encouraged, when at home, to look f o r s e n s i t i v e areas of t h e i r bodies that produced f e e l i n g s of p l e a s u r e . They were a l s o i n s t r u c t e d 40 to attempt masturbation. The male s e s s i o n focussed p r i m a r i l y on the value of f o r e p l a y as an e s s e n t i a l pre-r e q u i s i t e to communication and sexual s a t i s f a c t i o n . The f i l m s shown were Women on Orgasm ( B r e i t r o s e , 1973) and Handvoice (Sutton, 1970). D i s c u s s i o n d u r i n g t h i s p o r t i o n of the s e s s i o n focussed on the importance o f f o r e p l a y , feedback from the S e x o l o g i c a l Examination and the i n t r o d u c t i o n of v a r i o u s p r e c o i t a l behavior. The importance of the female communicating her f i n d i n g s r e g a r d i n g p l e a s u r a b l e areas d i s c o v e r e d d u r i n g the masturbation e x e r c i s e s and the S e x o l o g i c a l Examination was a l s o s t r e s s e d . Homework i n c l u d e d c o n t i n u a t i o n of the S e x o l o g i c a l Examination, d i s c u s s i o n of p r e f e r r e d modes of f o r e p l a y and d i s c u s s i o n of the remaining chapters of For Y o u r s e l f (Barbach, 1975). Se s s i o n 4: During the f o u r t h s e s s i o n women were again encouraged t set time aside f o r themselves to c a r r y out the homework assignments as t h i s problem was f r e q u e n t l y o f f e r e d as an " e x p l a n a t i o n " f o r f a i l u r e to comply with the treatment suggestions given i n Sessions 2 and 3. When necessary, i n s t r u c t i o n s were given f o r s e l f - m o n i t o r i n g the exact number of hours a week they devoted to themselves. The types and uses of a v i b r a t o r were d i s c u s s e d both f o r those women r e p o r t i n g d i f f i c u l t y with masturbation and f o r those i n d i c a t i n g t h at they wished to enhance t h e i r sexual response The value of e r o t i c f a n t a s y i n both masturbation and 41 i n t e r c o u r s e was a l s o d i s c u s s e d . The focus of the male s e s s i o n was d e f i n i t i o n and e x p l a n a t i o n of probable e t i o l o g i e s of premature e j a c u l a t i o n . During the second h a l f of the s e s s i o n , the b a s i c p r i n c i p l e s of the Semans' (1956) and Masters and Johnson's (1970) squeeze techniques were d i s c u s s e d and the f i l m S e x u a l i t y and Communication (Chernik and Chernick, 1975) was shown. Communication s t r a t e g i e s were a l s o d i s c u s s e d and s p e c i f i c examples of problematic communication were e l i c i t e d and c l e a r s t r a t e g i e s f o r a c c e p t i n g or r e j e c t i n g sexual o v e r t u r e s were r o l e -p l a y e d . The r e i n t r o d u c t i o n of i n t e r c o u r s e was d i s c u s s e d and couples were advised to u t i l i z e a l l the coping and communication s k i l l s they had p r e v i o u s l y been p r a c t i c i n g . Homework i n c l u d e d the p r e p a r a t i o n of a l i s t c i t i n g at l e a s t three i n s t a n c e s where communication, sexual or g e n e r a l , broke down or became d i f f i c u l t and a r e a d i n g assignment (My Secret Garden, F r i d a y , 1973) which was to be read and d i s c u s s e d by both p a r t n e r s . S e s s i o n 5: During the f i f t h s e s s i o n , the females d i s c u s s e d both c o n t r a c e p t i o n methods and v a g i n a l d i s o r d e r s and t h e i r e f f e c t s on a r o u s a l . In a d d i t i o n , communication s k i l l s were p r a c t i c e d i n areas where women expressed common d i f f i c u l t i e s . The major focus of the male s e s s i o n was a l s o on e f f e c t i v e communication with s p e c i a l emphasis p l a c e d on areas where the men r e p o r t e d the g r e a t e s t d i f f i c u l t y . In both 42 s i t u a t i o n s r o l e - p l a y i n g was u t i l i z e d when necessary. In the second h a l f of the s e s s i o n , the f i l m Squeeze Technique (Sutton, 1970) was shown. T h i s procedure was e x p l a i n e d at l e n g t h d u r i n g the d i s c u s s i o n p e r i o d and couples were i n s t r u c t e d t o t r y t h i s at l e a s t f o u r times d u r i n g the coming week. P o s i t i v e and negative r e s u l t s of r e -i n s t i t u t i n g i n t e r c o u r s e were a l s o d i s c u s s e d . Couples a l s o r o l e - p l a y e d t h e i r most problematic communications and a demonstration of more e f f e c t i v e s t r a t e g i e s was g i v e n . Couples were a l s o i n s t r u c t e d to p r a c t i c e t h e i r communication s k i l l s d u r i n g the coming week. Sessi o n 6: The o b j e c t i v e of the s i x t h s e s s i o n f o r both males and females was to prepare s u b j e c t s f o r t e r m i n a t i o n of therapy. S p e c i f i c a l l y , s u b j e c t s were asked to design t h e i r own maintenance program which was to i n c l u d e a d e s c r i p t i o n of problems the couple a n t i c i p a t e d i n the next three weeks and s t r a t e g i e s f o r coping with these problems. In a d d i t i o n , areas of p e r c e i v e d progress were to be noted and d i s c u s s e d over the three week p e r i o d . Feedback was e l i c i t e d from the s u b j e c t s about t h e i r impressions of the program and i t s u t i l i t y f o r t h e i r p a r t i c u l a r s i t u a t i o n . In the second h a l f of the s e s s i o n the q u e s t i o n n a i r e s were re a d m i n i s t e r e d (Sexual Arousal Inventory and Sexual S a t i s f a c t i o n Index), feedback from the couple as a u n i t about t h e i r experience i n the program was s o l i c i t e d and the importance of c o n t i n u a l 43 p r a c t i c e o f a l l s k i l l s l e a r n e d i n the program was s t r e s s e d . For homework, the c o u p l e s were i n s t r u c t e d t o r e v i e w s y s t e m a t i c a l l y each o t h e r ' s maintenance l i s t and d i s c u s s any p o i n t s of c o n t e n t i o n , t o c o n t i n u e m o n i t o r i n g t h e i r s e x u a l b e h a v i o r s by means of the Se x u a l B e h a v i o r I n v e n t o r y f o r the next t h r e e weeks and t o c a l l the t h e r a p i s t i f any problems arose.. No couple phoned the t h e r a p i s t s d u r i n g the f o l l o w - u p p e r i o d . At the t h r e e week f o l l o w - u p a l l c o u p l e s were seen i n d i v i d u a l l y . C u r r e n t p r o g r e s s , e x p e c t a t i o n s , problems and p l a n s f o r the ne x t t h r e e months were d i s c u s s e d . The S e x u a l A r o u s a l I n v e n t o r y and the Sexual S a t i s f a c t i o n Index were r e a d m i n i s t e r e d . S p e c i f i c c o n t e n t o f t h i s and the t h r e e month f o l l o w - u p was d i c t a t e d by the need of the i n d i v i d u a l c o u p l e . The S e x u a l A r o u s a l I n v e n t o r y and the S e x u a l S a t i s f a c t i o n Index were a g a i n r e a d m i n i s t e r e d a t the t h r e e month f o l l o w - u p . RESULTS The Se x u a l A r o u s a l I n v e n t o r y The S e x u a l A r o u s a l I n v e n t o r y was a d m i n i s t e r e d t o a l l s u b j e c t s a t the i n i t i a l i n t e r v i e w , the f i n a l t r e a t m e n t s e s s i o n and a t the t h r e e week and t h r e e month f o l l o w - u p s . A t o t a l s c o r e f o r each assessment was o b t a i n e d by s u b t r a c t i n g the sum o f the n e g a t i v e s c o r e s from the sum o f the p o s i t i v e s c o r e s , w i t h the h i g h e s t s c o r e s b e i n g a s s o c i a t e d w i t h h i g h e r l e v e l s o f s e x u a l a r o u s a l . The maximum p o s s i b l e s c o r e was one hundred and f o r t y . Means of each group f o r a l l assessment 4 4 p e r i o d s are presented i n F i g u r e 1 (see Appendix IX f o r a t a b l e of means and standard d e v i a t i o n s ) . Scores from both p a r t n e r s were averaged to y i e l d a combined couple score. The pretreatment scores of the groups on the Sexual Arousal Inventory were analyzed u s i n g a one-way ANOVA to a s c e r t a i n whether the groups were comparable i n i t i a l l y as random assignment to the treatment c o n d i t i o n s would i n d i c a t e . The assumption of equal treatment group means p r i o r to treatment on t h i s v a r i a b l e was supported (F(2,24) = .196, 2 >.05) (see Appendix IX). Data from the f i n a l treatment s e s s i o n and both follow-ups were analyzed s e p a r a t e l y u s i n g a one-way, f i x e d e f f e c t s ANCOVA with pretreatment scores s e r v i n g as the c o v a r i a t e . The r a t i o n a l e f o r u t i l i z i n g the c o v a r i a t e procedure was to i n c r e a s e the p r e c i s i o n of the experimental d e s i g n . Although both treatment groups i n c r e a s e d and the c o n t r o l group decreased i n terms of s e l f - r a t e d a r o u s a l by the time of the f i n a l s e s s i o n , the treatment e f f e c t was n o n - s i g n i f i c a n t (F(2 ,23) = 1.078, £ > . 0 5 ) (see Appendix IX). A n a l y s i s of the data from the three week follow-up, however, i n d i c a t e d a s i g n i f i c a n t treatment e f f e c t (F(2 ,23) = 3.456, p_<:.05) (see Appendix IX). Post hoc a n a l y s i s u s i n g the Tukey's St u d e n t i z e d Range Test (TSRT) i n d i c a t e d that the i n d i v i d u a l couple treatment c o n d i t i o n e x h i b i t e d s i g n i f i c a n t l y h i g h e r scores than the c o n t r o l c o n d i t i o n . 45 FIGURE 1 Mean Scores Over A d m i n i s t r a t i o n s For A l l S u b j e c t s On the Sexual A r o u s a l I n v e n t o r y Individual #—# Group A—A Control O — - O 46 A n a l y s i s of the data from the three month follow-up a l s o i n d i c a t e d a s i g n i f i c a n t treatment e f f e c t (F(2,23) = 5.593, £ < .05) (see Appendix IX). Post hoc a n a l y s i s i n d i c a t e d that both t r e a t e d groups r e p o r t e d s i g n i f i c a n t l y h i g h e r l e v e l s of sexual a r o u s a l than t h e i r c o n t r o l c o u n t e r p a r t s , but d i d not d i f f e r from each other. The Sexual S a t i s f a c t i o n Index The Sexual S a t i s f a c t i o n Index (SSI) was administered to a l l s u b j e c t s at the i n i t i a l i n t e r v i e w , the f i n a l treatment s e s s i o n , the three week and three month fol l o w - u p s . The twenty-two statements were grouped i n t o f i v e s ubtests a c c o r d i n g to the degree of conceptual s i m i l a r i t y of the items. The subtests and t h e i r Alpha or Hoyt c o e f f i c i e n t s are shown i n Table 1. Examination of the c o e f f i c i e n t s i n d i c a t e s a h i g h degree of i n t e r n a l c o n s i s t e n c y f o r each s u b t e s t . Group means f o r each subtest at each assessment are i n F i g u r e s two through s i x (see Appendix X f o r a t a b l e of means and standard d e v i a t i o n s ) . Again, scores from both p a r t n e r s were averaged to y i e l d a combined couple score. Pretreatment scores of the three groups on the subtests of the SSI were analyzed u s i n g a one-way MANOVA to assess whether the groups were comparable i n i t i a l l y on these v a r i a b l e s c o n s i s t e n t with random sub j e c t assignment to treatment c o n d i t i o n s . The a n a l y s i s i n d i c a t e d no s i g n i f i c a n t d i f f e r e n c e s (F(5,2,24) = .948, .05) (see Appendix X). 47 TABLE I Subtest Items and R e l i a b i l i t y C o e f f i c i e n t s Of the Sexual S a t i s f a c t i o n Index General S a t i s f a c t i o n (alpha=0.763) my r o l e i n our sexual r e l a t i o n s h i p my p a r t n e r ' s r o l e i n our sexual r e l a t i o n s h i p my l e v e l of s a t i s f a c t i o n with our sexual r e l a t i o n s h i p my p a r t n e r ' s l e v e l of s a t i s f a c t i o n with our sexual r e l a t i o n s h i p number of male sexual i n i t i a t i v e s number of female sexual i n i t i a t i v e s frequency of i n t e r c o u r s e d u r a t i o n of f o r e p l a y Communication S a t i s f a c t i o n (alpha=0.890) my a b i l i t y to communicate with my p a r t n e r my p a r t n e r ' s a b i l i t y to communicate with me my a b i l i t y to d i s c u s s sex with my p a r t n e r my p a r t n e r ' s a b i l i t y to d i s c u s s sex with me Orgasm S a t i s f a c t i o n (alpha=0.816) my a t t i t u d e towards masturbation my a b i l i t y to masturbate my a b i l i t y to achieve climax through i n t e r c o u r s e my a b i l i t y t o achieve climax through s e l f - m a s t u r b a t i o n my a b i l i t y to achieve climax through g e n i t a l m a n i p u l a t i o n by my p a r n t e r S e x u a l i t y S a t i s f a c t i o n (hoyt=0.830) my f e e l i n g s about my own s e x u a l i t y my f e e l i n g s about my body R e l a t i o n s h i p S a t i s f a c t i o n (hoyt=0.801) my l e v e l of s a t i s f a c t i o n with the r e l a t i o n s h i p i n general my p a r t n e r ' s l e v e l of s a t i s f a c t i o n with the r e l a t i o n s h i p i n gene r a l 48 Data from the f i n a l treatment s e s s i o n were analyzed u s i n g a one-way f i x e d e f f e c t s MANCOVA with the pretreatment scores s e r v i n g as.the c o v a r i a t e . An omnibus m u l t i v a r i a t e F was not c a l c u l a t e d as the h i g h degree of dependence between the dependent v a r i a b l e s and the c o v a r i a t e s f a i l e d to render the matrix p o s i t i v e d e f i n i t e . Instead a more c o n s e r v a t i v e procedure was u t i l i z e d whereby the a c t u a l number of s i g n i f i c a n t TSRTs f o r a l l subtests over a l l a d m i n i s t r a t i o n p e r i o d s was examined i n r e l a t i o n to the number that would be expected on the b a s i s of chance alone. The r e s u l t s were h i g h l y s i g n i f i c a n t (X = 37.213, p_ < .001) thus ensuring p r o t e c t i o n a g a i n s t a Type 1 e r r o r i n the subsequent an a l y s e s . U n i v a r i a t e ANCOVAS were performed on each of the subtes t s of the SSI i n t u r n , u s i n g the s i n g l e corresponding pretreatment measure as the c o v a r i a t e (see Appendix X). Thi s s t r a t e g y can be j u s t i f i e d as o v e r a l l s i g n i f i c a n c e with simultaneous Type 1 e r r o r p r o t e c t i o n had been a t t a i n e d f o r the treatment f a c t o r with the c h i square (Winer, 1971) and f u r t h e r probing was needed to a s c e r t a i n the locu s of the treatment group d i f f e r e n c e s . The u n i v a r i a t e analyses f o r a l l subtest scores obtained at the f i n a l s e s s i o n were s i g n i f i c a n t : general sexual s a t i s f a c t i o n (F(2,23) = 8.791, 2 < .005);communication s a t i s f a c t i o n (F(2,23) = 8.224, 2<-005); orgasm s a t i s f a c t i o n (F(2,23) = 11.091, 2 < - 0 0 1 ) ; s e x u a l i t y s a t i s f a c t i o n (F(2,23) = 12.166, .001) and r e l a t i o n s h i p s a t i s f a c t i o n (F(2,23) = 5.406, 2< -01). Moreover, i n each case TSRT analyses i n d i c a t e d t h a t the 4 9 c o n t r o l s u b j e c t s were s i g n i f i c a n t l y l e s s s a t i s f i e d than t h e i r treatment c o u n t e r p a r t s . There were no s i g n i f i c a n t d i f f e r e n c e s between the two treatment c o n d i t i o n s . S i m i l a r l y , u n i v a r i a t e ANCOVAS were performed on each of the subtests of the SSI at the three week and three month fol l o w - u p s . Analyses of the three week follow-up data on a l l subtests a l s o r e v e a l e d s i g n i f i c a n t treatment e f f e c t s : general sexual s a t i s f a c t i o n (F(2,23) = 8.841, £<i.005); communication s a t i s f a c t i o n (F(2,23) = 14.557, £ 4 .0001); orgasm s a t i s f a c t i o n (F(2,23) = 15.91, £ ^ . 0 0 0 5 ) ; s e x u a l i t y s a t i s f a c t i o n (F(2,23) = 10.57, £ c .0005) and r e l a t i o n s h i p s a t i s f a c t i o n (F(2,23) = 4.366, £ 4 . .05). Subsequent post hoc TSRT analyses r e v e a l e d that i n each case, s u b j e c t s i n the c o n t r o l c o n d i t i o n were s i g n i f i c a n t l y l e s s s a t i s f i e d on each v a r i a b l e than s u b j e c t s i n both treatment groups. There were no d i f f e r e n c e s between the two treatment c o n d i t i o n s . T h i s p a t t e r n of r e s u l t s , however, was not repeated i n the analyses of the three month f o l l o w -up data. U n i v a r i a t e ANCOVAS f o r fo u r of the f i v e subtests r e v e a l e d s i g n i f i c a n t treatment e f f e c t s ; general sexual s a t i s f a c t i o n (F(2,23) = 5.243, £ 4 . 0 2 ) ; communication s a t i s f a c t i o n (F(2,23) = 6.605, £ ^ . . 0 3 ) ; orgasm s a t i s f a c t i o n (F(2 ,23) = 4.573, £ ^ . 0 3 ) ; and s e x u a l i t y s a t i s f a c t i o n (F(2,23) = 4.954, £ 4 .03). Post hoc TSRT analyses f o r two of the s u b s c a l e s , general sexual s a t i s f a c t i o n and communication s a t i s f a c t i o n i n d i c a t e d s i g n i f i c a n t l y g r e a t e r 50 FIGURE 2 Mean Scores Over A d m i n i s t r a t i o n s F o r A l l S u b j e c t s on the "G e n e r a l S a t i s f a c t i o n " S u b s c a l e of the Sexual S a t i s f a c t i o n Index Individual Group Control A-O •A •o 30 § 20 <D a i i o 1 1 1 1 Pre Final 3 wk 3 mo session follow- follow-up up Administration Periods 51 FIGURE 3 Mean Scores Over A d m i n i s t r a t i o n s For A l l S u b j e c t s on the "Communication S a t i s f a c t i o n " S u b s c a l e of the Sexual S a t i s f a c t i o n Index • . • Individual # — . « Group A — — A Control o^—O 30 o20 a> a I 10J o o 1 1 1 1 Pre Final session 3 wk follow, up 3 mo follow-up Administration Periods 52 FIGURE 4 Mean Scores Over A d m i n i s t r a t i o n s For A l l S u b j e c t s on the "Orgasm S a t i s f a c t i o n " S u b s c a l e of the Sexual S a t i s f a c t i o n Index Individual %. Group A « Control o* •A •O 301-a 20 0) a o l i l Pre Final 3 wk 3 mo session follow- follow-up up Administration Periods 53 FIGURE 5 Mean Scores Over A d m i n i s t r a t i o n s For A l l S u b j e c t s on the " S e x u a l i t y S a t i s f a c t i o n " S u b s c a l e of the Se x u a l S a t i s f a c t i o n Index Individual < Group Am Control o-•A •o 30 r §20 a> a o 1 Pre Final 3 wk 3 mo session follow- follow-up up Administration Periods 54 FIGURE 6 Mean Scores Over Administrations For A l l Subjects on the "Relationship S a t i s f a c t i o n " Subscale of the Sexual S a t i s f a c t i o n Index Individual Group A-Control o •A •O 30 r o20 a ho I. Pre Final session 3 wk follow-up 1 3 mo follow, up Administration Periods 5-5 • s a t i s f a c t i o n among s u b j e c t s i n the tr e a t m e n t c o n d i t i o n s t h a n among s u b j e c t s i n the c o n t r o l c o n d i t i o n . The o n l y s i g n i f i c a n t d i f f e r e n c e s r e v e a l e d by po s t hoc a n a l y s e s of s e x u a l i t y s a t i s f a c t i o n and r e l a t i o n s h i p s a t i s f a c t i o n s u b s c a l e s , however, was between the group t r e a t m e n t c o n d i t i o n and the c o n t r o l c o n d i t i o n . A g a i n , as r e p o r t e d i n the p r e v i o u s a n a l y s e s , t h e r e were no s i g n i f i c a n t d i f f e r e n c e s between the two tr e a t m e n t c o n d i t i o n s . The S e x u a l B e h a v i o r I n v e n t o r y Both p a r t n e r s were i n s t r u c t e d t o complete the Se x u a l B e h a v i o r I n v e n t o r y (SBI) d a i l y f o r the two week p e r i o d p r i o r t o t r e a t m e n t , the f i v e weeks d u r i n g t r e a t m e n t and f o r the t h r e e weeks f o l l o w i n g t r e a t m e n t . Of the i n i t i a l f o u r t e e n i t e m s , f o u r were d i s c a r d e d because the s u b j e c t s complained t h a t they were too ambiguous d e s p i t e attempts t o make the b e h a v i o u r a l d e f i n i t i o n s e x p l i c i t . E x a m i n a t i o n of responses on these items c o n f i r m e d the s u b j e c t s ' c o n c e r n as t h e r e were g r o s s d i s c r e p a n c i e s i n r e p o r t f r e q u e n c i e s o f b e h a v i o r . See Appendix X I I f o r a d e t a i l e d c o r r e l a t i o n m a t r i x . The d i s c a r d e d items were, male s e e i n g female nude, female s e e i n g male nude, female i n i t i a t e d s e x u a l b e h a v i o r and male i n i t i a t e d s e x u a l b e h a v i o r . The r e m a i n i n g items were grouped i n terms of the sex of the a c t i v e p a r t i c i p a n t (see Table 2). Group means f o r each i t e m a t each assessment p e r i o d are p r e s e n t e d i n F i g u r e s seven t h r o u g h s i x t e e n (see Appendix XI f o r a t a b l e of group means and s t a n d a r d 56 TABLE 2 Breakdown of the S e x u a l B e h a v i o r I n v e n t o r y A c c o r d i n g t o the Sex o f the A c t i v e P a r t i c i p a n t Male Items n o n - s e x u a l massage se n s a t e f o c u s female b r e a s t s ( o r a l and manual touch) s e n s a t e f o c u s g e n i t a l s i n t e r c o u r s e Female Items n o n - s e x u a l massage se n s a t e f o c u s male g e n i t a l s orgasm t h r o u g h m a s t u r b a t i o n orgasm t h r o u g h f o r e p l a y i n t e r c o u r s e orgasm t h r o u g h i n t e r c o u r s e 57 d e v i a t i o n s ) . As the b e h a v i o r a l data were averaged over week p e r i o d s , i t seemed i n a p p r o p r i a t e to combine the f i v e weeks of treatment i n t o one score as one would expect marked progress over the f i v e week treatment p e r i o d . As such a d i v i s i o n was made between the i n i t i a l three weeks of treatment and the l a t t e r two weeks of treatment i n order to take i n t o c o n s i d e r a t i o n treatment p r o g r e s s . Analyses of Male Items by Males Weekly scores obtained p r i o r to treatment were averaged over the two week p e r i o d . The scores were then compared among the three groups by a one-way MANGVA to assess whether any s i g n i f i c a n t i n i t i a l between group i n e q u a l i t i e s e x i s t e d on these items d e s p i t e random subject assignment to experimental c o n d i t i o n s . The m u l t i v a r i a t e omnibus F i n d i c a t e d no s i g n i f i c a n t d i f f e r e n c e s (F(4,2,24) = 1.420, p_ ? .05) (see Appendix X I ) . Mean scores obtained d u r i n g the f i r s t three weeks of treatment were averaged and then analyzed u s i n g a one-way f i x e d e f f e c t s MANCOVA with the pretreatment scores s e r v i n g as the c o v a r i a t e . The frequency of i n t e r c o u r s e was omitted from t h i s a n a l y s i s as the behavior was p r o h i b i t e d f o r the f i r s t f o u r treatment s e s s i o n s . An omnibus m u l t i v a r i a t e F was not c a l c u l a t e d as the h i g h degree of dependence between the dependent v a r i a b l e s and the c o v a r i a t e s f a i l e d to render the matrix p o s i t i v e d e f i n i t e . Instead a more c o n s e r v a t i v e procedure was u t i l i z e d whereby the a c t u a l number of 5.8. s i g n i f i c a n t TSRTs f o r a l l b e h a v i o u r a l data over a l l a d m i n i s t r a t i o n p e r i o d s was examined i n r e l a t i o n to the number that would be expected on the b a s i s of chance alone. 2 The r e s u l t s were h i g h l y s i g n i f i c a n t (X = 24.076, £ * .001) thus e n s u r i n g p r o t e c t i o n a g a i n s t a Type 1 e r r o r i n the subsequent a n a l y s e s . U n i v a r i a t e ANCOVAS were then performed on each of the male items of the SBI f o r each assessment p e r i o d , u s i n g the s i n g l e corresponding pretreatment measure as the c o v a r i a t e (see Appendix X I ) . Of a l l the u n i v a r i a t e analyses performed on the averaged data from the f i r s t three weeks of treatment only non-sexual massage by males was s i g n i f i c a n t (F(2,23) = 11.202, £ 4 . 0 0 1 ) . R e s u l t s of the TSRT a n a l y s i s i n d i c a t e d that s e l f - r e p o r t e d non-sexual massage was s i g n i f i c a n t l y g r e a t e r among males i n the i n d i v i d u a l treatment c o n d i t i o n than i n e i t h e r the group or c o n t r o l c o n d i t i o n s . Of a l l the u n i v a r i a t e analyses performed on the averaged.data from the l a s t two weeks of treatment ( i n c l u d i n g frequency of i n t e r c o u r s e ) only sensate f o c u s - b r e a s t area was s i g n i f i c a n t (F(2,23) = 4.450, £ < .05). R e s u l t s of the TSRT r e v e a l e d that male s u b j e c t s i n the two treatment c o n d i t i o n s r e p o r t e d g i v i n g s i g n i f i c a n t l y more o r a l and manual bre a s t s t i m u l a t i o n to t h e i r p a r t n e r s than d i d t h e i r c o n t r o l c o u n t e r p a r t s . No d i f f e r e n c e s were evidenced between the two treatment c o n d i t i o n s . Of the f o u r u n i v a r i a t e ANCOVAS performed on the averaged data from 59 FIGURE 7 Mean Scores Over Administrations For Male Subjects on "Non-Sexual Massage" Item of the Sexual Behavior Inventory | n d ; v | d u a | # Group A Control O Administration Periods 60 FIGURE 8 Mean Scores Over A d m i n i s t r a t i o n s For Male S u b j e c t s on "Sensate Focus Female B r e a s t " Item o f the Sexu a l B e h a v i o r I n v e n t o r y . . i i ~ — individual • • Group A A Control O O Administration Periods 61 FIGURE 9 Mean Scores Over Administrations For Male Subjects on "Sensate Focus Female Genital" Item of The Sexual Behavior Individual • — • Inventory Group A A Control O O Administration Periods 62 < FIGURE 10 Mean Scores Over Administrations For Male Subjects on "Intercourse" Item of the Sexual Behavior Inventory Individual • — • Group A A Control O ^ — O Administration Periods 63 the three week follow-up only the item i n t e r c o u r s e was s i g n i f i c a n t (F(2,23) = 5.548, £ < .01). R e s u l t s of the TSRT i n d i c a t e t h a t s u b j e c t s i n both treatment c o n d i t i o n s r e p o r t e d a s i g n i f i c a n t l y higher frequency of i n t e r c o u r s e than d i d the c o n t r o l s u b j e c t s . No d i f f e r e n c e was evidenced between the i n d i v i d u a l and group s u b j e c t s . Analyses of Female Items by Female Scores obtained d u r i n g the two week pretreatment p e r i o d were averaged and then compared among the three groups by a one-way MANOVA to assess whether there were d i f f e r e n c e s on these v a r i a b l e s d e s p i t e random sub j e c t assignment to the experimental c o n d i t i o n s . The m u l t i v a r i a t e omnibus F r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s (F(2,23) = 1.563, £ > .05) (see Appendix XI) i n d i c a t i n g t h a t the groups were i n i t i a l l y comparable i n terms of the behaviors i n c l u d e d i n the SBI. Scores r e p o r t e d f o r the subsequent assessment p e r i o d s were averaged and u n i v a r i a t e ANCOVAS were performed on each item with the s i n g l e corresponding pretreatment measure being u t i l i z e d as the c o v a r i a t e (see Appendix X I ) . As i n the a n a l y s i s of the men's data, the items d e a l i n g with i n t e r c o u r s e were omitted from the f i r s t a n a l y s i s . The fou r analyses performed on the averaged data f o r the f i r s t three weeks of treatment, only sensate focus-male g e n i t a l s as s i g n i f i c a n t (F(2,23) = 3.831, £ ^ .05). R e s u l t s of the TSRT i n d i c a t e d t h at women i n the i n d i v i d u a l treatment 64 c o n d i t i o n r e p o r t e d s i g n i f i c a n t l y more touching of male g e n i t a l s than women i n the group c o n d i t i o n . The c o n t r o l s u b j e c t s d i d not d i f f e r s i g n i f i c a n t l y from e i t h e r of the treatment c o n d i t i o n s . Of the u n i v a r i a t e ANCOVAS performed on the averaged data f o r the l a s t two weeks of treatment, two items, sensate focus-male g e n i t a l s (F(2,23) = 6.914, 2< .01) and orgasm through masturbation (F(2,23) = 5.342, £ <.05) were s i g n i f i c a n t . R e s u l t s of the TSRT analyses r e v e a l e d t h a t women i n both treatment c o n d i t i o n s engaged i n s i g n i f i c a n t l y more male g e n i t a l sensate focus a c t i v i t i e s than d i d the c o n t r o l s u b j e c t s . With r e s p e c t to the second item, there was a l s o a s i g n i f i c a n t d i f f e r e n c e between the group and i n d i v i d u a l treatment s u b j e c t s with the group s u b j e c t s r e p o r t i n g s i g n i f i c a n t l y more orgasmic a c t i v i t y through masturbation. Of the u n i v a r i a t e analyses performed on the averaged data f o r the three week follow-up, two items, orgasm through f o r e p l a y (F(2,23) =5.347, £ < . 0 5 ) and i n t e r c o u r s e (F(2,23) = 8.77, £ <.01) were s i g n i f i c a n t . R e s u l t s of the TSRT analyses i n d i c a t e t hat at the three week follow-up women i n both treatment c o n d i t i o n s were e x p e r i e n c i n g a s i g n i f i c a n t l y h igher frequency of i n t e r c o u r s e and orgasm obtained through f o r e p l a y than t h e i r c o n t r o l c o u n t e r p a r t s . The two treatment groups, moreover, d i d not d i f f e r , s i g n i f i c a n t l y with r e s p e c t to e i t h e r of these b e h a v i o r s . With regard to the i n i t i a l d i a g n o s i s f o r the female p a r t n e r s i n the treatment c o n d i t i o n s , the b e h a v i o r a l data i n d i c a t e t hat f i v e of the seven p r i m a r i l y non-orgasmic females experience orgasm and 65 FIGURE 11 Mean Scores Over A d m i n i s t r a t i o n s F o r Female S u b j e c t s on "Non-Sexual Massage" Item of the Sex u a l B e h a v i o r I n v e n t o r y Individual • • Group A-Control O" •A •O 3r-c O <D a D O 6 i l l Pre First 3 wks of trt. Last 2 wks of trt. 3 wk follow-up Administration Periods 66 FIGURE 12 Mean Scores Over A d m i n i s t r a t i o n s F o r Female S u b j e c t s on "Sensate Focus Male G e n i t a l " Item of the S e x u a l B e h a v i o r I n v e n t o r y Individual • — • Group A " A Control O O 67 FIGURE 13 Mean Scores Over Administrations For Female Subjects on "Orgasm Through Masturbation" Item of the Sexual Behavior Inventoryinjjyijyai 9 . Group A-Control 0« 7 -6 -c J wks of wks of follow-trt. trt. up Administration Periods 68 FIGURE 14 Mean Scores Over A d m i n i s t r a t i o n s F o r Female S u b j e c t s On "Orgasm Through F o r e p l a y " Item o f the S e x u a l B e h a v i o r Inventor^ndjyjJuoi # * Group A — — A Control O O 7 -6 -"> 5 — Pre First 3 Last 2 3 wk wks of wks of follow-trt. trt. up Administration Periods FIGURE 15 Mean Scores Over A d m i n i s t r a t i o n s F o r Female S u b j e c t s on " I n t e r c o u r s e " Item Of The S e x u a l B e h a v i o r I n v e n t o r y Individual • • Group A A Control O — O Pre Last 2 3 wk wks of follow-trt. up Administration Periods 70 FIGURE 16 Mean Scores Over A d m i n i s t r a t i o n s F o r Female S u b j e c t s on "Orgasm Through I n t e r c o u r s e " Item of the Sexual B e h a v i o r I n v e n t o r y Individual • Group A Control O Last 2 wks of trt. Administration Periods 71 t h a t e i g h t o f the t w e l v e s e c o n d a r i l y i n o r g a s m i c females e x p e r i e n c e d orgasm t h r o u g h more than one form of s t i m u l a t i o n . DISCUSSION R e s u l t s from each o f the dependent measures w i l l be examined. These r e s u l t s w i l l t hen be d i s c u s s e d i n terms of t h e i r c o n t r i b u t i o n t o the c u r r e n t l i t e r a t u r e . F i n a l l y , i m p l i c a t i o n s f o r f u t u r e r e s e a r c h and c o n c l u s i o n s drawn from the p r e s e n t study w i l l be a d d r e s s e d . The S e x u a l A r o u s a l I n v e n t o r y (SAI) R e s u l t s from the SAI were c o n s i s t e n t w i t h e x p e c t a t i o n s , w i t h b o t h t r e a t m e n t groups showing a s i g n i f i c a n t l y h i g h e r l e v e l of r e p o r t e d a r o u s a l than the c o n t r o l c o n d i t i o n a t the t h r e e week and t h r e e month f o l l o w - u p s . As one would expect i n c r e a s e s i n s e x u a l a r o u s a l t o f o l l o w p o s i t i v e b e h a v i o r a l e x p e r i e n c e s , t h e n o n - s i g n i f i c a n t f i n d i n g s i m m e d i a t e l y p o s t - t r e a t m e n t were not unexpected. Indeed i t was assumed t h a t the c o n s o l i d a t i o n of the m u l t i - f a c e t e d c o p i n g s k i l l s l e a r n e d d u r i n g the t r e a t m e n t would o c c u r d u r i n g the f o l l o w - u p p e r i o d s . I n s p e c t i o n o f the group means at the t h r e e week and t h r e e month f o l l o w - u p p e r i o d s s u p p o r t s the above h y p o t h e s i s i n t h a t a t r e n d toward i n c r e a s e d d i f f e r e n t i a t i o n between the t r e a t m e n t and the c o n t r o l c o n d i t i o n s i s e v i d e n c e d . I n c r e a s e d exposure t o p o s i t i v e l y r e i n f o r c e d s e x u a l b e h a v i o r i n c o n j u n c t i o n w i t h r e d u c t i o n o f s e x u a l a n x i e t y may w e l l be r e s p o n s i b l e f o r the r e p o r t e d changes 72 i n the s u b j e c t s ' s e x u a l a r o u s a l . I n c o n t r a s t a t r e n d toward s u c c e s s i v e d e c r e a s e s i n s e x u a l a r o u s a l was e v i d e n c e d i n the c o n t r o l group over the same p e r i o d o f t i m e . As the c o n t r o l s u b j e c t s were asked t o m o n i t o r t h e i r s e x u a l a r o u s a l a t f o u r p o i n t s d u r i n g the t e n week p e r i o d , i t may be p o s s i b l e t o a t t r i b u t e the decrement i n r e p o r t e d a r o u s a l t o e i t h e r a s e n s i t i z a t i o n of the s u b j e c t s t o t h e i r own s e x u a l h a b i t s or t o an a c t u a l i n c r e a s e i n s e x u a l d i s s a t i s f a c t i o n . T h i s f i n d i n g i s e x t r e m e l y r e l e v a n t t o the e t h i c a l i s s u e o f u t i l i z i n g w a i t i n g l i s t c o n t r o l s f o r t r e a t m e n t i n v e s t i g a t i o n s ( F r a n k s and W i l s o n , 1980) i n t h a t i t suggests p o t e n t i a l l y d e t r i m e n t a l e f f e c t s a s s o c i a t e d w i t h the p u r p o s e f u l d e l a y o f t r e a t m e n t . The S e x u a l S a t i s f a c t i o n Index The r e s u l t s of the a n a l y s e s f o r t h i s v a r i a b l e w i l l be d i s c u s s e d i n terms of the s u b t e s t s . G e n e r a l S e x u a l S a t i s f a c t i o n . R e s u l t s from t h i s s u b t e s t were c o n s i s t e n t w i t h e x p e c t a t i o n s w i t h c o u p l e s i n b o t h the group and i n d i v i d u a l c o u p l e t r e a t m e n t c o n d i t i o n s r e p o r t i n g a s i g n i f i c a n t l y h i g h e r degree o f g e n e r a l s a t i s f a c t i o n than t h e i r c o n t r o l c o u n t e r p a r t s a t the f i n a l s e s s i o n , t h r e e week and t h r e e month f o l l o w - u p p e r i o d s . The d i f f e r e n c e between the t r e a t m e n t and c o n t r o l c o n d i t i o n means s t e a d i l y i n c r e a s e d t h r o u g h the t h r e e month f o l l o w - u p . When mean s c o r e s of the two t r e a t m e n t groups a r e compared over the cou r s e of the s t u d y , two d i s t i n c t l y d i f f e r e n t p a t t e r n s o f response emerge. Subjects assigned to the i n d i v i d u a l treatment c o n d i t i o n r e p o r t e d l a r g e i n c r e a s e s i n general s a t i s f a c t i o n at the f i n a l treatment s e s s i o n followed by maintenance of t h i s l e v e l through to the three month follow-up. In c o n t r a s t , s u b j e c t s i n the group c o n d i t i o n showed smal l e r increments through to the. three week follow-up, with l a r g e i n c r e a s e s r e p o r t e d at the three month assessment. T h i s d i f f e r e n t i a l p a t t e r n of response may be a t t r i b u t e d i n p a r t t o the p o s s i b i l i t y t h a t c l i e n t s i n the i n d i v i d u a l c o n d i t i o n . a r e more at ease with therapy a t an e a r l i e r p o i n t i n time,given the one to one t h e r a p e u t i c i n t e r a c t i o n and the format's i n h e r e n t a b i l i t y t o be more responsive to the couple's immediate needs. The l a r g e i n c r e a s e r e p o r t e d by group members at the three month follow-up may be d i r e c t l y a t t r i b u t e d to the f a c i l i t y f o r treatment g e n e r a l i z a t i o n and maintenance i n h e r e n t i n the group format (Leiblum, Rosen and P r i c e , 1976). Perhaps p a r t i c i p a t i o n i n the group s i t u a t i o n exposes the s u b j e c t s to group pressure to communicate about t h e i r c u r r e n t d i f f i c u l t i e s (Golden et a l . , 1978) and to develop s k i l l s at communicating wit h more than one set of o u t s i d e o b s e r v e r s . In a d d i t i o n , the group s i t u a t i o n allows the s u b j e c t s t o experience v i c a r i o u s l y the treatment b e n e f i t s of others (Bandura, 1969; Nemetz and C a i r d , 1978). The c o n t r o l s u b j e c t s r e p o r t e d v i r t u a l l y no change i n t h e i r l e v e l of general s a t i s f a c t i o n . Communication S a t i s f a c t i o n Subtest. R e s u l t s from the communication s a t i s f a c t i o n subtest were c o n s i s t e n t with 74 e x p e c t a t i o n s with s u b j e c t s i n both treatment c o n d i t i o n s r e p o r t i n g a s i g n i f i c a n t l y h i g h e r degree of s a t i s f a c t i o n with communication than t h e i r c o n t r o l c o u n t e r p a r t s at the f i n a l s e s s i o n , three week and three month follow-up p e r i o d s . I n s p e c t i o n of i n d i v i d u a l and group.treatment means r e v e a l s that s u b j e c t s i n these c o n d i t i o n s r e p o r t e d gradual increments i n s a t i s f a c t i o n with t h e i r communication up to the three week follow-up. At the three month follow-up couples i n the i n d i v i d u a l c o n d i t i o n maintained t h e i r improvement whereas couples i n the group c o n d i t i o n r e p o r t e d a s l i g h t a d d i t i o n a l i n c r e a s e i n communication s a t i s f a c t i o n . The group r e s u l t i s c o n s i s t e n t with previous r e s e a r c h (Nemetz et a l . , 1978; Hogan, 1978) and supports the n o t i o n that group procedures f o s t e r communication s k i l l s (Golden et a l . , 1978) and enhance the g e n e r a l i z a t i o n of problem-solving techniques (McGovern et al'. , 1978) . The c o n t r o l s u b j e c t s r e p o r t e d a decrease i n s a t i s f a c t i o n as measured by t h i s s u b t e s t . Increased s e n s i t i v i t y to poor communication h a b i t s and c o n t i n u a t i o n of maladaptive behavior i n the absence of attempts at p o s i t i v e change i s seen to account f o r t h i s r e s u l t . Orgasm S a t i s f a c t i o n Subtest. R e s u l t s from t h i s subtest were c o n s i s t e n t with e x p e c t a t i o n s with both treatment c o n d i t i o n s r e p o r t i n g a s i g n i f i c a n t l y h i g h e r degree of s a t i s f a c t i o n with orgasm than t h e i r c o n t r o l c o u n t e r p a r t s at the f i n a l s e s s i o n and three week follow-up. At the three month follow-up o n l y , s u b j e c t s i n the group c o n d i t i o n 75 r e p o r t e d s i g n i f i c a n t l y more s a t i s f a c t i o n w i t h t h e i r orgasmic e x p e r i e n c e than d i d t h e i r c o n t r o l c o u n t e r p a r t s . I n s p e c t i o n o f i n d i v i d u a l and group t r e a t m e n t means over a d m i n i s t r a t i o n p e r i o d s r e v e a l s a f a m i l i a r p a t t e r n . S u b j e c t s i n the i n d i v i d u a l t r e a t m e n t c o n d i t i o n r e p o r t e d a c o n s i d e r a b l e i n c r e a s e i n s a t i s f a c t i o n i m m e d i a t e l y a f t e r t r e a t m e n t f o l l o w e d by s l i g h t d e c r e a s e s a t the t h r e e week and t h r e e month f o l l o w - u p s . S u b j e c t s i n the group t r e a t m e n t c o n d i t i o n r e p o r t e d l i t t l e change i n s a t i s f a c t i o n u n t i l the t h r e e month f o l l o w - u p . A g a i n i t appears t h a t improvements r e p o r t e d by s u b j e c t s i n the group c o n d i t i o n are more g r a d u a l and a r e f a c i l i t a t i v e o f f u r t h e r changes f o l l o w i n g t e r m i n a t i o n of t h e r a p y . C o n t r o l s u b j e c t s r e p o r t e d a g r a d u a l d e c l i n e i n s a t i s f a c t i o n w i t h t h e i r o r g a s t i c p o t e n t i a l . G i v e n the c o n t r o v e r s y over the u t i l i z a t i o n of orgasm per se as an outcome measure, the s i g n i f i c a n c e o f t h e s e r e s u l t s i n tandem w i t h t h e i r b e h a v i o r a l c o u n t e r p a r t s w i l l be d i s c u s s e d a t a l a t e r p o i n t . S e x u a l i t y S a t i s f a c t i o n S u b t e s t . R e s u l t s from t h i s s u b t e s t i n d i c a t e d t h a t s u b j e c t s i n b o t h t r e a t m e n t c o n d i t i o n s , r e p o r t e d s i g n i f i c a n t l y h i g h e r l e v e l s of s a t i s f a c t i o n than d i d t h e i r c o n t r o l c o u n t e r p a r t s a t the f i n a l and t h r e e week f o l l o w - u p p e r i o d . At the t h r e e month f o l l o w - u p o n l y s u b j e c t s i n the group c o n d i t i o n r e p o r t e d s i g n i f i c a n t l y more s a t i s f a c t i o n t h a n t h o s e s u b j e c t s i n the c o n t r o l c o n d i t i o n . T h i s r e s u l t a g a i n a t t e s t s t o the t r e a t m e n t maintenance and g e n e r a l i z a t i o n i n h e r e n t i n the group s i t u a t i o n and argues f o r i n c r e a s e d 76' emphasis on g e n e r a l i z a t i o n techniques f o r those c l i e n t s r e c e i v i n g i n d i v i d u a l therapy. The c o n t r o l s u b j e c t s r e p o r t e d no change i n t h e i r o r i g i n a l l e v e l s of s a t i s f a c t i o n . The f i n d i n g of i n c r e a s e d s a t i s f a c t i o n with both t h e i r own and t h e i r p a r t n e r ' s s e x u a l i t y evidenced i n both treatment c o n d i t i o n s i s c o n s i s t e n t with previous r e s e a r c h (Frank, Anderson and R u b i n s t e i n , 1979) which suggests t h a t i n order to be able to r e l a t e i n t i m a t e l y to another i n d i v i d u a l one must f i r s t have p o s i t i v e f e e l i n g s about one's own s e x u a l i t y S a t i s f a c t i o n R e l a t i o n s h i p Subtest. R e s u l t s of the subtest were p a r t i a l l y c o n s i s t e n t w i t h e x p e c t a t i o n s with couples i n both treatment c o n d i t i o n s r e p o r t i n g a s i g n i f i c a n t l y h i g h e r degree of s a t i s f a c t i o n with t h e i r r e l a t i o n s h i p than t h e i r c o n t r o l c o u n t e r p a r t s at the f i n a l s e s s i o n and three week follow-up. The d i f f e r e n c e between the two treatments and the c o n t r o l c o n d i t i o n , however, was not maintained at the three month follow-up. Although couples i n the group c o n d i t i o n r e p o r t e d an i n c r e a s e i n s a t i s f a c t i o n at the three month follow-up, couples i n the i n d i v i d u a l treatment c o n d i t i o n r e p o r t e d a s l i g h t decrease. T h i s r e s u l t , coupled with a s l i g h t i n c r e a s e i n s a t i s f a c t i o n on the p a r t of the c o n t r o l c o n d i t i o n , l e d to the l a c k of d i f f e r e n t i a t i o n between the treatment s u b j e c t s and t h e i r c o n t r o l counter-p a r t s . Although e v i d e n c i n g only a s l i g h t i n c r e a s e i n s a t i s f a c t i o n , i t i s p o s s i b l e that the c o n t r o l group may have been responding to the imminent i n i t i a t i o n of 77 treatment. The i n c r e a s e i n s a t i s f a c t i o n evidenced by treatment couples, at the three week, follow-up i s c o n s i s t e n t with the observed r e l a t i o n s h i p between i n c r e a s e d sexual s a t i s f a c t i o n and m a r i t a l s a t i s f a c t i o n (Frank, Anderson and R u b i n s t e i n , 1979). The maintenance of t h i s i n c r e a s e d s a t i s f a c t i o n r e p o r t e d by group members at the three month follow-up again a t t e s t s to the g e n e r a l i z a t i o n e f f e c t s i n h e r e n t i n the group format. As r e p o r t e d above, a l l of the f i v e subtests were h i g h l y responsive to t h e r a p e u t i c i n t e r v e n t i o n . More s p e c i f i c a l l y , i n s p e c t i o n of treatment means appeared to manifest a common p a t t e r n . Subjects i n the i n d i v i d u a l couple c o n d i t i o n r e p o r t e d maximal s a t i s f a c t i o n i n four of the f i v e subscales immediately post treatment. This l e v e l of improvement d e t e r i o r a t e d s l i g h t l y through to the three month follow-up. Subjects i n the group couple c o n d i t i o n a c t u a l l y continued to improve on a l l measures post treatment and r e p o r t e d t h e i r h i g h e s t l e v e l s of s a t i s f a c t i o n at the three month follow-up. I t i s suggested that i n c r e a s e d v i s u a l and v e r b a l c o n t a c t with i n d i v i d u a l s e x p e r i e n c i n g s i m i l a r d i f f i c u l t i e s ( Lazarus, 1968), mutual probl e m - s o l v i n g d i s c u s s i o n s (Nemetz et a l . , 1978); Golden et a l . , 1978) and m u l t i p l e s h a r i n g of coping s t r a t e g i e s (Nemetz and C a i r d , 1979) a l l i n h e r e n t i n the group procedure combine to enhance communication and thus a i d i n treatment g e n e r a l i z a t i o n and maintenance of l e a r n e d coping s k i l l s . 78 The Sexual Behavior Inventory The r e s u l t s of the analyses f o r t h i s v a r i a b l e w i l l be d i s c u s s e d i n terms of the f o l l o w i n g items: Male Items Non-Sexual Massage. R e s u l t s from the analyses f o r non-sexual massage i n d i c a t e t h a t s u b j e c t s i n the i n d i v i d u a l c o n d i t i o n evidenced a s i g n i f i c a n t l y h i g h e r frequency of t h i s behavior than d i d t h e i r group or c o n t r o l c o u n t e r p a r t s d u r i n g the f i r s t three weeks of treatment. This r e s u l t i s p a r t i a l l y c o n s i s t e n t with e x p e c t a t i o n s i n that the importance of non-sexual c o n t a c t was emphasized d u r i n g s e s s i o n s i n the f i r s t three weeks of treatment. No s i g n i f i c a n t d i f f e r e n c e s were noted on t h i s v a r i a b l e at any other p o i n t i n the program. I f one views d y s f u n c t i o n as a d e f i c i t i n simple s k i l l s a c q u i s i t i o n (McMullen and Rosen, 1979) i t would be c o n s i s t e n t f o r such b a s i c and e s s e n t i a l l y non-sexual behavior to be e i t h e r n e g l e c t e d or m a r g i n a l l y maintained i n the face of i n c r e a s i n g sexual a c t i v i t i e s . Sensate Focus Breast Area. R e s u l t s from the analyses f o r t h i s item were c o n s i s t e n t with e x p e c t a t i o n s with both treatment groups showing s i g n i f i c a n t l y higher f r e q u e n c i e s of behavior than t h e i r c o n t r o l c o u n t e r p a r t s d u r i n g the l a s t two weeks of treatment. As the importance of f o r e p l a y and sensate focus a c t i v i t i e s was being emphasized d u r i n g t h i s phase of treatment, t h i s r e s u l t i s c o n s i s t e n t with t h e r a p e u t i c i n s t r u c t i o n s . F a i l u r e of t h i s item to achieve 79 s i g n i f i c a n c e at the three week follow-up was not expected and w i l l be discussed, l a t e r . Sensate Focus Female G e n i t a l s . No s i g n i f i c a n t e f f e c t s were obtained f o r t h i s v a r i a b l e a t any of the r e p o r t i n g p e r i o d s , although i t would have been expected d u r i n g the l a s t two weeks of treatment and the three week follow-up p e r i o d . I n t e r c o u r s e . As i n t e r c o u r s e was p r o h i b i t e d f o r the f i r s t f o u r weeks of treatment the r e s u l t of s i g n i f i c a n c e of the treatment e f f e c t at the three week follow-up i s c o n s i s t e n t with t h e r a p e u t i c e x p e c t a t i o n s and r e p r e s e n t s evidence of c o n s o l i d a t i o n of the s k i l l s t r a i n i n g g i v e n d u r i n g the treatment s e s s i o n s . R e s u l t s from the male b e h a v i o r a l analyses were g e n e r a l l y c o n s i s t e n t with a simple s k i l l s a c q u i s i t i o n model of sexual d y s f u n c t i o n ( L o P i c c o l o , 1978; McMullen and Rosen, 1979). The d i f f i c u l t i e s i n h e r e n t i n the b e h a v i o r a l instrument w i l l be d i s c u s s e d at a l a t e r p o i n t . Female Items Non-Sexual Massage. No s i g n i f i c a n c e was obtained f o r t h i s v a r i a b l e at any of the r e p o r t i n g p e r i o d s . T h i s f i n d i n g c o n f l i c t s w i t h both t h e r a p e u t i c i n s t r u c t i o n given d u r i n g the f i r s t two weeks of treatment and i s i n c o n s i s t e n t with the male r e p o r t of male i n i t i a t e d non-sexual massage d u r i n g t h i s same time p e r i o d . I t may w e l l be t h a t whereas males were comfortable i n i t i a t i n g non-sexual massage, females were not. The u n s t r u c t u r e d nature of the a c t i v i t y may 8G have c o n t r i b u t e d t o t h e i r r e l u c t a n c e . I n a d d i t i o n , the amount of male i n i t i a t e d massage may have r e p r e s e n t e d the maximal amount.of time c o u p l e s wanted t o spend i n t h a t p a r t i c u l a r a c t i v i t y . Sensate Focus Male G e n i t a l s . R e s u l t s from t h i s i t e m i n d i c a t e d t h a t s u b j e c t s i n t h e i n d i v i d u a l t r e a t m e n t c o n d i t i o n e v i d e n c e d a s i g n i f i c a n t l y h i g h e r f r e q u e n c y o f t h i s b e h a v i o r t h a n the c o n t r o l s u b j e c t s d u r i n g the f i v e weeks of t r e a t -ment. Group s u b j e c t s r e p o r t e d s i g n i f i c a n t l y h i g h e r f r e q u e n c i e s o f t h i s b e h a v i o r d u r i n g the l a s t two weeks of t r e a t m e n t o n l y . The S e x o l o g i c a l E x a m i n a t i o n , a h i g h l y s t r u c t u r e d , l i m i t e d e x e r c i s e was a s s i g n e d d u r i n g the second week of t r e a t m e n t and c o n s e q u e n t l y s i g n i f i c a n t r e s u l t s from the s e n s a t e f o c u s male g e n i t a l s items would have been ex p e c t e d f o r b o t h t r e a t m e n t groups d u r i n g the f i r s t t h r e e weeks o f t r e a t m e n t . The group c o u p l e s ' f a i l u r e t o r e p o r t t h i s i n c r e a s e d f r e q u e n c y u n t i l the l a s t two weeks i s c o n s i s t e n t w i t h the e v o l v i n g p a t t e r n o f g r a d u a l compliance and l e a r n i n g e v i d e n c e d f o r c o u p l e s i n the group c o n d i t i o n . Orgasm Through M a s t u r b a t i o n . Women from th e i n d i v i d u a l and group t r e a t m e n t c o n d i t i o n s r e p o r t e d s i g n i f i c a n t l y h i g h e r f r e q u e n c i e s on t h i s i t e m d u r i n g the l a s t two weeks of t r e a t m e n t t h a n the c o n t r o l c o u n t e r p a r t s . T h i s f i n d i n g i s c o n s i s t e n t w i t h t h e r a p e u t i c i n s t r u c t i o n i n t h a t m a s t u r b a t i o n t r a i n i n g ( L o b i t z and L o P i c c o l o , 1972) was emphasized d u r i n g t h i s p e r i o d of t i m e . In a d d i t i o n , t h i s i s the o n l y v a r i a b l e i n which the group members 81 r e p o r t e d a s i g n i f i c a n t l y h i g h e r frequency of behavior than t h e i r i n d i v i d u a l c o u n t e r p a r t s . As masturbation i s c o n c e p t u a l i z e d as an important p r e c u r s o r to c o i t a l orgasmic a c t i v i t y (Bardwick, 1971; Masters and Johnson, 1970) t h i s f i n d i n g of s i g n i f i c a n c e f o r both treatment c o n d i t i o n s i s extremely important i n terms of f u t u r e development of orgasmic behavior. Given the prevalence of negative a t t i t u d e s towards masturbatory behavior (Barbach, 1974; B a i l e y , 1978) the f i n d i n g of group s u p e r i o r i t y with r e s p e c t to t h i s behavior argues f o r the d i s i n h i b i t i n g e f f e c t of group member-ship on a t t i t u d e change (Nemetz et a l . , 1978), t r a n s m i s s i o n of coping s k i l l s (McGovern et a l . , 1978) and communication f a c i l i t a t i o n (Golden et a l . , 1978). The c o n t r i b u t i o n of t h i s f i n d i n g to the previous r e s e a r c h on t r a n s f e r e n c e of orgasmic p o t e n t i a l w i l l be d i s c u s s e d at a l a t e r p o i n t . Orgasm Through F o r e p l a y . Reported f r e q u e n c i e s i n t h i s b ehavior d i f f e r e n t i a t e d women i n both treatment c o n d i t i o n s from c o n t r o l s u b j e c t s at the three week follow-up. Given the p r e v i o u s l y d i s c u s s e d i n c r e a s e d frequency i n masturbation coupled with the t h e r a p e u t i c e x p e c t a t i o n of communication of masturbatory s k i l l s t o male p a r t n e r s , t h i s r e s u l t was t o t a l l y expected. Given the l a c k of s p e c i f i c i t y of t h i s item (McMullen and Rosen, 1979) the nature of the s t i m u l a t i o n u t i l i z e d i s not a v a i l a b l e . Again the be a r i n g of t h i s r e s u l t on previous r e s e a r c h w i l l be d i s c u s s e d at a l a t e r p o i n t . 82 I n t e r c o u r s e . As i n t e r c o u r s e was p r o h i b i t e d f o r the f i r s t f o u r weeks of treatment, the r e s u l t of s i g n i f i c a n t f i n d i n g s obtained d u r i n g the three week follow-up i s not i n c o n s i s t e n t with t h e r a p e u t i c e x p e c t a t i o n s . C o n s i s t e n t with a gradual s k i l l s r e t r a i n i n g model of sexual d y s f u n c t i o n (Nemetz and C a i r d , 1978), couples i n both treatment groups r e p o r t e d a s i g n i f i c a n t l y h i g h e r frequency of i n t e r c o u r s e than t h e i r c o n t r o l c o u n t e r p a r t s . These r e s u l t s are a l s o c o n s i s t e n t with those obtained from the male b e h a v i o r a l a n a l y s i s f o r t h i s item. Orgasm Through I n t e r c o u r s e . No s i g n i f i c a n c e was obtained f o r t h i s v a r i a b l e at any of the r e p o r t i n g p e r i o d s . Given the p r e v i o u s r e s e a r c h f i n d i n g s , t h i s r e s u l t i s not incongruent Again the c o n t r i b u t i o n of t h i s r e s u l t to the more general i s s u e of t r a n s f e r e n c e of orgasmic a b i l i t y w i l l be d i s c u s s e d at a l a t e r p o i n t . General Issues C o n c e p t u a l i z a t i o n about the nature of sexual d y s f u n c t i o n i s changing (McMullen and Rosen, 1979; L o P i c c o l o , 1978; Hogan, 1978). The new broad band t h e r a p i e s address themselves to t h i s change i n t h a t they do not adhere to a s i m p l i s t i c c o n c e p t u a l i z a t i o n of e t i o l o g y where one or two c a u s a t i v e f a c t o r s are given prominence. Rather, they u t i l i z e a broad, m u l t i f a c e t e d treatment approach where a wider range of problematic behaviors are d e a l t with. Components of t h i s approach i n c l u d e : i n f o r m a t i o n and 83 education; s k i l l s t r a i n i n g ; communication f a c i l i t a t i o n ; reduction of a l l forms of sexual anxiety and graduated behavioral homework assignments. The present study u t i l i z i n g a l l of the above components and addressing i t s e l f to a number of methodological flaws which have characterized previous research (LoPiccolo, 1978; S o t i l e and Kilmann, 1977), has demonstrated the e f f i c a c y of this approach. The u t i l i z a t i o n of multiple dependent measures (S o t i l e and Kilmann, 1977) in response to the broadened conceptualization of the nature of sexual dysfunction adds to the robust quality of the r e s u l t s . Given the demonstrated e f f i c a c y of these broad band therapies and their d i r e c t treatment of behavioral symptomatology (Golden et a l . , 1978; Leiblum et a l . , 1976; Leiblum et a l . , 1977), the adequacy of the current diagnostic system must be questioned. The unitary diagnosis of "premature ejaculation" or "secondary orgasmic dysfunction" does not give the therapist s u f f i c i e n t information as to the current behaviors of the c l i e n t . In one instance of "secondary orgasmic dysfunction" communication d i f f i c u l t i e s may be a major therapeutic focus, i n another, lack of sexual s k i l l s may be the target for therapeutic intervention. While the broad based therapies do deal with this inadequacy by o f f e r i n g a spectrum of therapeutic techniques, the process would be f a c i l i t a t e d by the introduction of a behaviorally based diagnostic system. For example, a woman might s t i l l be termed "secondary inorgasmic" however, 84 a b e h a v i o r a l a n a l y s i s i n d i c a t i n g mode of communication, l e v e l of sexual a n x i e t y ; p a r t n e r sexual competency and couple's general l e v e l of sexual knowledge would be i n c l u d e d . T h i s i n f o r m a t i o n would a i d the t h e r a p i s t i n f o c u s s i n g on s p e c i f i c problem areas and a l s o i n d i c a t e the therapy of c h o i c e . The r e s u l t s of the present study are a l s o r e l e v a n t to a number of e x i s t i n g i s s u e s i n the l i t e r a t u r e . F i r s t l y , the present r e s e a r c h i s r e l e v a n t to the i s s u e of group composition i n terms of h e t e r o g e n e i t y versus homogeneity of d i a g n o s i s . Homogeneity of group composition was o r i g i n a l l y c o n c e p t u a l i z e d to d e a l with the p o t e n t i a l d i f f i c u l t i e s inherent i n a group s i t u a t i o n ; s p e c i f i c a l l y , i n s u f f i c i e n t a t t e n t i o n to i n d i v i d u a l problems and d i f f e r e n t i a l pacing of homework assignments (Kaplan et a l . , 1974; Barbach, 1974). Proponents of the heterogeneous group composition (Leiblum, Rosen and P e i r c e , 1976; Leiblum and E r s n e r - H e r s h f i e l d , 1977) suggest that group members are exposed to a broadened range of a t t i t u d e s , sexual problems and p o t e n t i a l coping s k i l l s and accept new i n f o r m a t i o n and s k i l l s t r a i n i n g more r e a d i l y . Although not d i r e c t l y comparing h e t e r o g e n e i t y versus homogeneity of group composition, the heterogeneous group u t i l i z e d i n the present study evidenced an a b i l i t y to g e n e r a l i z e and maintain t h e r a p e u t i c g a i n s . Secondly, r e s u l t s from the present study bear on the i s s u e of t r a n s f e r e n c e of o r g a s t i c a b i l i t y from masturbation to c o i t u s . Previous r e s e a r c h has c o n s i s t e n t l y found a low 85 frequency of orgasm achieved through c o i t u s alone among women undergoing sex.therapy e i t h e r . i n d i v i d u a l l y or with a pa r t n e r (Leiblum and E r s n e r - H e r s h f i e l d , 1977; Barbach, 1974; Schneidman and MeGuire, 1976). These r e s u l t s have been obtained d e s p i t e the r e p o r t e d success of orgasm through masturbation f o r the same s u b j e c t s . When o r g a s t i c a b i l i t y does t r a n s f e r to couple a c t i v i t y , a d d i t i o n a l s t i m u l a t i o n p a r t i c u l a r l y a v i b r a t o r i s o f t e n necessary (Leiblum and Ersner-Hershield,. 1977; Schniedman and MeGuire). These experimental data are co r r o b o r a t e d by i n s p e c t i o n of l a r g e samples of normative data c o l l e c t e d on the frequency of orgasm through i n t e r c o u r s e alone ( H i t e , 1976). Given these r e s u l t s coupled- with Kaplan's (1974) o b s e r v a t i o n that type and d u r a t i o n of s t i m u l a t i o n i n a d d i t i o n to v a r i a t i o n s i n anatomical s t r u c t u r e makes orgasm with i n t e r c o u r s e u n r e l i a b l e , the u t i l i z a t i o n of orgasm through i n t e r c o u r s e alone, as a v a l i d t h e r a p e u t i c c r i t e r i o n must be questioned (McMullen and Rosen, 1979). R e s u l t s from the present study are c o n s i s t e n t with the noted e f f i c a c y of masturbation t r a i n i n g ( E r s n e r - H e r s h f i e l d and Kopel, 1979; Barbach, 1974). The f i n d i n g s of s i g n i f i c a n c e f o r the v a r i a b l e measuring orgasm through f o r e p l a y at the three week follow-up suggests the u t i l i t y of s p e c i f i c , m u l t i p l e measures i n i d e n t i f y i n g areas of t h e r a p e u t i c g a i n . The t r a n s f e r e n c e of o r g a s t i c a b i l i t y to a c o u p l e - r e l a t e d a c t i v i t y other than i n t e r c o u r s e i n c o n j u n c t i o n with the h i g h degree -of s a t i s f a c t i o n with o r g a s t i c behavior r e p o r t e d on the Sexual S a t i s f a c t i o n Index 86 a g a i n s e r i o u s l y questions the t r a d i t i o n a l treatment c r i t e r i o n of i n t e r c o u r s e with orgasm. Because the d e f i n i t i o n of t h i s category does not s p e c i f y the nature of the f o r e p l a y s t i m u l a t i o n , a d d i t i o n a l c o n c l u s i o n s from i t s s i g n i f i c a n c e are l i m i t e d . T h i r d l y , as p r e v i o u s l y mentioned, the f i n d i n g of the w a i t i n g l i s t c o n t r o l ' s d e t e r i o r a t i o n over time has i m p l i c a -t i o n s f o r i t s u t i l i z a t i o n i n f u t u r e r e s e a r c h (Franks and Wilson, 1980; Nemetz et a l . , 1978). I f t h i s f i n d i n g i s r e p l i c a t e d by f u t u r e r e s e a r c h the e t h i c a l b a s i s of the w a i t i n g l i s t c o n t r o l must be thoroughly examined. Suggestions f o r f u t u r e r e s e a r c h are contained i n the I m p l i c a t i o n s f o r Future Research S e c t i o n . The major focus of the present study was to d i r e c t l y compare group to i n d i v i d u a l treatment formats. The present r e s e a r c h i s a p p a r e n t l y the only i n v e s t i g a t i o n r e p o r t e d which attempts to d i r e c t l y compare i n d i v i d u a l couple to group couple a p p l i c a t i o n of a broad based therapy i n c o n t r a s t to a c o n t r o l c o n d i t i o n . Given the g e n e r a l l y p o s i t i v e r e s u l t s obtained f o r the group format i n c o n j u n c t i o n with a b i l i t y to decrease p a t i e n t c o s t and i n c r e a s e t h e r a p e u t i c a v a i l a b i l i t y , a p p l i c a t i o n of t h i s format f o r a m a j o r i t y of c l i e n t s i s seen as h i g h l y d e s i r a b l e . T h i s f i n d i n g i s e n t i r e l y c o n s i s t e n t with previous r e s e a r c h i n the area i n terms of the p o s i t i v e b e n e f i t s a t t r i b u t e d to group p a r t i c i p a t i o n (Nemetz et a l . , 1978; Golden et a l . , 1978; 87 McGovern et a l . , 1978; E r s n e r - H e r s h f i e l d and Kopel, 1979). A c h a r a c t e r i s t i c response p a t t e r n emerged f o r couples p a r t i c i p a t i n g i n the group treatment. I n s p e c t i o n of the Sexual S a t i s f a c t i o n Index r e v e a l s a tendency towards a more gradual and maintained improvement i n a l l f a c e t s of s a t i s f a c t i o n f o r group couples. Group components p o t e n t i a l l y c o n t r i b u t i n g to t h i s maintenance and g e n e r a l i z a t i o n of t h e r a p e u t i c techniques i n c l u d e the a b i l i t y to share other couples' coping s t r a t e g i e s (Nemetz and C a i r d , 1978, 1979); peer support and encouragement (Leiblum, Rosen and P e i r c e , 1976; Leiblum and Ersner-Hershf ield., 1977); p r o v i s i o n of an atmosphere conducive to communication (Golden et a l . , 1978) and the exposure to modeling e f f e c t s (McGovern, 1978). To the w r i t e r ' s knowledge, weekly.monitoring of sexual behavior has not been r e p o r t e d p r e v i o u s l y i n the l i t e r a t u r e . The present study i n d i c a t e s a number of problems a s s o c i a t e d both with the c o n s t r u c t i o n and a c t u a l u t i l i z a t i o n of the Sexual Behavior Index. F i r s t l y , d e s p i t e repeated e x p l a n a t i o n s of the b e h a v i o r a l c a t e g o r i e s , s u b j e c t s were confused as to the s p e c i f i c nature of the behaviors to be monitored. T h i s c o n f u s i o n p r i m a r i l y occurred when behaviors were of a cumulative nature. For example, i t would be d i f f i c u l t to engage i n i n t e r c o u r s e without some degree of b r e a s t and g e n i t a l m a n i p u l a t i o n , however, i t i s f e l t t h a t s u b j e c t s o f t e n only i n d i c a t e d an occurrence of i n t e r c o u r s e r a t h e r than e n t e r i n g a frequency count i n a l l three c a t e g o r i e s . 88 The r e s u l t s from the Sexual Behavior Index would tend to uphold t h i s n o t i o n . Secondly, the d i f f i c u l t y of e l i m i n a t i n g the n o i s e i n the monitored data i s apparent. Menstrual c y c l e s , p a r t n e r h o l i d a y s and v i s i t i n g r e l a t i v e s a l l s e v e r e l y i n t e r f e r e with r e c o r d i n g of data e s p e c i a l l y when data weeksare averaged together. L a s t l y , there i s d i f f i c u l t y i n i n v e s t i g a t i n g pre-post b e h a v i o r a l data. Often i n d i v i d u a l s engage i n optimal l e v e l s of sexual behavior with minimal s a t i s f a c t i o n . T h i s appears to be e s p e c i a l l y true f o r females (Barbach, 1980; Nemetz and C a i r d , 1979). I f pre and post l e v e l s are examined f o r s u b j e c t s i n t h i s s i t u a t i o n , the b e h a v i o r a l data w i l l not a c c u r a t e l y r e f l e c t treatment g a i n , whereas a measure of sexual s a t i s f a c t i o n w i l l . Some suggestions f o r improvement of sexual b e h a v i o r a l monitoring are contained i n I m p l i c a t i o n s f o r Future Research. I m p l i c a t i o n s f o r Future Research Given the demonstrated e f f i c a c y of the a p p l i c a t i o n of group format to a short term, broad band, therapy, a number of b a s i c i s s u e s warrant f u r t h e r i n v e s t i g a t i o n . F i r s t l y , group composition should be examined. Does h e t e r o g e n e i t y or homogeneity of p r e s e n t i n g d i a g n o s i s more e f f e c t i v e l y f a c i l i t a t e group i n t e r a c t i o n ? Is there a combination of c l i e n t demographic c h a r a c t e r i s t i c s that would optimize group p a r t i c i p a t i o n ? Which c l i e n t s should be d i r e c t e d towards 89 p a r t i c i p a t i o n i n the group format? S e c o n d l y , the f i n d i n g t h a t the group c o u p l e s ' a b i l i t y t o m a i n t a i n t r e a t m e n t g a i n s and i n d e e d i n c r e a s e b e n e f i t s three,months p o s t d i s c h a r g e s h o u l d be r e p l i c a t e d . I f these r e s u l t s a re u p h e l d , i n v e s t i g a t i o n as t o f a c t o r s which promote t r e a t m e n t maintenance and g e n e r a l i z a t i o n would be w a r r a n t e d . I f g e n e r a l i z a t i o n i s f a c i l i t a t e d by m u l t i p l e problem s h a r i n g and maximal exposure t o v a r y i n g models, the format of the t r e a t m e n t s e s s i o n s might be r e a r r a n g e d . For example, the f i r s t p a r t of each s e s s i o n might c o n t a i n b oth males and females ( n ot n e c e s s a r i l y b o th p a r t n e r s ) , w i t h the male and female t h e r a p i s t s s w i t c h i n g groups weekly. T h i r d l y , the e f f e c t i v e t r e a t m e n t components of the group format s h o u l d be i s o l a t e d . F a c t o r s which s h o u l d be examined i n c l u d e : m u l t i p l e problem s h a r i n g ; exposure t o i n d i v i d u a l s e x p e r i e n c i n g s i m i l a r d i f f i c u l t i e s ; peer p r e s s u r e and support i n terms o f homework assignments and communication and exposure t o numerous models employing suggested c o p i n g s t r a t e g i e s w i t h p o s i t i v e consequences. In terms of the b a s i c program i t s e l f , the r e s u l t s of t h i s s t u d y suggest f u r t h e r a r e a s of c o n c e r n . A g a i n , as mentioned above, e f f e c t i v e t r e a t m e n t components s h o u l d be i s o l a t e d . To t h i s end a number of t r e a t m e n t groups c o u l d be r u n , each u t i l i z i n g a d i f f e r e n t t h e r a p e u t i c component. For example, the b e n e f i t s of a s e x u a l e d u c a t i o n group-r e a d i n g o n l y as compared t o a s e x u a l e d u c a t i o n g r o u p - v i d e o o n l y c o u l d be i n v e s t i g a t e d . 90-The d i f f i c u l t y evidenced by i n d i v i d u a l treatment couples i n maintenance of t h e r a p e u t i c gains suggests a p o s s i b l e e l o n g a t i o n of the treatment phase of the program i n c o n j u n c t i o n with s h o r t e r i n t e r v a l s between.follow-up assessments. For example, treatment may be comprised of e i g h t weekly s e s s i o n s with an a d d i t i o n of e i g h t follow-up assessments each o c c u r r i n g at three week i n t e r v a l s . As the group c l i e n t s evidenced no d i f f i c u l t y i n maintenance of treatment g a i n s , a group format f o r i n d i v i d u a l couple follow-up might be b e n e f i c i a l . As the present study was p r i m a r i l y concerned with demonstration of treatment e f f i c a c y , p r o g n o s t i c i n d i c a t o r s were not examined. T h i s i s s u e , however, remains of paramount concern ( S o t i l e and Kilmann, 1977; L o P i c c o l o , 1978). To t h i s end a s e r i e s of s t u d i e s should examine c l i e n t s with a wide range of p r e s e n t i n g problems at v a r y i n g l e v e l s of s e v e r i t y i n t h e i r response to r a d i c a l l y d i f f e r e n t forms of t h e r a p e u t i c i n t e r v e n t i o n . Given the v a s t l y d i f f e r i n g types of sexual d y s f u n c t i o n , i t i s imperative to a s c e r t a i n which type of p r e s e n t i n g problem responds best to a s p e c i f i c therapy. There were two areas of the present study that posed s e r i o u s concern. Although the "assessment o n l y " c o n t r o l had evidenced d e t e r i o r a t i o n i n previous s t u d i e s (Nemetz et a l . , 1978) r e p l i c a t i o n of t h i s phenomena was nonethless d i s t u r b i n g . In order to f u r t h e r i n v e s t i g a t e t h i s f i n d i n g the "assessment o n l y " c o n t r o l c o n d i t i o n should be compared 91 t o b o t h a " w a i t i n g l i s t " and a " p l a c e b o " c o n t r o l c o n d i t i o n . I f d e t e r i o r a t i o n i s e v i d e n c e d i n a l l forms of c o n t r o l c o n d i t i o n s , f u r t h e r r e s e a r c h i n t o the e f f e c t of w a i t i n g f o r tr e a t m e n t on c o u p l e s e x p e r i e n c i n g s e x u a l d i f f i c u l t i e s i s needed. I f however, o n l y the assessment c o n t r o l c o n d i t i o n e v i d e n c e s i n c r e a s e d d i s s a t i s f a c t i o n , the r e a c t i v e e f f e c t s o f s e l f - m o n i t o r i n g i n c o u p l e s w i t h s e x u a l d y s f u n c t i o n would wa r r a n t i n t e r e s t . As d i s c u s s e d p r e v i o u s l y , t h e r e were a number of o b s t a c l e s t o a c c u r a t e usage of the b e h a v i o r a l i n d e x . F u t u r e r e s e a r c h s h o u l d i n v e s t i g a t e the v a r i o u s methods o f o b t a i n i n g b e h a v i o r a l d a t a and make recommendations as t o the most e f f i c i e n t f o r m a t . G i v e n the c o n f u s i o n caused by f i n e r measures of s e x u a l b e h a v i o r , e x a m i n a t i o n of more g r o s s measures might prove b e n e f i c i a l . Some s u g g e s t i o n s i n c l u d e : usage of a b a s i c o c c u r r e n c e - n o n o c c u r r e n c e measure; c o l l a p s e of f i n e r measures i n t o b r o a d e r c a t e g o r i e s , i . e . f o r e p l a y , i n t e r c o u r s e , orgasm; and the i n s t i t u t i o n o f d a i l y m o n i t o r i n g s h e e t s t o r e p l a c e the weekly r e p o r t . 92 BIBLIOGRAPHY Annon, J.S. The t h e r a p e u t i c use of masturbation i n the treatment of sexual d i s o r d e r s . In R.D. Rubin, P. Brady, & J.D. Henderson ( E d s . ) , Advances i n behavior therapy ( V o l . 3 ) . New York: Academic Press, 1973, 199-215. Annon, J.S. B e h a v i o r a l Treatment of sexual problems ( V o l . 1 ) . B r i e f therapy. Honolulu: K a p i o l i a n i H e a l t h S e r v i c e s Press, 1974. 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Stone, A., & Le v i n e , J . Group therapy i n sexual malad-justment. American J o u r n a l of P s y c h i a t r y , 1950, 107, 195-202. Wallace, D.H., & Barbach, L.G. Preorgasmic group treatment. J o u r n a l of Sex and M a r i t a l Therapy, 1974, 1, 146-154. Wincze, J . A comparison of systematic d e s e n s i t i z a t i o n and " v i c a r i o u s e x t i n c t i o n " i n a case of f r i g i d i t y . J o u r n a l of Behavior Therapy and Experimental P s y c h i a t r y , 1971, 2, 285-290. Wincze, J.P.., & C a i r d , W.K. The e f f e c t s of systematic d e s e n s i t i z a t i o n and v i d e o - d e s e n s i t i z a t i o n i n the treatment of e s s e n t i a l sexual d y s f u n c t i o n i n women. Behavior Therapy, 1976, 7, 335-342. 98 Winer, B. S t a t i s t i c a l p r i n c i p l e s i n experimental d e s i g n . New York: McGraw-Hill, 1971. Wolpe, J . Psychotherapy by r e c i p r o c a l i n h i b i t i o n . S t a n f o r d : S t a n f o r d U n i v e r s i t y P r e s s , 1958. Wolpin, M. Guided imagining to reduce avoidance behavior. Psychotherapy: Theory Research and P r a c t i c e , 1969, 6, pp. 122-124. Woody, R., & Schauble, P. Videotaped v i c a r i o u s d e s e n s i t i -z a t i o n . J o u r n a l of Nervous and Mental Disease, 1969, 148, 281-286. Z e i s s , R.A., C h r i s t e n s e n , A., & Lev i n e , A.G. Treatment f o r premature e j a c u l a t i o n through male only groups. J o u r n a l of Sex and M a r i t a l Therapy, 1978, 4,2. 99 AUDIO VISUAL B r i t r o s e , P. Women on Orgasm. San F r a n c i s c o : M u l t i Media, 1973. Chernik, A., & Chernik, B. S e x u a l i t y and Communication. Toronto: U n i v e r s i t y of Toronto, 1975. Sutton, L. Handvoice. San F r a n c i s c o : M u l t i Media, 1970. Sutton, L. Squeeze Technique. San F r a n c i s c o , M u l t i Media, 1970. Sutton, L. The S e x o l o g i c a l Examination. San F r a n c i s c o : M u l t i Media, 1973. Szasz, G. Human Sexual Response. Vancouver: H e a l t h Sciences Center H o s p i t a l , 1974. 100 APPENDIX I T h e r a p i s t Manual T h i s o u t l i n e was w r i t t e n to ensure standard treatment conent and procedure across a l l experimental c o n d i t i o n s . Th use of t h i s o u t l i n e serves as one check a g a i n s t the p o s s i b l e e f f e c t s of experimenter b i a s (Barber 1976). I n i t i a l Interview Both male and female t h e r a p i s t s are present, and the couple remains together throughout the hour long s e s s i o n . As s t a t e d to the c l i e n t s , the main purpose of the s e s s i o n i s "to f i n d out from both of you, what problems you are e x p e r i e n c i n g , d e t a i l what our program has to o f f e r and decide i f t h i s i s the best p l a c e f o r you." I n i t i a l l y , demographic data such as age, o c c u p a t i o n , e d u c a t i o n , m a r i t a l s t a t u s , d u r a t i o n of problem, and d u r a t i o n of the r e l a t i o n s h i p i s obtained. A problem statement from e i t h e r p a r t n e r i s then e l i c i t e d and a comprehensive s e r i e s of questions ensues. The areas covered by both q u e s t i o n and d i s c u s s i o n are i d e n t i c a l f o r both p a r t n e r s and i n c l u d e the f o l l o w i n g : 1. S a t i s f a c t i o n with and commitment to the r e l a t i o n s h i 2. Current sexual h a b i t s - frequency of i n t e r c o u r s e - i d e a l frequency of i n t e r c o u r s e - p e r c e i v e d q u a l i t y of i n t e r c o u r s e i n terms of s a t i s f a c t i o n r e c e i v e d 101 - foreplay a c t i v i t i e s - masturbation practices - use of fantasy or stimulation aids - preferred times for intercourse 3. Attitudes towards sexuality - perception of own sexuality - perception of partner's sexuality - role of sexual behavior i n a marriage - feelings towards - intercourse - masturbation - ^manual genital stimulation - *oral genital stimulation 4. Psychosexual history - parental attitude towards sexuality - quality and quantity of information from patents - quality and quantity of information from educational sources, s i b l i n g s and peers - attempts at and attitudes towards masturbation - attitudes towards premarital intercourse - i n i t i a l attempts at intercourse - incidences of rape, molestation or incest - other traumatic sexual experiences 5. Details of contact with physician 6. Details of any previous treatment experiences *these are e l i c i t e d with a view to the c l i e n t both giving and receiving the stimulation 102 7. Assessment of m o t i v a t i o n f o r treatment - t h i s t o p i c area i n c l u d e s questions as to "why treatment now," e x p e c t a t i o n s of outcome and w i l l i n g n e s s to take r e s p o n s i b i l i t y f o r the m a j o r i t y of the "therapy work" i n the form of b e h a v i o r a l homework assignments 8. Current self-assessment of l e v e l of sexual knowledge and areas that c l i e n t f e e l s need to be worked on At t h i s p o i n t , the c l i e n t s are asked i f there i s any more i n f o r m a t i o n that might be r e l e v a n t to t h e i r s p e c i f i c problem. An attempt i s then made by e i t h e r t h e r a p i s t to give a synpsis of the p r e s e n t i n g problem and the p o s s i b l e e t i o l o g i c a l and m a i n t a i n i n g f a c t o r s . A d e t a i l e d e x p l a n a t i o n of the Human S e x u a l i t y Program i s then g i v e n . P o i n t s covered i n c l u d e the t h e o r e t i c a l framework of the program, importance of c o n t i n u a l attendance, r e s p o n s i b i l i t y i n terms of the " b e h a v i o r a l homework" assignments, cost per s e s s i o n and a p p r o p r i a t e s e s s i o n times. Questions and f e e l i n g s about the program are s o l i c i t e d . I f the d e c i s i o n to p a r t i c i p a t e i s yes: - the d e t a i l s of q u e s t i o n n a i r e s and use of data are e x p l a i n e d - an informed consent form i s g i v e n - the purpose and use of the B e h a v i o r a l Index i n the two week b a s e l i n e p e r i o d i s e x p l a i n e d - the Sexual S a t i s f a c t i o n Index and Sexual A r o u s a l Inventory are completed - couples are t o l d t h a t both group and i n d i v i d u a l s e s s i o n s are run and that they w i l l be p l a c e d i n the f i r s t a v a i l a b l e form of treatment 103 - an appointment time f o r next s e s s i o n i s d e c i d e d upon I f the c o u p l e f e e l s t h a t t h i s i s not the a p p r o p r i a t e t r e a t m e n t m o d a l i t y o r c o n v e r s e l y , i f the t h e r a p i s t s f e e l t h a t the c o u p l e are not s u i t a b l e f o r the program, an a l t e r n a t e r e f e r r a l source i s always g i v e n . F a c t o r s c o n t r a i n d i c a t i n g t h e r a p e u t i c i n t e r v e n t i o n - l a c k of commitment t o the r e l a t i o n s h i p o r t o the t h e r a p y program - r e c e n t d i a g n o s i s of a m e d i c a l c o n d i t i o n which would i m p a i r s e x u a l f u n c t i o n i n g - severe m a r i t a l d i s c o r d which would p r e c l u d e c o n j o i n t t h e r a p y - presence of p s y c h o t i c symptomatology - presence of an a d d i c t i v e b e h a v i o r which would j e o p a r d i z e e f f e c t i v e i n t e r v e n t i o n - l a c k of a stea d y and c o - o p e r a t i v e s e x u a l p a r t n e r Couples are always g i v e n one of the t h e r a p i s t ' s home te l e p h o n e numbers and are encouraged t o c a l l i f any q u e s t i o n s or problems a r i s e i n the i n t e r - t r e a t m e n t p e r i o d s . S e s s i o n a l c o n t e n t o u t l i n e d below i s i d e n t i c a l f o r both group and i n d i v i d u a l t h e r a p y c o n d i t i o n s . S e s s i o n 1 A. F i r s t h a l f of s e s s i o n f e m a l e ( s ) w i t h female t h e r a p i s t : The purpose o f t h i s s e s s i o n i s t o make the c l i e n t ( s ) c o m f o r t a b l e i n the new s i t u a t i o n and the n o u t l i n e 104 the procedures f o r the next f i v e weeks. S p e c i f i c questions and comments i n c l u d e : - how do you f e e l about being here - what co u l d be done to make you f e e l more comfortable - assurances by the t h e r a p i s t that f e e l i n g s of a n x i e t y and h e s i t a t i o n are r e a l i s t i c r e a c t i o n s to a novel s i t u a t i o n - e x p e c t a t i o n f o r treatment progress are d i s c u s s e d - the importance of l o o k i n g f o r small progress steps i n s t e a d of dramatic changes i s underscored Q u e s t i o n n a i r e s i n c l u d i n g the Sexual A r o u s a l Inventory and S a t i s f a c t i o n Index are r e - a d m i n i s t e r e d . An o u t l i n e of the program, t e n s i o n management phamphlet and r e a d i n g l i s t are d i s t r i b u t e d and e x p l a i n e d . B. F i r s t h a l f of s e s s i o n male(s) wi t h male t h e r a p i s t : I d e n t i c a l to female s e s s i o n C. Male(s) and Female(s) Together: F i l m : Anatomy and Human Sexual Response D i s c u s s i o n P e r i o d : 1. r e p o r t on s e s s i o n from male and female r e p r e s e n t a t i v e 2. d i s c u s s i o n of the l e a r n i n g theory of sexual d y s f u n c t i o n s 3. r a t i o n a l e f o r r e s t r a i n i n g from i n t e r c o u r s e f o r the f i r s t f o u r weeks 4. emphasis on r e s p o n s i b i l i t y f o r homework assignments 5. r a t i o n a l e f o r and a c t u a l demonstration of t e n s i o n management techniques 105 Homework - Couples are I n s t r u c t e d t o : 1.. i n c r e a s e non-sexual p h y s i c a l contact terms of hugging, k i s s i n g , back rub, m e t c . I t i s important to emphasize to c l i e n t s , t h a t very o f t e n when couples are having sexual d i f f i c u l t i e s , forms of p r e v i o u s l y p l e a s u r a b l e non-sexual a c t i v i t i e s cease due to t h e i r a r o u s a l p o t e n t i a l . The ob j e c t of t h i s homework assignment i s to r e i n t r o d u c e some of these behaviors i n a s i t u a t i o n where both p a r t n e r s r e a l i z e t h a t i n t e r c o u r s e i s p r o h i b i t e d . 2. i t i s suggested t h a t both p a r t n e r s use the r e l a x a t i o n e x e r c i s e s at l e a s t twice d a i l y f o r the coming week 3. the three i n t r o d u c t o r y chapters from Our Bodies, Ourselves: A Book By and For Women (Boston Womens He a l t h C o l l e c t i v e , 1971) are assigned I t i s suggested that each c l i e n t read a chapter and then d i s c u s s i t with h i s or her p a r t n e r . This not only f a c i l i t a t e s communication, but a l s o helps p a r t n e r s explore and d i s c u s s new areas of sexual knowledge. Sess i o n 2 A. F i r s t h a l f of s e s s i o n female(s) with female t h e r a p i s t : The f i r s t p o r t i o n of t h i s and a l l succeeding s e s s i o n s i s g i v e n t o a review of the past week's homework with emphasis on both new l e a r n i n g and prog r e s s . I f any d i f f i c u l t i e s have a r i s e n they are d e a l t with and a l t e r n a t e s t r a t e g i e s are suggested. 106 The focus of t h i s s e s s i o n r e v o l v e s around a t t i t u d e s towards and experience with masturbation. The r o l e of p a r e n t a l a t t i t u d e s and t e a c h i n g towards masturbation and i t s e f f e c t s are d i s c u s s e d 1. the f i r s t two steps of L o P i c c o l o and L o b i t z ' s (1972) nine step masturbation program Step 1 - to i n c r e a s e body s e l f awareness the woman i s encouraged to use a hand m i r r o r to explore her g e n i t a l area. Women are a l s o encouraged to begin to p r a c t i c e the Kegel e x e r c i s e s (1952). Step 2 - i f the woman f e e l s p e r f e c t l y comfortable with Step 1 she i s now encouraged to explore her g e n i t a l s both t a c t u a l l y and v i s u a l l y . I f the woman has any a n x i e t y i n performing these e x e r c i s e s she i s encouraged to break the e x e r c i s e s down i n t o manageable p a r t s and to u t i l i z e her r e l a x a t i o n e x e r c i s e s . B. F i r s t h a l f of s e s s i o n male(s) with male t h e r a p i s t : The f i r s t p o r t i o n of t h i s and a l l succeeding sessions i s giv e n to a review of the past week's homework with emphasis on both new l e a r n i n g and p r o g r e s s . I f any d i f f i c u l t i e s have a r i s e n they are d e a l t with and a l t e r n a t e s t r a t e g i e s are suggested. The focus of t h i s s e s s i o n r e v o l v e s around a t t i t u d e s towards and experience with masturbation. The r o l e of p a r e n t a l a t t i t u d e s and t e a c h i n g towards masturbation and i t s 107 e f f e c t s ared d i s c u s s e d . Homework: 1. attempt masturbation and note any d i f f i c u l t i e s C. Male(s) and Female(s) Together F i l m : S e x o l o g i c a l Examination - a short documentary on how to give feedback to p a r t n e r ' s s t i m u l a t i o n . Systematic methods of s t i m u l a t i o n and feedback are modeled. D i s c u s s i o n P e r i o d : 1. r e p o r t on s e s s i o n from male and female r e p r e s e n t a t i v e 2. progress to date 3. feedback and questions about r e l a x a t i o n e x e r c i s e s 4. exact use and b e n e f i t s of S e x o l o g i c a l Examination Here, the importance of being able to communicate l i k e s and d i s l i k e s to p a r t n e r i s emphasized. For those who f e e l anxious or apprehensive about t r y i n g the e x e r c i s e , i t i s suggested that they break i t down i n t o two p a r t s - the g e n i t a l and n o n - g e n i t a l stages. U t i l i z a t i o n of the r e l a x a t i o n e x e r c i s e s are a l s o suggested as an a d d i t i o n a l a i d . Homework: 1. both p a r t n e r s are to begin r e a d i n g For Y o u r s e l f , by L.G. Barbach. In order to f a c i l i t a t e d i s c u s s i o n i t i s suggested that each p a r t n e r u n d e r l i n e the p o i n t s he or she would l i k e to d i s c u s s with t h e i r p a r t n e r and proceed to do so at the end 108 o f each c h a p t e r . 2. c o u p l e s a re i n s t r u c t e d t o c o n t i n u e w i t h the r e l a x a t i o n e x e r c i s e s 3. c o u p l e s are i n s t r u c t e d t o t r y grad u a t e d and f u l l form of s e x o l o g i c a l e x a m i n a t i o n a t l e a s t t h r e e times d u r i n g the week S e s s i o n 3 A. F i r s t h a l f o f s e s s i o n f e m a l e ( s ) w i t h female t h e r a p i s t : 1. r e v i e w of homework and d i s c u s s i o n of r e a d i n g s 2. s p e c i a l emphasis i s p l a c e d on each c l i e n t ' s ( c l i e n t s ) e x p e r i e n c e w i t h the f i r s t two st e p s i n the m a s t u r b a t i o n program 3. a t t i t u d e s and f e e l i n g s towards m a s t u r b a t i o n a r e a g a i n d i s c u s s e d Homework: 1. women are now encouraged t o t a c t u a l l y l o o k f o r s e n s i t i v e a r e a s t h a t produce f e e l i n g s o f p l e a s u r e 2. once these a r e a s have been a s c e r t a i n e d women a r e encouraged t o use manual s t i m u l a t i o n t o produce orgasm ( i f p o s s i b l e ) B. F i r s t h a l f of s e s s i o n m a l e ( s ) w i t h male t h e r a p i s t : 1. d i s c u s s i o n of r e a d i n g s and statement as t o how week went 2. q u e s t i o n s about s p e c i f i c problems w i t h male m a s t u r b a t i o n 3. d i s c u s s i o n of the v a l u e of f o r e p l a y w i t h an emphasis on the l e n g t h of time needed t o arouse t h e i r p a r t n e r s C. M a l e ( s ) and Female(s) Together: F i l m : Documentary on Women and Orgasm-both i n s t r u c t i o n a l i n f o r m a t i o n and d i s c u s s i o n of the n a t u r e of orgasm 109 Di s c u s s i o n 1. r e p o r t on s e s s i o n from both male and female r e p r e s e n t a t i v e 2. f e e l i n g s on and or problems with male or female masturbation 3. f o r e p l a y - why i t i s important - d i f f e r e n t s t r a t e g i e s , e.g. i n c o r p o r a t i n g massages and the s e x o l o g i c a l examination i n t o f o r e p l a y 4. the importance of the female communicating her f i n d i n g s re p l e a s u r a b l e areas from the masturbation e x e r c i s e s - t h i s may be done e i t h e r v e r b a l l y or n o n - v e r b a l l y whichever method i s more comfortable Homework: 1. continue s e x o l o g i c a l examinations 2. d i s c u s s p r e f e r r e d modes of f o r e p l a y 3. f i n i s h and d i s c u s s For Y o u r s e l f S e s s i o n 4 A. F i r s t h a l f female(s) with female t h e r a p i s t : 1. d i s c u s s i o n of readings and r e p o r t on masturbation attempts A major focus of t h i s s e s s i o n i s the importance of s e t t i n g time a s i d e f o r pers o n a l a c t i v i t i e s . Very o f t e n women w i l l complain that they have no time f o r masturbation i n short f o r themselves. I f necessary i n s t r u c t i o n s are given f o r s e l f - m o n i t o r i n g of e x a c t l y how many hours a week are devoted to s e l f . 110 For those women having d i f f i c u l t y with masturbation or f o r those women who want to enhance t h e i r sexual response, the u t i l i z a t i o n of v i b r a t o r s i s suggested. Here, a t t i t u d e s and questions of types are d e a l t with. Women are assured that they w i l l not become "hooked" on the v i b r a t o r and are give n s t r a t e g i e s f o r g r a d u a l l y i n t r o d u c i n g i t i n t o t h e i r f o r e p l a y s e s s i o n . 2. the use of f a n t a s y i n both masturbation and i n t e r c o u r s e i s a l s o d i s c u s s e d Homework: 1. i f masturbation i s not s u c c e s s f u l continue attempts with or without v i b r a t o r s 2. i f masturbation produces p l e a s u r a b l e r e s u l t s , women are r e s p o n s i b l e f o r communicating these areas to the male 3. read My Secret Garden by Nancy F r i d a y B. F i r s t h a l f male(s) w i t h male t h e r a p i s t : 1. r e p o r t on homework, readings and progress i n g eneral The major focus of t h i s s e s s i o n i s d e f i n i t i o n of and e x p l a n a t i o n of probable e t i o l o g i c a l causes of premature e j a c u l a t i o n . The nature of l e a r n i n g and a n x i e t y i n causing and m a i n t a i n i n g the problem i s underscored. The b a s i c p r i n c i p l e s of the Seamans (1956) and Masters and Johnson (1970) squeeze technique are i n t r o d u c e d . C. Male(s) and Female(s) Together: F i l m : S e x u a l i t y and Communication Drs. A. and B. Chernick I l l D i s c u s s i o n P e r i o d : 1. r e p o r t on s e s s i o n from, both male and female r e p r e s e n t a t i v e s 2. d i s c u s s i o n of communication s t r a t e g i e s i n the f i l m as they apply to the cou p l e ( s ) I f p o s s i b l e s p e c i f i c examples are e l i c i t e d . The d i s c u s s i o n a l s o encompasses the importance of sexual communication i n terms of l i k e s and d i s l i k e s and a l s o i n terms of saying "yes and no" to sexual advances. C l e a r s t r a t e g i e s f o r a c c e p t i n g or r e j e c t i n g sexual o v e r t u r e s are r o l e - p l a y e d and d i s c u s s e d . 3. r e - i n t r o d u c t i o n of i n t e r c o u r s e i s d i s c u s s e d Here couples are admonished to u t i l i z e a l l the coping and communication s k i l l s they have been p r a c t i c i n g i n the past three weeks Homework: 1. both p a r t n e r s are to make a l i s t of at l e a s t three i n s t a n c e s where communication, sexual or g e n e r a l , breaks down or becomes d i f f i c u l t 2. l i s t i s to be d i s c u s s e d d u r i n g the week and brought to the.next s e s s i o n 3. r e a d i n g My Secret Garden ( F r i d a y , 1973) Sessi o n 5 A. F i r s t h a l f female(s) with female t h e r a p i s t : 1. d i s c u s s i o n of readings and statement as to how week went 2. questions and progress with masturbation 3. d i s c u s s i o n of c o n t r a c e p t i o n and v a g i n a l d i s o r d e r s and t h e i r e f f e c t s on a r o u s a l and i n t e r c o u r s e 112 The major f o c u s of t h i s s e s s i o n i s on e f f e c t i v e communication. S p e c i a l emphasis i s p l a c e d on the c o u p l e ' s ( c o u p l e s ' ) s p e c i f i c communication d i f f i c u l t i e s . Areas where the woman has d i f f i c u l t y communicating are h i g h -l i g h t e d . R o l e - p l a y i n g i s u t i l i z e d i f n e c e s s a r y . B. F i r s t h a l f m a l e ( s ) w i t h male t h e r a p i s t : 1. statements as t o how week went and p r o g r e s s i n g e n e r a l 2. d i s c u s s i o n of methods o f c o n t r a c e p t i o n 3. causes and t r e a t m e n t s of impotence are d i s c u s s e d The major f o c u s of t h i s s e s s i o n i s on e f f e c t i v e communication. S p e c i a l emphasis i s p l a c e d on the c o u p l e ' s ( c o u p l e s ' ) s p e c i f i c communication d i f f i c u l t i e s . Areas where the man has d i f f i c u l t y communicating are h i g h l i g h t e d . R o l e - p l a y i n g i s u t i l i z e d i f n e c e s s a r y . C. M a l e ( s ) and Female(s) Together: F i l m : The Squeeze Technique D i s c u s s i o n P e r i o d : 1. r e p o r t on s e s s i o n from both male and female r e p r e s e n t a t i v e s 2. c o u p l e ( s ) r o l e p l a y t h e i r communication d i f f i c u l t i e s i l l u s t r a t i n g the " r i g h t " s t r a t e g i e s t o u t i l i z e 3. the r e p e r c u s s i o n s , b o t h p o s i t i v e and n e g a t i v e of r e i n s t i t u t i n g i n t e r c o u r s e are d i s c u s s e d 4. f u r t h e r e x p l a n a t i o n of the squeeze t e c h n i q u e and s p e c i f i c i n s t r u c t i o n s f o r use 5. reminder of f i n a l s e s s i o n n e x t week 113 Homework: 1. p r a c t i c e communication s k i l l s 2. t r y the squeeze technique at l e a s t f o u r times d u r i n g the week Sessi o n 6 A. F i r s t h a l f female(s) with female t h e r a p i s t : 1. statements as to how week went and progress i n g e n e r a l 2. q u e s t i o n s s p e c i f i c a l l y about communication problems and the squeeze technique are s o l i c i t e d The f o c a l p o i n t of t h i s s e s s i o n i s to prepare c l i e n t s f o r t e r m i n a t i o n of therapy. S p e c i f i c a l l y , c l i e n t s are asked to w r i t e a maintenance program i n c l u d i n g : 1. problems they foresee coming up i n the next three weeks 2. s t r a t e g i e s f o r coping with these problems 3. document a l l aspects of p e r c e i v e d p r o g r e s s , no matter how small Feedback i s e l i c i t e d from the c l i e n t s as to t h e i r impression of the program, s p e c i f i c a l l y : 1. what b e n e f i t s they experienced 2. p a r t s of the program they f e l t were most u s e f u l 3. areas i n the program they would l i k e to see improved 4. suggestions f o r f u t u r e i n c l u s i o n s or d e l e t i o n s B. F i r s t h a l f male(s) with male t h e r a p i s t : T h i s s e s s i o n i s i d e n t i c a l t o the female s e s s i o n d e s c r i b e d above 114 Male(s) and Female(s) Together: 1. Sexual Arousal Inventory and S a t i s f a c t i o n Index are r e - a d m i n i s t e r e d 2. feedback from c o u p l e ( s ) as a u n i t about t h e i r experience i n the program i s s o l i c i t e d 3. the importance of c o n t i n u i n g a l l s k i l l s l e a r n e d i n the program i s s t r e s s e d Homework: 1. c o u p l e ( s ) are i n s t r u c t e d to s y s t e m a t i c a l l y go through each other's maintenance l i s t and d i s c u s s any p o i n t s of c o n t e n t i o n or areas that need c l a r i f i c a t i o n 2. c o u p l e ( s ) are i n s t r u c t e d to continue r e c o r d i n g t h e i r sexual behaviors v i a the Sexual Behavior C h e c k l i s t f o r the next three weeks 3. i f problems a r i s e c o u p l e ( s ) are t o l d to immediately contact the t h e r a p i s t s whether at home or at the o f f i c e 4. an appointment i s made f o r the three week f o l l o w up Three Week Follow-Up At t h i s s e s s i o n a l l couples are seen i n d i v i d u a l l y . T h i s s e s s i o n i s seen as a check s e s s i o n where pr o g r e s s , problems and plans f o r the next three months are d i s c u s s e d . The Sexual A r o u s a l Inventory, the Post Program Questi o n n a i r e and the S a t i s f a c t i o n Index are r e - a d m i n i s t e r e d . Content of both t h i s and the three month follow-up i s t a i l o r e d to the i n d i v i d u a l couple's s p e c i f i c needs. Three Month Follow-Up Format and focus i s i d e n t i c a l to the three week s e s s i o n . 115 APPENDIX II Sexual Behavior Inventory Name: Date: Please i n d i c a t e your weekly frequency of the f o l l o w i n g Male seeing female nude 1...5....10....15....20 Female seeing male nude 1...5....10....15....20 Male g i v i n g female body massage e x c l u d i n g b r e a s t s and g e n i t a l s 1...5....10....15....20 Female g i v i n g male body massage e x c l u d i n g g e n i t a l s 1...5....10....15....20 Male c a r e s s i n g female b r e a s t s with hands 1...5....10....15....20 Male c a r e s s i n g female b r e a s t s with mouth 1...5....10....15....20 Female c a r e s s i n g male g e n i t a l s with hands 1...5....10....15....20 Male c a r e s s i n g female g e n i t a l s with hands 1...5....10....15....20 In t e r c o u r s e 1...5....10....15....20 Female orgasm through masturbation 1...5....10....15....20 Female orgasm through g e n i t a l m a n i p u l a t i o n by male 1...5....10....15....20 Female orgasm through i n t e r c o u r s e 1. . .5....10....15....20 Number of female i n i t i a t e d sexual behaviors 1... 5 ....10....15 .... 20 Number of male i n i t i a t e d sexual behaviors 1...5....10....15....20 116 APPENDIX I I I Sexual S a t i s f a c t i o n Index The f o l l o w i n g s c a l e i s to be used when responding to the q u e s t i o n n a i r e : 0 = e n t i r e l y d i s s a t i s f i e d 4 = s l i g h t l y s a t i s f i e d 1 = moderately d i s s a t i s f i e d 5 = moderately s a t i s f i e d 2 = s l i g h t l y d i s s a t i s f i e d 6 = extremely s a t i s f i e d 3 = n e u t r a l Please i n d i c a t e your l e v e l of s a t i s f a c t i o n with r e s p e c t to the f o l l o w i n g : c i r c l e the number that most a p p l i e s to your present f e e l i n g s . 1. my f e e l i n g s about my own s e x u a l i t y 0 1 2 3 4 5 6 2. my f e e l i n g s about my body 0 1 2 3 4 5 6 3. my r o l e i n our sexual r e l a t i o n s h i p 0 1 2 3 4 5 6 4. my p a r t n e r ' s r o l e i n our sexual r e l a t i o n s h i p 0 1 2 3 4 5 6 5. my a b i l i t y to communicate wi t h my p a r t n e r 0 1 2 3 4 5 6 6. my p a r t n e r ' s a b i l i t y to communicate wit h me 0 1 2 3 4 5 6 7. my a b i l i t y to d i s c u s s sex with my p a r t n e r 0 1 2 3 4 5 6 8. my p a r t n e r ' s a b i l i t y to d i s c u s s sex with me 0 1 2 3 4 5 6 9. my l e v e l of s a t i s f a c t i o n with the r e l a t i o n s h i p i n general 0 1 2 3 4 5 6 10. my p a r t n e r ' s l e v e l of s a t i s f a c t i o n with the r e l a t i o n s h i p i n general 0 1 2 3 4 5 6 11. my l e v e l of s a t i s f a c t i o n with our sexual r e l a t i o n s h i p 0 1 2 3 4 5 6 12 . my p a r t n e r ' s l e v e l of s a t i s f a c t i o n w i t h our sexual r e l a t i o n s h i p 0 1 2 3 4 5 6 13. my knowledge about sex as l e a r n e d from my parents 0 1 2 3 4 5 6 14. my a t t i t u d e towards masturbation 0 1 2 3 4 5 6 15. my a b i l i t y to masturbate 0 1 2 3 4 5 6 117 16. number of male sexual i n i t i a t i v e s 0 1 2 3 4 5 6 17. number of female, sexual i n i t i a t i v e s 0 1 2 3 4 5 6 18. frequency of i n t e r c o u r s e 0 1 2 3 4 5 6 19. d u r a t i o n of f o r e p l a y 0 1 2 3 4 5 6 20. my a b i l i t y to achieve climax through i n t e r c o u r s e 0 1 2 3 4 5 6 21. my a b i l i t y to achieve climax through s e l f - m a s t u r b a t i o n 0 1 2 3 4 5 6 22. my a b i l i t y t o achieve climax through g e n i t a l m a n i p u l a t i o n by my p a r t n e r 0 1 2 3 4 5 6 118 APPENDIX IV Sexual A r o u s a l Index I n s t r u c t i o n s The experiences i n t h i s i n v e n t o r y may or may not be s e x u a l l y arousing to you. There are no r i g h t or wrong answers. Read each item c a r e f u l l y , and then c i r c l e the number which i n d i c a t e s how s e x u a l l y aroused you f e e l when you have the d e s c r i b e d experience, or how s e x u a l l y aroused you t h i n k you would f e e l i f you a c t u a l l y experienced i t . Be sure to answer every item. I f you aren't c e r t a i n about an item, c i r c l e the number that seems about r i g h t . The meaning of the numbers i s given below: -1 a d v e r s e l y e f f e c t s a r o u s a l ; u n t h i n k a b l e , r e p u l s i v e , d i s t r a c t i n g 0 doesn't a f f e c t sexual a r o u s a l 1 p o s s i b l y causes sexual a r o u s a l 2 sometimes causes sexual a r o u s a l ; s l i g h t l y a r o u s i n g 3 u s u a l l y causes sexual a r o u s a l ; moderately a r o u s i n g 4 almost always s e x u a l l y a r o u s i n g ; very a r o u s i n g 5 always causes sexual a r o u s a l ; extremely a r o u s i n g 119 How you f e e l or t h i n k you ANSWER EVERY ITEM would f e e l i f you were a c t u a l l y i n v o l v e d i n t h i s experience *1. When a loved one s t i m u l a t e s - 1 0 1 2 3 4 5 your g e n i t a l s with mouth & tongue *2. When a loved one fon d l e s - 1 0 1 2 3 4 5 your b r e a s t s with h i s / her hands 3. When you see a loved one - 1 0 1 2 3 4 5 nude 4. When a loved one caresses you with h i s / h e r eyes -1 0 1 2 3 4 5 *5. When a loved one s t i m u l a t e s - 1 0 1 2 3 4 5 your g e n i t a l s with h i s / h e r f i n g e r *6. When you are touched or - 1 0 1 2 3 4 5 k i s s e d on the in n e r t h i g h s by a loved one 7. When you caress a loved - 1 0 1 2 3 4 5 one's g e n i t a l s with your f i n g e r s 8. When you read a pornographic - 1 0 1 2 3 4 5 or " d i r t y " s t o r y *9. When a loved one undresses - 1 0 1 2 3 4 5 you *10. When you dance with a loved - 1 0 1 2 3 4 5 one *11. When you have i n t e r c o u r s e - 1 0 1 2 3 4 5 with a loved one *12.- When a love d one touches -1 0 1 2 3 4 5 or k i s s e s your n i p p l e s 13. When you caress a loved one - 1 0 1 2 3 4 5 (other than g e n i t a l s ) "14. When you see pornographic - 1 0 1 2 3 4 5 p i c t u r e s or s l i d e s 120 *15. When you l i e i n bed with a - 1 0 1 2 3 4 5 loved one *16. When a loved one k i s s e s you - 1 0 1 2 3 4 5 p a s s i o n a t e l y 17. When you hear sounds of - 1 0 1 2 3 4 5 pl e a s u r e d u r i n g sex *18. When a love d one k i s s e s - 1 0 1 2 3 4 5 you with an e x p l o r i n g tongue *19. When you read suggestive or -1 0 1 2 3 4 5 pornographic poetry 20. When you see a s t r i p show -1 0 1 2 3 4 5 21. When you s t i m u l a t e your - 1 0 1 2 3 4 5 par t n e r s g e n i t a l s with your mouth & tongue 22. When a love d one caresses - 1 0 1 2 3 4 5 you (other than g e n i t a l s ) 23. When you see a pornographic - 1 0 1 2 3 4 5 movie ( s t a g f i l m ) 24. When you undress a loved one - 1 0 1 2 3 4 5 25. When a loved one fon d l e s - 1 0 1 2 3 4 5 your b r e a s t s with mouth and tongue *26. When you make love i n a new - 1 0 1 2 3 4 5 or unusual p l a c e 27. When you masturbate - 1 0 1 2 3 4 5 28. When your p a r t n e r has an - 1 0 1 2 3 4 5 orgasm Note - Maximum p o s s i b l e score = 140. T o t a l score i s obtained by (a) adding p o s i t i v e s c o r e s , (b) adding negative s c o r e s , and (c) s u b t r a c t i n g the sum of any negative scores from the sum of p o s i t i v e s c o r e s . A s t e r i s k s i n d i c a t e those items comprising Form A. Form B c o n s i s t s of items without a s t e r i s k s . 121 APPENDIX V A d v i s e d Consent Form To a s s u r e us t h a t you are f u l l y i n f o r m e d , w i l l you p l e a s e answer the f o l l o w i n g q u e s t i o n s : 1. Do you w i l l i n g l y c onsent t o p a r t i c i p a t e i n t h i s t r e a t m e n t ? YES* NO 2. I am not f r e e t o withdraw from t h i s t r e a t m e n t whenever I choose. TRUE FALSE* 3. D e t a i l s about t h e t r e a t m e n t have been e x p l a i n e d t o me. TRUE* FALSE 4. I u n d e r s t a n d t h a t some o f the t e c h n i q u e s and i n f o r m a t i o n may be used f o r r e s e a r c h p u r p o s e s , but o n l y i f s t e p s are t a k e n t o p r o t e c t my c o n f i d e n t i a l i t y . YES* NO SIGNED: DATE: WITNESSED: DATE: * I n d i c a t e s c o r r e c t response 122 Informed Consent Form I have been i n f o r m e d o f the pr o c e d u r e s t h a t w i l l be u t i l i z e d a t the Human S e x u a l i t y C l i n i c , O u t p a t i e n t Department, S t . P a u l ' s and H e a l t h S c i e n c e s C e n t r e H o s p i t a l . W h i l e the s t a f f w i l l make e v e r y r e a s o n a b l e e f f o r t t o h e l p me, I u n d e r s t a n d t h a t the u l t i m a t e success of such a program of t r e a t m e n t i s l a r g e l y my own r e s p o n s i b i l i t y . I u n d e r s t a n d t h a t t r e a t m e n t success r e q u i r e s home p r a c t i c e and e v a l u a t e r e c o r d i n g , and t h a t b e n e f i t s from t r e a t m e n t w i l l d i m i n i s h w i t h o u t such r e g u l a r p r a c t i c e . Not everybody b e n e f i t s from t r e a t m e n t and c e r t a i n l y no one i s even problem f r e e a t the end o f t r e a t m e n t . P a r a d o x i c a l l y , the t e r m i n a t i o n of tr e a t m e n t i s o f t e n the s t a r t of r e a l p r o g r e s s . On the o t h e r hand, the r e t u r n of problems may ser v e as an i m p o r t a n t reminder t o c o n t i n u e t h e r a p e u t i c p r a c t i c e s . F u r t h e r , I u n d e r s t a n d t h a t some of the pr o c e d u r e s and d a t a w i l l be used f o r r e s e a r c h p u r p o s e s . A l l i n f o r m a t i o n about my t r e a t m e n t i s s t r i c t l y c o n f i d e n t i a l and w i l l not be r e l e a s e d w i t h o u t my p e r m i s s i o n and/or s t e p s b e i n g t a k e n t o p r o t e c t my i d e n t i t y . I t i s my r i g h t t o withdraw from t h i s program whenever I choose. 123 APPENDIX VI Program O u t l i n e : Human S e x u a l i t y C l i n i c I n i t i a l Interview 1 D e t a i l e d sexual h i s t o r y S ession 1 Female: Male: Couple: Homework: 2. Program e x p l a n a t i o n 3. D e c i s i o n as to p a r t i c i p a t i o n i n program 4. Informed consent 5. D i s c u s s i o n of and a d m i n i s t r a t i o n of the Sexual S a t i s f a c t i o n Index and the Sexual Arousal Inventory 6. D i s c u s s i o n of and i n s t r u c t i o n f o r the Sexual Behavior Inventory 7. Treatment assignment 1. Treatment e x p e c t a t i o n s 2. Problem statement 1. Treatment e x p e c t a t i o n s 2. Problem statement 1. D i s c u s s i o n of l e a r n i n g theory of sexual d y s f u n c t i o n 2. R a t i o n a l e r e : c e s s a t i o n of i n t e r c o u r s e 3. R e l a x a t i o n t r a i n i n g 4. F i l m : Human S e x u a l i t y (Szasz, 1974) 1. R e l a x a t i o n e x e r c i s e s , twice d a i l y 2. Increase non-sexual p h y s i c a l contact 124 3. Reading: Our Bodies, Ourselves, (Boston Women's Hea l t h C o l l e c t i v e , 1971) Sess i o n 2 Female: Male: Couple: Homework: Sess i o n 3 Female 1. Weekly summary 2. A t t i t u d e s towards and experience with masturation 1. Weekly summary 2. A t t i t u d e s towards and experience with masturbation 1. D i s c u s s i o n of f i r s t h a l f of s e s s i o n 2. Feedback on r e l a x a t i o n e x e r c i s e s 3. F i l m : The S e x o l o g i c a l Examination (Sutton, 1973) 4. D i s c u s s i o n of the S e x o l o g i c a l Examination 1. Female: do f i r s t two steps of L o P i c c o l o and L o b i t z (1972) Masturbation t r a i n i n g . A l s o do Kegel e x e r c i s e s (1952) 2. Male: attempt masturbation and note p h y s i c a l sensations and c o g n i t i o n s 3. Couple: continue r e l a x a t i o n e x e r c i s e s 4. A t t e m p t s e x o l o g i c a l examination at l e a s t 3 times 5. Reading: For Y o u r s e l f (Barbach, 1975) Chapters 1-3 1. Weekly summary 125 Male : Couple: Homework: Session 4 Female: Male: 2. D i s c u s s i o n of masturbation attempts 3. D i s c u s s i o n of r e a d i n g 1. Weekly summary 2. D i s c u s s i o n of masturbation attempts 3. D i s c u s s i o n of re a d i n g 4. Emphasis on value of f o r e p l a y 1. D i s c u s s i o n of f i r s t h a l f of s e s s i o n 2. F i l m : Handvoice (Sutton, 1970), Women on Orgasm ( B r e i t r o s e , 1973) 3. F e e l i n g s on and or problems with male or female masturbation 4. D i s c u s s i o n of importance of f o r e p l a y 5. Importance of p a r t n e r s communicating masturbatory s t r a t e g i e s 1. Female: attempt masturbation 2. Couple: continue s e x o l o g i c a l examinations 3. Discuss p r e f e r r e d modes of f o r e p l a y 4. F i n i s h and d i s c u s s For Y o u r s e l f (Barbach, 1975) 1. Weekly summary 2. D i s c u s s i o n of readings 3. D i s c u s s i o n of masturbation attempts 4. S e l f - m o n i t o r i n g of pers o n a l time 5. Use of f a n t a s y and u t i l i z a t i o n of v i b r a t o r s 1. Weekly summary 2. D i s c u s s i o n of readings 126 3. D i s c u s s i o n of premature e j a c u l a t i o n 4. E x p l a n a t i o n of Semans (1956) and Masters and Johnson (1970) Squeeze Technique Couple: 1. D i s c u s s i o n of f i r s t h a l f of s e s s i o n 2. F i l m : S e x u a l i t y and Communication (Chernik and Chernik, 1975) 3. D i s c u s s i o n of f i l m 4. D i s c u s s i o n of communication s t r a t e g i e s i n c l u d i n g r o l e - p l a y i n g 5. R e - i n t r o d u c t i o n of i n t e r c o u r s e and summation of s k i l l s l e a r n e d to date 1. Continue masturbation i f not s u c c e s s f u l t r y v i b r a t o r 2. Communication of p l e a s u r a b l e areas to p a r t n e r Couple: 3. L i s t three i n s t a n c e s where communication, sexual or general breaks down or becomes d i f f i c u l t 4. Reading: My Secret Garden ( F r i d a y , 1973) 5. D i s c u s s i o n of and perhaps r e - i n t r o d u c t i o n of i n t e r c o u r s e Homework: Female: Sess i o n 5 Female: 1. Weekly summary 2. D i s c u s s i o n of readings 3. D i s c u s s i o n of masturbation 127 Male: Couple: Homework: Sessi o n 6 Female: Male : 4. D i s c u s s i o n of attempts or thoughts about i n t e r c o u r s e 5. D i s c u s s i o n of c o n t r a c e p t i o n and v a g i n a l d i s o r d e r s 6. P r a c t i s e of communication s k i l l s 1. Weekly summary 2. D i s c u s s i o n of readings 3. D i s c u s s i o n of attempts or thoughts about i n t e r c o u r s e 4. Causes and treatment of impotence 5. P r a c t i c e of communication s k i l l s 1. D i s c u s s i o n of f i r s t h a l f of s e s s i o n 2. F i l m : Squeeze Technique (Sutton, 1970) 3. D i s c u s s i o n of f i l m and techniques f o r premature e j a c u l a t i o n and impotence 4. Ro l e - p l a y of communication s t r a t e g i e s 5. D i s c u s s i o n of i n t e r c o u r s e 1. P r a c t i c e communication s k i l l s 2. Try squeeze technique at l e a s t 4 times 1. Weekly summary 2. D i s c u s s i o n of communication s k i l l s 3. D i s c u s s i o n of squeeze technique 4. Design maintenance l i s t 1. Weekly summary 2. D i s c u s s i o n of communication s k i l l s 128 3. D i s c u s s i o n of squeeze technique 4. Design maintenance l i s t Couple: 1. D i s c u s s i o n of f i r s t h a l f of s e s s i o n 2. D i s c u s s i o n of maintenance l i s t s 3. Feedback about the program 4. R e - a d m i n i s t r a t i o n of the Sexual Arousal Inventory and the Sexual S a t i s f a c t i o n Index 5. Summation of s k i l l s l e a r n e d Homework: 1. D i s c u s s i o n of maintenance l i s t s 2. Continue with the Sexual Behavior Index 3 Week Follow Up 1. I n d i v i d u a l s e s s i o n 2. Sexual S a t i s f a c t i o n Index 3. Sexual Arousal Inventory 3 Month Follow Up 1. I n d i v i d u a l s e s s i o n 2. Sexual S a t i s f a c t i o n Index 3. Sexual Arousal Inventory 129 APPENDIX V I I T e n s i o n Management When peopl e d i s c u s s the a n x i e t y t h a t t h e y f e e l t h ey t y p i c a l l y r e p o r t q u i t e a b i t o f t e n s e n e s s and a n x i e t y i n a v a r i e t y o f s i t u a t i o n s . T h i s can take t h e form of stomach and neck becoming t e n s e , pounding h e a r t , sweaty palms, heavy b r e a t h i n g and so on. At the same time they f r e q u e n t l y d e s c r i b e how d i f f i c u l t i t i s t o f o c u s a t t e n t i o n on o n l y the t a s k a t hand. Somehow t h e i r a t t e n t i o n wanders away from what they are d o i n g or what they are i n v o l v e d i n , and they become p r e o c c u p i e d w i t h i r r e l e v a n t t h o u g h t s . T h e i r t h i n k i n g o r s e l f - s t a t e m e n t s , seem t o get i n the way of what they are a t t e m p t i n g t o do. They t h i n k about c a t a s t r o p h e s and how t e r r i b l e the consequences would be and t h e s e i n t e r f e r e w i t h the way t h a t one p e r f o r m s . One g o a l of t r e a t m e n t i s f o r you'to become aware of the f a c t o r s which are m a i n t a i n i n g your a n x i e t y . Once you know what these f a c t o r s are you can change or combat them. One of the s u r p r i s i n g t h i n g s i s t h a t the f a c t o r s c o n t r i b u t i n g t o a n x i e t y are not something s e c r e t i v e but seem t o be the t h i n k i n g p r o c e s s e s you go t h r o u g h i n e v a l u a t i o n s i t u a t i o n s . S i m p l y p u t , t h e r e seems t o be a r e l a t i o n s h i p between how a n x i o u s and t e n s e p e o p l e f e e l and the k i n d s o f thoughts t h e y are e x p e r i e n c i n g . For example, the a n x i e t y you e x p e r i e n c e i n a p a r t i c u l a r s i t u a t i o n may be t i e d to the k i n d s of thoughts you had, what you chose t o t h i n k about o r how 130 you chose t o f o c u s your a t t e n t i o n . Somehow your t h i n k i n g g e t s a l l t i e d up w i t h how you are f e e l i n g . One purpose of t h e s e s e s s i o n s w i l l be t o e x p l o r e and share t h e s e f e e l i n g s and t h o u g h t s . We w i l l d e v e l o p the a b i l i t y t o n o t i c e these t h i n k i n g p r o c e s s e s , t o become aware of s e l f -s t a t e m e n t s , and t o see how we f o c u s our a t t e n t i o n . T h i s may sound new t o you, but you w i l l p r o b a b l y come t o see the r o l e t h a t t h i n k i n g p l a y s i n i n f l u e n c i n g your b e h a v i o r . What i s i s t h a t makes up a n x i e t y ? F i r s t o f a l l , t h e r e i s a h e i g h t e n e d e m o t i o n a l i t y and t e n s e n e s s . S e c o n d l y , t h e r e i s worry or t h i n k i n g p r o c e s s e s which cause you t o s h i f t your a t t e n t i o n t o y o u r s e l f and away from what i t i s you want t o a c c o m p l i s h . Over the next l i t t l e w h i l e we are g o i n g t o work on ways t o c o n t r o l how you f e e l ; on ways of c o n t r o l l i n g your a n x i e t y and t e n s e n e s s . We w i l l do t h i s by l e a r n i n g how t o r e l a x . You w i l l be t r a i n e d t o s y s t e m a t i c a l l y r e l a x a l l p o r t i o n s of your body. One of the advantages of l e a r n i n g how t o r e l a x i s t h a t the muscle systems i n your body cannot be b o t h t e n s e and r e l a x e d a t the same t i m e . T h e r e f o r e , once you have l e a r n e d the r e l a x a t i o n t e c h n i q u e , you can use i t t o c o u n t e r a n x i e t y , t e n seness and f e e l i n g s l i k e t hose you e x p e r i e n c e d i n a v a r i e t y of s i t u a t i o n s i n the p a s t . I n a d d i t i o n t o l e a r n i n g and p r a c t i c i n g the r e l a x a t i o n s k i l l s , you w i l l l e a r n how t o c o n t r o l your t h i n k i n g p r o c e s s e s and 131 a t t e n t i o n . The c o n t r o l of t h i n k i n g or what we say t o o u r s e l v e s , comes about by f i r s t becoming aware of when we are p r o d u c i n g n e g a t i v e s e l f - s t a t e m e n t s , c a t a s t r o p h i z i n g , b e i n g t a s k i r r e l e v a n t , e t c . The r e c o g n i t i o n t h a t we a r e i n f a c t d o i n g t h i s w i l l be a ste p f o r w a r d i n ch a n g i n g . T h i s r e c o g n i t i o n w i l l a l s o a c t as a re m i n d e r ; a cue f o r you t o produce d i f f e r e n t t houghts and s e l f - i n s t r u c t i o n s , t o c h a l l e n g e your t h i n k i n g s t y l e s and t o produce i m c o m p a t i b l e t a s k - r e l e v a n t , s e l f - i n s t r u c t i o n s and i n c o m p a t i b l e b e h a v i o r s . You w i l l l e a r n how t o c o n t r o l your t h i n k i n g p r o c e s s e s by some s p e c i f i c t e c h n i q u e s which w i l l be d e s c r i b e d l a t e r on. Some examples of n e g a t i v e s e l f - s t a t e m e n t s are the f o l l o w i n g : "people w i l l l a u g h a t me." " I am a f r a i d of l o o k i n g r i d i c u l o u s . " " I must a c h i e v e . " " I f I f a i l , t hen what?" " I c a n ' t do a n y t h i n g . I'M i n f e r i o r . I never c o u l d do a n y t h i n g . " " I don't know what t o say. I'm coming a c r o s s v e r y b a d l y , " and so on. The t h i n k i n g p r o c e s s e s of pe o p l e who are tense and h i g h l y a n x i o u s might be c a t e g o r i z e d as f o l l o w s : 1. W o r r y i n g about one's performance, i n c l u d i n g how w e l l o t h e r s a re d o i n g o r might do as compared w i t h h i m s e l f . 2. R u m i n a t i n g too l o n g and f r u i t l e s s l y over a l t e r n a t i v e answers or r e s p o n s e s . B e i n g p r e o c c u p i e d . w i t h b o d i l y r e a c t i o n s a s s o c i a t e d w i t h a n x i e t y . R u m i n a t i n g about p o s s i b l e consequences f o r d o i n g p o o r l y . Concern about d i s a p p r o v a l , punishment, l o s s of s t a t u s or esteem, damage t o one's work r e c o r d . Thoughts or f e e l i n g s o f inadequacy. These may i n c l u d e a c t i v e s e l f - c r i t i c i s m o r s e l f - c o n d e m n a t i o n -c a l l i n g y o u r s e l f s t u p i d or c o n s i d e r i n g y o u r s e l f w o r t h l e s s . Very o f t e n , people who are e x c e s s i v e l y t e n s e and a n x i o u s , h o l d i r r a t i o n a l b e l i e f and f u r t h e r m o r e t h e y a c t as i f t h e s e i r r a t i o n a l b e l i e f s were i n f a c t t r u t h . For example: I must be l o v e d or approved by p r a c t i c a l l y e very s i g n i f i c a n t p e r s o n i n my l i f e and i f I'm n o t , i t ' s a w f u l . I must not make e r r o r s or do p o o r l y and i f I do, i t ' s t e r r i b l e . P eople and events s h o u l d always be the way I want them t o be. One way t o c o u n t e r a c t t h e s e i r r a t i o n a l i d e a s i n orde t h a t you may f u n c t i o n more e f f e c t i v e l y , you might c o n s i d e r an a l t e r n a t i v e t o t h e s e . For example: 133 1. I t ' s d e f i n i t e l y n i c e t o have p e o p l e ' s l o v e and a p p r o v a l but even w i t h o u t i t , I can s t i l l a c c e p t and e n j o y m y s e l f . 2. Doing t h i n g s w e l l i s s a t i s f y i n g but i t ' s human to make m i s t a k e s . 3. People are g o i n g t o a c t the way they want, not the way I want. B a s i c a l l y , r e l a x a t i o n t r a i n i n g c o n s i s t s of l e a r n i n g t o ten s e and then r e l a x v a r i o u s groups of muscles a l l t h r o u g h the body, w h i l e a t the same time p a y i n g v e r y c l o s e and c a r e f u l a t t e n t i o n t o the f e e l i n g s a s s o c i a t e d w i t h b o t h t e n s i o n and r e l a x a t i o n . That i s , i n a d d i t i o n t o l e a r n i n g how t o r e l a x , you w i l l a l s o l e a r n how t o r e c o g n i z e and p i n p o i n t t e n s i o n and r e l a x a t i o n as they appear i n everyday s i t u a t i o n s as w e l l as i n the s e s s i o n s h e r e . You s h o u l d u n d e r s t a n d q u i t e c l e a r l y t h a t l e a r n i n g r e l a x a t i o n s k i l l s i s v e r y much l i k e l e a r n i n g any o t h e r k i n d s o f s k i l l such as swimming, g o l f i n g . , o r r i d i n g a b i c y c l e . I n o r d e r f o r you t o get b e t t e r a t r e l a x i n g you w i l l have t o p r a c t i c e i t j u s t as you would have t o p r a c t i c e o t h e r s k i l l s . I t ' s v e r y i m p o r t a n t t h a t you r e a l i z e t h a t p r o g r e s s i v e r e l a x a t i o n t r a i n i n g i n v o l v e s l e a r n i n g on your p a r t . There i s n o t h i n g m a g i c a l about the p r o c e d u r e s . I w i l l not be d o i n g a n y t h i n g to you, I w i l l m e r e l y be i n t r o d u c i n g you t o the t e c h n i q u e , d i r e c t i n g your a t t e n t i o n t o v a r i o u s a s p e c t s o f i t , such as the presence o f c e r t a i n f e e l i n g s i n the mu s c l e s . Without 134 your a c t i v e c o - o p e r a t i o n and r e g u l a r p r a c t i c i n g o f the t h i n g s you l e a r n , the p r o c e d u r e s are of l i t t l e u se. As I mentioned, I ' l l be a s k i n g you t o t e n s e and t h e n r e l a x v a r i o u s groups o f muscles i n your body. You may wonder why, i f we want t o produce r e l a x a t i o n we s t a r t o f f by p r o d u c i n g t e n s i o n . The r e a s o n i s t h a t f i r s t o f a l l everyone i s always a t some l e v e l o f t e n s i o n . I f a p e r s o n were not tense t o some e x t e n t , he'd s i m p l y f a l l down. The amount of t e n s i o n a c t u a l l y p r e s e n t i n everyday l i f e d i f f e r s from i n d i v i d u a l t o i n d i v i d u a l and.we say t h a t each p e r s o n has reached some a d a p t a t i o n l e v e l i n the amount of t e n s i o n under which he o p e r a t e s day t o day. The g o a l of p r o g r e s s i v e r e l a x a t i o n t r a i n i n g i s t o h e l p you l e a r n t o reduce muscles t e n s i o n i n your body f a r below your a d a p t a t i o n l e v e l a t any time you w i s h t o do so. In o r d e r t o a c c o m p l i s h t h i s I c o u l d ask you t o f o c u s your a t t e n t i o n f o r example, on the muscles i n your r i g h t hand and lower arm and t o t h e n j u s t l e t them r e l a x . Now you might t h i n k t h a t you can l e t these muscles drop down below t h e i r a d a p t a t i o n l e v e l j u s t by l e t t i n g them go and t o a c e r t a i n e x t e n t you p r o b a b l y can. However, i n p r o g r e s s i v e r e l a x a t i o n we want you t o l e a r n t o produce l a r g e r and v e r y much more n o t i c e a b l e r e d u c t i o n s i n t e n s i o n and the b e s t say t o do t h i s i s f i r s t t o produce a good d e a l of t e n s i o n i n the muscle group. That i s , t o r a i s e the t e n s i o n w e l l above the a d a p t a t i o n l e v e l and then a l l a t once r e l e a s e the 135 t e n s i o n . The r e l e a s e c r e a t e s a momentum which allows the muscles to drop w e l l below the a d a p t a t i o n l e v e l . Another important advantage to c r e a t i n g and r e l e a s i n g t e n s i o n i s that i t w i l l g i v e you a good chance to focus your a t t e n t i o n upon and become c l e a r l y aware of what t e n s i o n r e a l l y f e e l s l i k e i n each of the v a r i o u s groups of muscles we w i l l be d e a l i n g with. In a d d i t i o n , the t e n s i n g procedures w i l l make a v i v i d c o n t r a s t between t e n s i o n and r e l a x a t i o n and w i l l give you an e x c e l l e n t o p p o r t u n i t y to d i r e c t l y compare the two and a p p r e c i a t e the d i f f e r e n c e i n f e e l i n g s a s s o c i a t e d with each of these s t a t e s . The purpose of the f i r s t s e s s i o n i s to help you to l e a r n to become deeply r e l a x e d . Perhaps more r e l a x e d than you've ever been b e f o r e . We can begin by going over the muscle groups that we're going to be d e a l i n g with i n r e l a x a t i o n t r a i n i n g . At t h i s p o i n t , there are 16 muscle groups to be d e a l t w i t h . S i x t e e n groups which are tensed and r e l a x e d . As your s k i l l develops t h i s number w i l l be reduced s i g n i f i c a n t l y . The s i g n i f i c a n t muscle groups which w i l l be d e a l t w i t h are as f o l l o w s : 1. Right hand and forearm. 2. Right bicep 3. L e f t hand and forearm 136 4. L e f t b l e e p . 5. Forehead. 6. Upper cheeks and nose. 7. Lower cheeks and jaws. 8. Neck and t h r o a t . 9. Chest, shoulders and upper back. 10. Abdominal or stomach r e g i o n . 11. Right t h i g h . 12. Right c a l f . 13. Right f o o t . 14. L e f t t h i g h . 15. L e f t c a l f . 16. L e f t f o o t . In l e a r n i n g to r e l a x , the f o l l o w i n g sequence i s observed: 1. Your a t t e n t i o n i s focussed on the muscle group on which you are working. 2. At a s i g n a l from me, the muscle group i s tensed. 3. Tension i s maintained f o r a p e r i o d of 5 to 7 second 4. At a predetermined cue the muscle group i s r e l e a s e d 5. Your a t t e n t i o n i s maintained upon the muscle group as i t r e l a x e s . To make t h i s a l i t t l e c l e a r e r , what we might do i s go over a l l of the muscle groups t h a t y o u ' l l be working on. F i r s t of a l l , tense the muscles i n the r i g h t hand and the r i g h t lower arm by making a t i g h t f i s t . You should be a b l 137 to f e e l the t e n s i o n i n the hand, over the knucles and up i n t o the lower arm. Hold t h a t t e n s i o n f o r a few seconds and now r e l a x . Let a l l of the t e n s i o n go. Now, concentrate on the f e e l i n g i n your hand and i n your lower arm when a l l of the t e n s i o n i s gone. Now the r i g h t b i c e p . Tense these muscles by pushing your elbow down a g a i n s t the arm of che c h a i r . You should be able to get a f e e l i n g of t e n s i o n i n the biceps without i n v o l v i n g the muscles i n the lower arm and hand. J u s t h o l d that t e n s i o n f o r 5, 6, 7 seconds and then r e l a x and concentrate on the f e e l i n g i n your bicep when a l l of the t e n s i o n i s gone. Okay, now you w i l l do the same with the l e f t hand and forearm i n the same way. Hold the t e n s i o n , then r e l a x . J u s t as you d i d with your other hand. Concentrate on the f e e l i n g when a l l the t e n s i o n i s gone. Now do the same t h i n g with the muscles i n the l e f t b i c e p , j u s t as you d i d with your r i g h t arm. Tense, h o l d the t e n s i o n f o r a few seconds, concentrate on the f e e l i n g while i t ' s tense. Now r e l a x and concentrate on the f e e l i n g when a l l the t e n s i o n i s gone. To make th i n g s a l i t t l e e a s i e r , w e ' l l d i v i d e the f a c i a l muscles i n t o three groups. F i r s t the muscles i n the forehead area, the upper p a r t of the f a c e ; then the muscles i n the c e n t r a l p a r t of the face - the upper p a r t of the cheeks and nose - and f i n a l l y , the lower p a r t of the face -138 the jaws and the lower p a r t o f the cheeks. We can b e g i n w i t h the muscles i n the upper p a r t of the f a c e .and you can te n s e t h e s e muscles by l i f t i n g t he eyebrows j u s t as h i g h as you can and g e t t i n g t e n s i o n i n the f o r e h e a d and up i n t o the s c a l p r e g i o n . H o l d t h i s t e n s i o n , c o n c e n t r a t e on the f e e l i n g w h i l e the muscles a r e ten s e and c o n c e n t r a t e on the f e e l i n g when the t e n s i o n i s gone. Now t h e muscles i n t h e c e n t r a l p a r t o f the f a c e . I n o r d e r t o t e n s e t h e s e , s q u i n t your eyes v e r y t i g h t l y and a t the same time w r i n k l e up your nose and get t e n s i o n t h r o u g h the c e n t r a l p a r t o f your f a c e . You s h o u l d be a b l e t o f e e l the t e n s i o n i n the upper p a r t of the cheeks and through the eyes. J u s t c o n c e n t r a t e on t h i s - r e l a x - and c o n c e n t r a t e on the f e e l i n g when a l l the t e n s i o n i s gone. Nex t , te n s e the muscles i n the l o w e r p a r t of your f a c e by b i t i n g your t e e t h t o g e t h e r and p u s h i n g your tongue a g a i n s t the r o o f o f your mouth. C o n c e n t r a t e on the f e e l i n g i n the s e m u s c l e s , r e l a x and now c o n c e n t r a t e on the f e e l i n g when the t e n s i o n i s gone. Now w e ' l l move on t o r e l a x the muscles i n the neck. To do t h i s , p u l l your c h i n down towards your c h e s t and a t the same t i m e , t r y t o p r e v e n t i t from a c t u a l l y t o u c h i n g your neck. That i s , c o u n t e r p o s e the muscles i n the f r o n t p a r t of your neck a g a i n s t those o f the back p a r t of the neck. You s h o u l d f e e l a l i t t l e b i t o f s h a k i n g o r t r e m b l i n g i n these muscles as you ten s e them. Okay, now r e l a x and c o n c e n t r a t e 139 on t h e f e e l i n g when the t e n s i o n i s gone. Now the muscles of the c h e s t , s h o u l d e r s and the upper back. Take a deep b r e a t h and h o l d i t , w h i l e a t the same t i m e , p u l l i n g the s h o u l d e r b l a d e s t o g e t h e r . That i s , p u l l your s h o u l d e r s back so t h a t you are t r y i n g t o make your s h o u l d e r b l a d e s t o u c h . You s h o u l d fee the t e n s i o n i n your c h e s t , s h o u l d e r s and upper back. C o n c e n t r a t e on.the f e e l i n g here and r e l a x and c o n c e n t r a t e on the f e e l i n g when the t e n s i o n i s gone. Now the muscles i n the abdomen. Here, make your stomach h a r d . J u s t t e n s e i t up as though you were g o i n g t o h i t y o u r s e l f i n the stomach. You s h o u l d f e e l a good d e a l o f t e n s i o n and t i g h t n e s s i n the stomach a r e a . C o n c e n t r a t e on the f e e l i n g , r e l a x , and c o n c e n t r a t e on the f e e l i n g when the t e n s i o n i s gone. Now the muscles i n the l e g s and the f e e t . We can b e g i n w i t h the r i g h t upper l e g , the r i g h t t h i g h . Tense the muscles of your r i g h t upper l e g by c o u n t e r p o s i n g t h e one l a r g e muscle on top o f the l e g w i t h the two s m a l l e r ones under-n e a t h . You s h o u l d be a b l e t o f e e l t h a t l a r g e muscle on top get q u i t e h a r d . Hold t h e t e n s i o n , c o n c e n t r a t e on the f e e l i n g and r e l a x and c o n c e n t r a t e on the f e e l i n g when the t e n s i o n has been removed. Now the muscles o f t h e r i g h t c a l f , the r i g h t l ower l e g . Tense the muscles here by p u l l i n g your t o e s up toward 140 your head. You should be able to f e e l t e n s i o n a l l through the c a l f a r e a. Concentrate on t h i s f e e l i n g and r e l a x . Concentrate on the f e e l i n g now. Now the muscles of the r i g h t f o o t . In order to do t h i s , p o i n t your toe away from your body while at the same time t u r n i n g your f o o t inward and at the same time, c u r l your t o e s . Don't tense these muscles too hard. J u s t f e e l the t i g h t n e s s under the a r c h and the b a l l of the f o o t . Now r e l a x and concentrate on the f e e l i n g with a l l the te n s i o n s gone. Now the muscles i n the l e f t upper l e g . J u s t tense and r e l a x these as you d i d on the other s i d e . Now do the muscles on the lower p a r t of your l e f t l e g , and again u s i n g the same procedure, and f i n a l l y the l e f t foot - t e n s i n g and r e l a x i n g i t as you d i d with your other f o o t . T h i s i s the general procedure t h a t you should f o l l o w when you're doing these e x e r c i s e s at home. Since l e a r n i n g to r e l a x r e q u i r e s p r a c t i c e , what you should do i s spend about 20 minutes i n the morning going through these e x e r c i s e s and another 20 minutes i n the e a r l y evening. Once you have l e a r n e d to tense and r e l a x these 16 muscle groups i t ' s p o s s i b l e then to combine some of the groups so as to reduce the amount of time r e q u i r e d to go through the e x e r c i s e . The f i r s t step i s to reduce the o r i g i n a l 16 groups to 7. These 7 groups are as f o l l o w s : 141 1. A l l of the muscles i n the l e f t arm. 2. A l l of the muscles i n the r i g h t arm. 3. A l l of the f a c i a l muscles. 4. The neck and the t h r o a t and t h i s i s the same as i n the 16 group procedure. 5. The c h e s t , s h o u l d e rs , upper back and abdomen. 6. The muscles i n the r i g h t l e g . 7. The muscles i n the l e f t l e g . Once you have acquainted y o u r s e l f with, and p r a c t i s e d these 7 muscle groups they are reduced f u r t h e r to 4 muscle groups by combining v a r i o u s groups. These 4 are: 1. The muscles i n both the r i g h t and l e f t arms. 2. The muscles i n the face and neck. 3. The muscles of the c h e s t , neck, shoulders and abdomen. 4. The muscles i n both l e f t and r i g h t l e g s . Having gone through a l l of these procedures, you should be able t o r e l a x v e r y w e l l . Once r e l a x a t i o n has been achieved there are a v a r i e t y of s t r a t e g i e s t hat can be used to achieve r e l a x a t i o n without the n e c e s s i t y of going through a l l of the e x e r c i s e s . These w i l l be d i s c u s s e d i n d e t a i l as we progress i n the program. Once you have l e a r n e d to achieve deep muscle r e l a x a t i o n u s i n g the f o u r muscle group procedure, you're ready to go on 142 t o the nex t s t e p . T h i s i s r e l a x a t i o n t h r o u g h r e c a l l . R e l a x a t i o n Through R e c a l l The r e c a l l p rocedure i s q u i t e d i f f e r e n t from what you have l e a r n e d so f a r , i n t h a t no mu s c u l a r t e n s i o n and r e l a x a t i o n i s r e q u i r e d . However, i t does r e q u i r e the f u l l use of your a b i l i t y t o f o c u s on t e n s i o n and r e l a x a t i o n . R e l a x a t i o n w i t h r e c a l l employs the same f o u r muscle groups which you have been u s i n g t o date.. The proce d u r e i s t o f i r s t o f a l l s e a t y o u r s e l f i n . a c o m f o r t a b l e c h a i r and now fo c u s a l l your a t t e n t i o n on the muscles of the arms and hands and v e r y c a r e f u l l y i d e n t i f y any f e e l i n g of t i g h t n e s s o r t e n s i o n t h a t might be p r e s e n t t h e r e now. N o t i c e where t h i s t e n s i o n i s and what i t f e e l s l i k e . C o n c e n t r a t e on t h i s f o r about 30 seconds and t h e n r e l a x and r e c a l l what i t was l i k e when you r e l e a s e d these muscles a f t e r g o i n g t h rough the e x e r c i s e s . Repeat t h i s two o r t h r e e o r f o u r times u n t i l you f e e l t h a t the muscles i n your hands and arms are c o m p l e t e l y r e l a x e d . Now you do the same t h i n g w i t h a l l the muscles i n the f a c e and the neck. Focus your a t t e n t i o n on these m u s c l e s , r e c a l l what i t f e l t l i k e when you r e l e a s e d the t e n s i o n i n t h e s e muscles and t r y to a c h i e v e the same s e n s a t i o n . C o n c e n t r a t e on t h i s f o r about 30 seconds and then r e p e a t i t t h r e e or f o u r times u n t i l t he f e e l i n g and s e n s a t i o n you get i s 143 s i m i l a r to those a f t e r having done the e x e r c i s e s . Now you j u s t do the same t h i n g with the t h i r d muscles group which i n c l u d e s the che s t , shoulders, back and abdomen. When you are ab l e to r e l a x these muscles by r e c a l l , go on to the f o u r t h muscle group, those i n both legs and f e e t . I f you experience any d i f f i c u l t y i n a c h i e v i n g r e l a x a t i o n w h i l e doing these e x e r c i s e s , go back and tense the muscles i n q u e s t i o n and then l e t them r e l a x . R e l a x a t i o n by R e c a l l with Counting T h i s i s simply an e x t e n s i o n of the R e l a x a t i o n by R e c a l l and the procedure i s : Once having gone through a r e c a l l s e s s i o n where you have achieved a reasonable degree of r e l a x a t i o n , you can deepen t h i s r e l a x a t i o n by co u n t i n g . The procedure f o r t h i s i s to become r e l a x e d and then to count to y o u r s e l f from 1 to 10. As you count allow a l l the muscles throughout your body to become even more deeply and more completely r e l a x e d at each count. What you might do to f a c i l i t a t e t h i s i s to have your counting c o i n c i d e with e x h a l i n g . Every time you exhale add one more number. As you count you should be able to f e e l y o u r s e l f becoming more and more r e l a x e d . You j u s t focus your a t t e n t i o n on a l l the muscles i n the body and n o t i c e them as they become more and more deeply r e l a x e d . 144 Another s t r a t e g y f o r a c h i e v i n g t h i s i s to r a l a t e the co u n t i n g to p a r t i c u l a r muscle groups so th a t you might say to y o u r s e l f : "1, 2, my hands and arms are becoming more and more r e l a x e d . 3, 4, the muscles i n my face and my neck are becoming more and more r e l a x e d . 5, 6, the muscles i n my ch e s t , shoulders, back and abdomen, are r e l a x i n g even more deeply. 7, 8, the muscles i n my le g s and f e e t are becoming more and more r e l a x e d , 9, 10." The r e l a x a t i o n by r e c a l l and r e l a x a t i o n by r e c a l l with c o u n t i n g should be p r a c t i c e d every day f o r a week or two or u n t i l you are able to achieve a f a i r l y deep f e e l i n g of r e l a x a t i o n by the end of each s e s s i o n . D i f f e r e n t i a l R e l a x a t i o n D i f f e r e n t i a l r e l a x a t i o n i s one of the most common a p p l i c a t i o n s of the b a s i c p r o g r e s s i v e r e l a x a t i o n s k i l l . When you are i n v o l v e d i n some a c t i v i t y , a v a r i e t y of muscles become tensed d u r i n g t h i s . Muscles necessary f o r the accomplishment of an a c t i v i t y are f r e q u e n t l y more tense than they need be and the muscles unnecessary f o r e f f i c i e n t performance become tense d u r i n g the a c t i v i t y . In both cases there i s r e s i d u a l t e n s i o n which c o n t r i b u t e s n o t h i n g to the behavior and which n e e d l e s s l y i n c r e a s e s p s y c h o l o g i c a l s t r e s s . I d e a l l y , i n terms of c o n s e r v a t i o n of energy, and maintenance of a low t e n s i o n l e v e l , only those muscles d i r e c t l y r e l e v a n t to an a c t i v i t y should be tense only to the degree r e q u i r e d f o r 145 t h e e f f i c i e n t performance of t h e a c t i v i t y . D i f f e r e n t i a l r e l a x a t i o n can h e l p you t o approach t h i s i d e a l s i t u a t i o n . Deep r e l a x a t i o n i s i n d u c e d and m a i n t a i n e d i n the muscles not r e q u i r e d f o r the ongoing a c t i v i t y . For muscles i n v o l v e d i n t h e a c t i v i t y , excess t e n s i o n i s e l i m i n a t e d . Only the amount o f t e n s i o n n e c e s s a r y f o r b e h a v i o r a l performance remains. The r e s u l t i s t h a t you can p e r f o r m most d a i l y a c t i v i t i e s w i t h a minimum of t e n s i o n and a maximum of r e l a x e d c o m f o r t . P r o p e r and c o n s i s t e n t use of d i f f e r e n t i a l r e l a x a t i o n has t h r e e advantages. F i r s t , f o r any i n d i v i d u a l i n v o l v e d i n p r o g r e s s i v e r e l a x a t i o n t r a i n i n g i t p r o v i d e s many o p p o r t u n i t i e s t o p r a c t i c e and thus improve the s k i l l of r e l a x a t i o n . Second f o r c h r o n i c a l l y tense i n d i v i d u a l s i t h e l p s m a i n t a i n l o w e r e d a r o u s a l throughout the day. T h i r d , f o r i n d i v i d u a l s who become ten s e o n l y i n p a r t i c u l a r s i t u a t i o n s i t a l l o w s f o r s i t u a t i o n s p e c i f i c r e l a x a t i o n . The proc e d u r e i n v o l v e s the p e r i o d i c i d e n t i f i c a t i o n o f t e n s i o n d u r i n g d a i l y a c t i v i t i e s and the subsequent r e l a x a t i o n of muscles t h a t are u n n e c e s s a r i l y t e n s e . I d e n t i f i c a t i o n of t e n s i o n i s one of the s k i l l s t h a t are l e a r n e d d u r i n g p r o g r e s s i v e r e l a x a t i o n t r a i n i n g . R e l a x a t i o n of those muscles i d e n t i f i e d as tense may then be a c c o m p l i s h e d by u s i n g e i t h e r t e n s i o n r e l e a s e c y c l e s or r e c a l l . The program f o r d i f f e r e n t i a l r e l a x a t i o n i n v o l v e s a s e r i e s of p r a c t i c e s t e p s b e g i n n i n g w i t h r e l a t i v e l y q u i e t 146 a c t i v i t i e s , n o n - e s s e n t i a l muscles predominate and p r a c t i s e i s s i m i l a r t o b a s i c r e l a x a t i o n . As you c o n t i n u e w i t h more complex b e h a v i o r s , t e n s i o n i d e n t i f i c a t i o n and e l i m i n a -t i o n become q u i t e easy. There are t h r e e c o n t i n u a e over which the p r a c t i c e may d e v e l o p . Lower l e v e l s of each continuum i n v o l v e l e s s d i s t r a c t i o n and you may more e a s i l y c o n c e n t r a t e on the r e l a x a t i o n p r o c e s s . The t h r e e c o n t i n u a e a re s i t u a t i o n , p o s i t i o n and a c t i v i t y l e v e l . S i t u a t i o n v a r i e s from b e i n g a l o n e i n a q u i e t room t o b e i n g w i t h o t h e r s i n a n o i s y p l a c e . P o s i t i o n v a r i e s from s i t t i n g t o s t a n d i n g . A c t i v i t y l e v e l ranges from i n a c t i v i t y t o r o u t i n e , complex l e v e l s . You s h o u l d f i r s t p r a c t i c e d e f i n i n g e s s e n t i a l and non-e s s e n t i a l muscles groups f o r v a r i o u s a c t i v i t i e s . I t ' s i m p o r t a n t t h a t you not o n l y become aware of the n e c e s s a r y muscle groups i n v o l v e d but can a l s o i d e n t i f y and be s e n s i t i v e t o the n o n - e s s e n t i a l ones. The way t o a c h i e v e t h i s i s t o t h i n k about the v a r i o u s d a i l y a c t i v i t i e s i n terms o f the muscles groups r e q u i r e d f o r t h e i r performance. There i s a f a i r amount o f homework i n l e a r n i n g d i f f e r e n t i a l r e l a x a t i o n . What t h i s means i s p r a c t i c i n g i n a v a r i e t y o f s i t u a t i o n s . The s c h e d u l i n g of p r a c t i c e can f o l l o w 8 s t e p s . These s t e p s a l o n g w i t h some examples of each a r e as f o l l o w s : 147 1. S i t t i n g , n o n - a c t i v e , i n a q u i e t p l a c e , e.g., s i t t i n g u p r i g h t i n a c h a i r i n the bedroom. 2. S i t t i n g , n o n - a c t i v e , i n a non-quiet p l a c e , e.g., s i t t i n g i n a c a f e t e r i a . 3. S i t t i n g i n an a c t i v e , q u i e t p l a c e , e.g., t y p i n g i n a study. 4. S i t t i n g i n an a c t i v e , non-quiet p l a c e , e.g., e a t i n g i n a c a f e t e r i a . 5. Standing, n o n - a c t i v e , i n a qu i e t p l a c e , e.g., stan d i n g i n a l i v i n g room. 6. Standing i n a non-active,non-quiet p l a c e , e.g., w a i t i n g i n l i n e f o r a bus. 7. Standing a c t i v e i n a q u i e t p l a c e , e.g. working alone at a counter, perhaps at home. 8. Standing i n an a c t i v e , non-quiet p l a c e , e.g., walking on a s t r e e t downtown. The f i r s t step i n v o l v e s a t r a n s i t i o n from the us u a l r e l a x a t i o n p r a c t i c e p o s i t i o n ( a l l muscles supported, eyes c l o s e d ) to a common s i t t i n g posture (head supportec by neck muscles, eyes open). You should p e r i o d i c a l l y r e l a x a l l muscle groups by u s i n g e i t h e r the t e n s i o n r e l e a s e c y c l e s or by r e c a l l . There w i l l be r e s i d u a l t e n s i o n remaining i n the eyes and neck muscles, but t h i s t e n s i o n should be minimal. A l l other muscles are to be r e l a x e d . 148 Steps 2 through 8 i n v o l v e i n c r e a s i n g d i s t r a c t i o n as w e l l as a c t i v i t y i n more muscle groups. The procedure i s the same. F i r s t i d e n t i f y and then e l i m i n a t e the t e n s i o n i n each non-e s s e n t i a l muscle. There i s no need to be concerned about r e s i d u a l t e n s i o n i n muscles r e q u i r e d f o r performance of ongoing behavior. Your progress through these 8 steps should be determined by your a b i l i t y to r e l a x n o n - e s s e n t i a l muscles deeply and to r e l a x e s s e n t i a l muscles to the p o i n t where t e n s i o n i n them i s not uncomfortable. Once t h i s goal i s c o n s i s t e n t l y achieved at one step you may continue to the next step, proceeding at your own r a t e . The speed of progress depends upon the frequency and the q u a l i t y of p r a c t i c e . A reasonable time t a b l e would be, the f i r s t week step 1, the second week steps 2, 3, and 4; the t h i r d week steps 5, 6, 7, and 8. This time t a b l e assumes that you are adept at the fo u r muscle group r e l a x a t i o n stage and that your p r a c t i c e each d i f f e r e n t i a l r e l a x a t i o n step f o r about 5 minutes, f o u r times a day. Once you are able to r e l a x f a i r l y w e l l i n step 8, you should p e r i o d i c a l l y throughout the day p r a c t i c e r e l a x a t i o n . The u l t i m a t e goal might be c h a r a c t e r i z e d by the f o l l o w i n g example. A man i s d r i v i n g to work. He needs to use the muscles of h i s eyes, neck, arms, hands, r i g h t f o o t and l e g . A f t e r s t a r t i n g the motor he i d e n t i f i e s t e n s i o n and r e l a x e s i n each of the f o u r muscle groups, a l l i n about 60 seconds. As he i s d r i v i n g he may p e r i o d i c a l l y 149 n o t i c e t e n s i o n i n unused muscles or d i s c o m f o r t i n used m u s c l e s . T h i s may be q u i c k l y e l i m i n a t e d by r e c a l l . He pa r k s h i s c a r and walks a few b l o c k s t o h i s p l a c e of work. As he i s w a l k i n g he r e l a x e s some t e n s i o n i n h i s f a c i a l and t r u n k m u s c l e s . At h i s desk he g e t s c o m f o r t a b l y s e a t e d and spends a few seconds e l i m i n a t i n g t e n s i o n i n a l l m u s c l e s . He r e p e a t s t h i s each time he s i t s down. F u r t h e r , w h i l e d o i n g paper work, i f he n o t i c e s u n c o m f o r t a b l e t e n s i o n i n h i s w r i t i n g arm he spends a moment r e l a x i n g i t by r e c a l l . There are two t h i n g s t h a t you s h o u l d know about t h i s p r o c e d u r e . F i r s t , i t i s not i n t e n d e d t h a t n o n - e s s e n t i a l muscles be c o m p l e t e l y i n a c t i v e . The i d e a i s t o l i m i t a c t i v i t y t o a minimum but not t o such an e x t e n t t h a t ongoing b e h a v i o r i s d i s r u p t e d . Second, a l t h o u g h i t i n i t i a l l y t a k e s some d e l i b e r a t e e f f o r t t o remember t o use d i f f e r e n t i a l r e l a x a t i o n p r o c e d u r e s , as the s k i l l i n c r e a s e s i t becomes h a b i t u a l and v e r y l i t t l e time and e f f o r t are r e q u i r e d . C o n d i t i o n e d R e l a x a t i o n The g o a l of c o n d i t i o n e d r e l a x a t i o n t r a i n i n g i s t o enable t o a c h i e v e r e l a x a t i o n i n response t o a s e l f - p r o d u c e d cue. That i s , a f t e r you've mastered t h e p r o g r e s s i v e r e l a x a t i o n , you l e a r n an a s s o c i a t i o n between the r e s u l t i n g d e e p l y r e l a x e d s t a t e and a s e l f produced cue word such a s . ' c a l m , r e l a x , c o n t r o l ' , o r something s i m i l a r . The way i n which t h i s i s a c h i e v e d i s by f i r s t of a l l b e i n g s e a t e d i n a c o m f o r t a b l e c h a i r and becoming c o m p l e t e l y r e l a x e d . When you r e a c h t h i s 150 s tage then s u b - v o c a l l y , t o y o u r s e l f , you say the cue word 'calm, r e l a x , c o n t r o l ' or whatever. The cue c o i n c i d e s w i t h your e x h a l i n g , i . e . , e v e r y time you b r e a t h e out you say t o y o u r s e l f , ' r e l a x ' . You s h o u l d spend about 5 minutes d o i n g t h i s a t each s e s s i o n and t h i s s h o u l d be r e p e a t e d a t l e a s t once d a i l y f o r a t l e a s t two weeks. F o l l o w i n g t h i s you then p r a c t i c e u s i n g the cue word i n a v a r i e t y o f s i t u a t i o n s ; perhaps as d e s c r i b e d i n the d i f f e r e n t i a l r e l a x a t i o n . For example, i f you are s t a n d i n g i n an e l e v a t o r o r i f you're d r i v i n g your c a r and you n o t i c e some excess t e n s i o n i n some m u s c l e s , you p r a c t i c e r e l e a s i n g t h i s t e n s i o n s i m p l y by p r o v i d i n g y o u r s e l f w i t h the s u b - v o c a l cue. T h i s i s the k i n d of e x e r c i s e t h a t you can do almost anywhere, any t i m e . As w i t h o t h e r a s p e c t s of r e l a x a t i o n t r a i n i n g , the more p r a c t i c e you have d o i n g t h i s , the more e f f e c t i v e i t i s g o i n g t o be. I f t h i s i s done c o n s c i e n t i o u s l y , w i t h i n a c o u p l e of months you s h o u l d have t h i s mastered t o the p o i n t where you can t u r n o f f t e n s i o n s i m p l y by c u i n g y o u r s e l f . 151 APPENDIX VIII Reading L i s t Ayres,R .., Rubenstein, M. , and Smith, C H . Masturbation  Techniques f o r Women: G e t t i n g i n Touch. 340 Jones S t r e e t , #439E, San F r a n c i s c o C a l i f o r n i a , 94102, M u l t i Media Resource Center, 1972. Barbach, L.G. For Y o u r s e l f : The F u l f i l l m e n t of Female  S e x u a l i t y . New York, Doubleday & Co., 1975. Brecher, R. , and Brecher, E. ( E d i t o r s ) . An A n a l y s i s of Human  Sexual Response. New York, S i g n e t , 1966. The Boston Women's Health Book C o l l e c t i v e : Our Bodies, O u r s e l v e s . New York, Simon & Schuster, 1971. C a i r d , W.K., and Wincze, J.P. Sex Therapy: A B e h a v i o r a l  Approach. New York, Harper and Row, 1977. Chartham, R. The Sensuous Couple. New York, B a l l a n t i n e , 1971. Copelan, R. The S e x u a l l y F u l f i l l e d Man. New York, Weybright & T a l l e y , 1972 (paperback e d i t i o n : New York, New American L i b r a r y , 1973). Copelan, R. The S e x u a l l y F u l f i l l e d Woman. New York, Weybright & T a l l e y , 1972 (paperback e d i t i o n : New American L i b r a r y , 1973). Deutsch, R.M. The Key to Feminine Response i n Marriage. New York, Random House, 1968 (paperback e d i t i o n : New York, B a l l a n t i n e , 1973). E l l i s , A. The A r t and Science of Love. New York, L y l e S t u a r t , 1962. F a s t , J . What You Should Know About Human Sexual Response. New York, Putnam's Sons, 1966. F r i d a y , Nancy. My Secret Garden: Women's Sexual F a n t a s i e s . New York, T r i d e n t P r e s s , 1973. Gottman, J . et a l . A Couples Guide to Communication. Research P r e s s , 1976. Has t i n g s , D.W. Impotence and F r i g i d i t y . Boston, L i t t l e , Brown, 1963. 152 H a s t i n g s , D.W. A Doctor.Speaks on Sexual E x p r e s s i o n i n Marriage. Boston, L i t t l e , Brown, 1966. Heiman, J . , L o P i c c o l o , L. & LoPiccolo., J . Becoming Orgasmic: A Sexual Growth Program f o r Women. New J e r s e y , P r e n t i c e H a l l , 1976. H i t e , C. The H i t e Report. MacMillan, New York, 1976. J " . The Sensuous Woman. New York, L y l e S t u a r t , 1970 (paperback e d i t i o n : New York, D e l l , 1971). M". The Sensuous Man. New York, L y l e S t u a r t , 1971 (paperback e d i t i o n : New York, D e l l , 1972). Lehrman, N. ( E d i t o r ) . Masters and Johnson E x p l a i n e d . Chicago, Playboy Press, 1970. Masters, W., and Johnson, V. The Pleasure Bond. Boston, L i t t l e , Brown & Co., 1973. McCary, J.L. Sexual Myths and F a l l a c i e s . New York, Van Nostrand Reinhold Co., 1971. McCary, J.L. Human S e x u a l i t y (2nd e d i t i o n ) . New York, D. Van Nostrand Co., 1973). McCarthy, B.W., Ryan, M., and Johnson, F.A. Sexual Awareness, A P r a c t i c a l Approach. San F r a n c i s c o , Scrimshaw P r e s s , 1975. M o r n e l l , P. The Lovebook: What Works i n a L a s t i n g Sexual  R e l a t i o n s h i p . New York, Harper & Row, 1974. , Otto, H.Av, and Otto, R. T o t a l Sex. New York, Wyden, 1972 (paperback e d i t i o n : New York, New American L i b r a r y , 1973) Pomeroy, W.B. Boys and Sex. New York, D e l a c o r t e Press, 1968. Pomeroy, W.B. G i r l s and Sex. New York, D e l a c o r t e Press, 1969. Race, A.R., L e e c r a f t , J.F., and C r i s t , T. The Sex Scene: Understanding S e x u a l i t y . New York, Harper & Row, 1975. Rosenberg, J.L. T o t a l Orgasm. New York, Random House, 1973 (paperback e d i t i o n : Berkeley, Bookworks, 1973). S h i l a h , A. ( E d i t o r ) . Studies i n Human Sexual Behavior: The American Scene, S p r i n g f i e l d , I I I . C C . Thomas, 1970. Vandervoot, H.E., and Mcllvenna, T. You Can Last Longer. 340 Jones S t r e e t , #439E, San F r a n c i s c o , C a l i f o r n i a , 94102, M u l t i Media Resource Center, 1972. 153 Wright, H. More About the Sex Factor i n Marriage. London, Benn Ltd., 1969. 154 APPENDIX IX Means and Standard D e v i a t i o n s ( i n Parentheses) of the Sexual A r o u s a l Inventory at Pretreatment, F i l i a l S e s s i o n , Three Week and Three Month Follow-ups ( F i n a l Three Measures are Adjusted f o r C o v a r i a t e s ) . Assessment P e r i o d Pretreatment F i n a l S e s s i o n Three Week Follow-Up I n d i v i d u a l Group X SD C o n t r o l X SD X SD 69.00(22.23) 68.81(18.97) 75.25(25.51) 79.88(12.83) 79.14(15.61) 71.08(23.15) 91.24(13.81) 84.00(20.13) 69.69(22.86) Three Month Follow-Up 96.25(15.74) 95.39(17.72) 69.68(23.14) A n a l y s i s of Variance f o r Sexual A r o u s a l Inventory - Pretreatment Data Source df SS. MS F Prob. T r e a t 2 188.06 94.03 0.196 0.8211 E r r o r 24 11362.01 473.42 T o t a l 26 11550.07 A n a l y s i s of Covariance f o r Sexual Arousal I n v e n t o r y - F i n a l S e s s i o n Data Source df SS MS F Prob. T r e a t 2 327.25 163.62 1.078 0.3601 E r r o r 23 3509.92 152.61 T o t a l 26 6726.79 155 APPENDIX IX (continued) A n a l y s i s of Covariance f o r Sexual Arousal Inventory - Three Week Follow-Up Source Tr e a t E r r o r T o t a l df 2 23 26 SS 1726.10 5671.88 9670.50 MS 863.05 246.60 F 3.456 Prob. 0.0462 A n a l y s i s of Covariance f o r Sexual Arousal Inventory - Three Month Follow-Up Source df SS MS F Prob. Tr e a t 2 3136.26 1568.13 5.593 0.0083 E r r o r 23 6059.45 263.45 T o t a l 26 10625.50 APPENDIX X Means and Standard D e v i a t i o n s ( i n Parentheses) on Subtests of the Sexual S a t i s f a c t i o n Index at Pretreatment, F i n a l Session, Three Week and Three Month Follow-Up ( F i n a l Three Measures are Adjusted f o r C o v a r i a t e s ) Assessment Pe r i o d Pretreatment I n d i v i d u a l X SD Group X SD C o n t r o l X SD general s a t i s f a c t i o n 17, .45 (7, .86) 14, .13 (5. 05) 13. .00 (9, .38) communication s a t i s f a c t i o n 14. .90 (6. .40) 12. ,18 (4. 87) 10. ,25 (7. ,03) orgasm s a t i s f a c t i o n 15. .25 (5. .24) 19, .45 (3. 36) 15. ,58 (6. .24) s e x u a l i t y s a t i s f a c t i o n 6. .25 (2, .62) 7, .59 (1. 26) 6, ,26 (2, ,44) r e l a t i o n s h i p s a t i s f a c t i o n 9. .00 (2, .83) 7, .00 (3. 00) 6. ,50 (3. .31) F i n a l S e s s i o n g e n e r a l s a t i s f a c t i o n 28. .73 (5, .21) 22, .78 (11 .88) 12. ,50 (4. .33) communication s a t i s f a c t i o n 17. .76 (3, .96) 17 , .80 (4. 98) 9, ,32 (4, .46) orgasm s a t i s f a c t i o n 22. .55 (5. .31) 20, .26 (4. 61) 13. .68 (4, .86) s e x u a l i t y s a t i s f a c t i o n 9, .57 (2. .17) 9, .07 (1. 54) 6, .23 (2, .01) r e l a t i o n s h i p s a t i s f a c t i o n 8, .68 (1. .34) 7, .58 (2. 91) 5, .37 (2, .97) Means and Standard D e v i a t i o n s APPENDIX X ( C o n t i n u e d ) f o r Sexual S a t i s f a c t i o n Index C o n t i n u e d Assessment P e r i o d Three Week Follow-Up g e n e r a l s a t i s f a c t i o n communication s a t i s f a c t i o n orgasm s a t i s f a c t i o n s e x u a l i t y s a t i s f a c t i o n r e l a t i o n s h i p s a t i s f a c t i o n Three Month Follow-Up g e n e r a l s a t i s f a c t i o n communication s a t i s f a c t i o n orgasm s a t i s f a c t i o n s e x u a l i t y s a t i s f a c t i o n r e l a t i o n s h i p s a t i s f a c t i o n I n d i v i d u a l X SD 2 5 . 5 2 ( 6 . 0 4 ) 1 6 . 7 2 ( 5 . 1 0 ) 2 1 . 2 2 ( 5 . 8 5 ) 8 . 5 5 ( 1 . 8 4 ) 8 . 8 0 ( 1 . 3 4 ) 2 6 . 5 5 ( 1 1 . 9 8 ) 1 7 . 1 6 ( 7 . 2 8 ) 2 0 . 9 3 ( 9 . 1 5 ) 9 . 1 3 ( 3 . 4 7 ) 8 . 4 6 ( 3 . 5 5 ) Group X SD 1 9 . 7 2 ( 8 . 6 9 ) 1 6 . 2 2 ( 4 . 9 2 ) 1 8 . 6 8 ( 3 . 3 1 ) 8 . 8 3 ( 0 . 9 5 ) 7 . 4 3 ( 2 . 9 1 ) 2 7 . 5 7 ( 1 2 . 1 6 ) 1 9 . 3 1 ( 5 . 2 7 ) 2 3 . 6 8 ( 4 . 9 9 ) 9 . 9 0 ( 1 . 5 2 ) 8 . 6 7 ( 3 . 4 4 ) C o n t r o l X SD 1 2 . 3 0 ( 8 . 1 6 ) 1 0 . 0 5 ( 4 . 5 9 ) 1 4 . 2 8 ( 5 . 4 7 ) 6 . 2 2 ( 2 . 0 1 ) 5 . 4 4 ( 2 . 9 7 ) 1 2 . 6 7 ( 7 . 4 0 ) 8 . 9 8 ( 4 . 4 6 ) 1 3 . 0 1 ( 4 . 8 6 ) 6 . 2 0 ( 2 . 0 1 ) 5 . 9 0 ( 3 . 2 7 ) 158 APPENDIX X (Continued) M u l t i v a r i a t e A n a l y s i s of Variance f o r Sexual S a t i s f a c t i o n Index Pretreatment Data Wilks Summary Table  Source Wilks Lambda df Approx. F. df Prob. A 6.5342E-01 5,2,24 0.9484 10.00, 40.00 0.5014 Analyses of Covariance f o r Sexual S a t i s f a c t i o n I n d e x - F i n a l Session Data Source df SS MS F Prob. S a t i s f a c t i o n General T r e a t 2 620.61 310.30 8.7913 0.0015* E r r o r 23 811.83 35.30 T o t a l 26 2442.67 S a t i s f a c t i o n Communication Tre a t 2 181.16 90.58 8.2249 0.0021* E r r o r 23 253.30 11.01 T o t a l 26 937.46 S a t i s f a c t i o n Orgasm Tr e a t 2 180.67 90.33 11.00 0.0005* E r r o r 23 118.87 8.21 T o t a l 26 811.41 *When s i g n i f i c a n t ANCOVA retest.ed a g a i n s t i t s own c o v a r i a t e o n l y 159 APPENDIX X (Continued) Source T r e a t E r r o r T o t a l df SS MS F S a t i s f a c t i o n S e x u a l i t y 2 28.22 14.11 12.16 23 26.67 1.16 26 103.91 Prob. 0.0003* Tr e a t E r r o r T o t a l S a t i s f a c t i o n R e l a t i o n s h i p 2 38.164 19.08 5.41 23 81.17 3.53 26 232.00 0.0118* Analyses of Covariance f o r Sexual S a t i s f a c t i o n Index Three Week Follow-Up Source T r e a t E r r o r T o t a l df 2 23 26 SS MS S a t i s f a c t i o n General 933.91 1214.77 3371.63 466.95 52.82 8.8412 Prob. 0.0015* Trea t E r r o r T o t a l 2 23 26 S a t i s f a c t i o n Communication 316.95 250.39 982.02 158.47 10.89 14.5570 0.0001* *When s i g n i f i c a n t ANCOVA r e t e s t e d a g a i n s t i t s own c o v a r i a t e o n l y 160 APPENDIX X (Continued) Source Tre a t E r r o r T o t a l Treat E r r o r T o t a l T r e a t E r r o r T o t a l df 2 23 26 2 23 26 1"9 26 SS MS F Prob. S a t i s f a c t i o n Orgasm 301.67 150.84 15.913 0.0006* 218.059 9.48 986.407 S a t i s f a c t i o n S e x u a l i t y 45.01 22.50 10.57 0.0006* 48.95 2.13 143.79 S a t i s f a c t i o n R e l a t i o n s h i p 32.031 16.1555 4.366 0.0131 84.370 3.668 245.78 Analyses of Covariance f o r Sexual S a t i s f a c t i o n Index -Three Month Follow-Up Source df SS MS F Prob. S a t i s f a c t i o n General Tre a t 2 955.147 477.573 5.2493 0.0131* E r r o r 23 2092.492 90.977 T o t a l 2;6\ 4379.166 *When s i g n i f i c a n t ANC0VA r e t e s t e d a g a i n s t i t s own c o v a r i a t e o n l y 161 APPENDIX X (Continued) Source Tre a t E r r o r T o t a l T r e a t E r r o r T o t a l T r e a t E r r o r T o t a l T r e a t E r r o r T o t a l df 2 23 26 2 23 26 2 23 26 2 19 26 SS MS F S a t i s f a c t i o n Communication 416.110 724.486 1382.666 208.055 31.499 6.6051 S a t i s f a c t i o n Orgasm 417.975 108.987 4.5730 1051.100 45.700 1684.629 S a t i s f a c t i o n S e x u a l i t y 52.829 26.414 4.9546 122.619 5.331 227.129 S a t i s f a c t i o n R e l a t i o n s h i p 39.845 19.922 1.9740 191.754 10.092 339.240 Prob. 0.0055* 0.0210* 0.0161* 0.1643 *When ANCOVA s i g n i f i c a n t r e t e s t e d a g a i n s t i t s own c o v a r i a t e only APPENDIX XI Means and Standard D e v i a t i o n s ( i n P a r e n t h e s e s ) on Male Items of the S e x u a l B e h a v i o r Index a t P r e t r e a t m e n t , F i r s t Three Weeks of Treatment, L a s t Two Weeks of Treatment and Three Week Follow-Up ( F i n a l Three Measures a re A d j u s t e d f o r C o v a r i a t e s ) Assessment P e r i o d P r e t r e a t m e n t Non-sexual massage Sensate f o c u s female b r e a s t s Sensate f o c u s gemale g e n i t a l s I n t e r c o u r s e I n d i v i d u a l X SD Group X SD C o n t r o l X SD 1 . 1 0 0 ( 1 . 3 7 0 ) 1 . 4 5 5 ( 1 . 6 9 5 ) 1 . 3 3 3 ( 1 . 3 6 6 ) 6 . 6 0 0 0 ( 5 . 6 4 1 ) 3 . 2 7 3 ( 2 . 7 6 ) 1 . 6 6 7 ( 4 . 3 2 0 ) 2 . 5 0 0 ( 2 . 1 7 3 ) 1 . 4 5 5 ( 1 . 4 4 0 ) 2 . 6 6 5 ( 2 . 5 8 2 ) 2 . 1 0 0 ( 1 . 8 5 3 ) 0 . 9 0 9 ( 1 . 1 3 6 ) 2 . 0 0 0 ( 1 . 6 7 3 ) F i r s t Three Weeks of Treatment Non-sexual massage Sensate f o c u s female b r e a s t s Sensate f o c u s female g e n i t a l s 3 . 8 6 1 ( 2 . 4 1 5 ) 1 . 3 9 0 ( 1 . 4 8 9 ) 1 . 3 5 0 ) ( 1 . 3 6 6 ) 6 . 5 8 3 ( 5 . 9 7 8 ) 4 . 8 8 3 ( 2 . 9 8 2 ) 2 . 7 4 2 ( 3 . 1 2 0 ) 2 . 3 5 1 ( 1 . 4 1 8 ) 2 . 4 4 8 ( 1 . 3 0 0 ) 1 . 7 6 2 ( . 9 3 1 ) Assessment P e r i o d L a s t Two Weeks of Treatment Non-sexual massage Sensate f o c u s female b r e a s t s Sensate f o c u s female g e n i t a l s I n t e r c o u r s e Three Week Follow-Up Non-sexual massage Sensate f o c u s female b r e a s t s Sensate f o c u s female g e n i t a l s I n t e r c o u r s e APPENDIX XI (C o n t i n u e d ) I n d i v i d u a l Group X SD X SD 3.138 ( 2 . 8 4 6 ) 6.776 ( 4 . 1 4 2 ) 2 .576 ( 1 . 0 5 9 ) 1.348 ( 1 . 2 6 5 ) 3 .034 ( 2 . 4 7 0 ) 7.247 ( 3 . 4 9 8 ) 3 .142 ( 1 . 4 9 4 ) 3.652 ( 1 . 2 8 7 ) 1.668 ( 1 . 6 6 2 ) 6 .297 ( 2 . 9 7 9 ) 2 . 1 4 4 ( 1 . 1 3 6 ) 1.665 ( 1 . 2 7 2 ) 2 .574 ( 2 . 4 6 1 ) 6 .620 ( 5 . 7 2 9 ) 2 . 6 6 0 ( 1 . 7 5 3 ) 3 .826 ( 1 . 2 1 4 ) C o n t r o l X SD 1.378 ( 1 . 2 2 5 ) 2 .662 ( 3 . 6 5 6 ) 2 .275 ( 2 . 5 1 0 ) 1.367 ( 1 . 2 1 1 ) 1.392 ( 1 . 2 2 5 ) 2 .785 ( 3 . 3 2 7 ) 1.720 ( 1 . 8 3 5 ) 1.425 ( 1 . 1 1 9 ) 164 APPENDIX XI(Continued) M u l t i v a r i a t e A n a l y s i s f o r Sexual Behavior Inventory Male -Pretreatment Data Source Wilks Lambda df Approx. F. df Prob. A 6.1312E-01 4,2,24 1.4202 8.00, 41.00 0.1273 Analyses of Covariance f o r Sexual Behavior Inventory Male F i r s t Three Weeks of Treatment Source df SS MS F Prob. Non-Sexual Massage A 2 30.703566 15.351783 12.029476 0.0006* E r r o r 23 29.352152 1.2761805 T o t a l 26 107.629630 Sensate Focus Female Breasts A 2 15.190268 7.595134 0.6494 0.05370 E r r o r 21 245.613577 11.695884 T o t a l 26 782.74071 Sensate Focus Female G e n i t a l s A 2 1.615414 8.077067E-01 0.6609 0.5312 E r r o r 21 25.664004 1.222095 T o t a l 26 73.185185 *When s i g n i f i c a n t ANCOVA r e t e s t e d a g a i n s t i t s own c o v a r i a t e o n l y 165 APPENDIX XI" (Continued) Analyses of Covariance f o r Sexual Behavior Inventory - Male Last Two Weeks of Treatment Source df SS MS F Prob. Non-Sexual Massage A 2 12.256578 6.128288 1.5460 0.2366 E r r o r 20 79.280126 3.964005 T o t a l 26 117.407407 Sensate Focus Female Breasts A 2 51.520297 25.760147 4.4500428 0.0373* E r r o r 23 133.141052 5.7887413 T o t a l 26 396.000000 Sensate Focus Female G e n i t a l s A 2 8.235406E-01 4.117703E-01 0.3355 0.7228 E r r o r 20 24.549448 1.227472 T o t a l 26 58.000000 Int e r c o u r s e A 2 5.341686E-01 2.670842E-01 0.3056 0.7433 E r r o r 20 17.478426 8.739213E-01 T o t a l 26 38.740741 *When s i g n i f i c a n t ANC0VA r e t e s t e d a g a i n s t i t s own c o v a r i a t e o n l y 166 APPENDIX XI. (Continued) Analyses of Covariance f o r Sexual Behavior Inventory Male -Three Week Follow-Up Source df. SS MS F Prob. Non-Sexual Massage A 2 7.413822 3.706861 0.7344 0.4962 E r r o r 20 100.950734 5.047536 T o t a l 26 130.740741 Sensate Focus Female Breasts A 2 59.348206 29.674103 1.9560 0.1659 E r r o r 20 303.423003 15.171149 T o t a l 26 590.000000 Sensate Focus Female G e n i t a l s A 2 5.487315 2.743657 1.4867 0.2493 E r r o r 20 36.908916 1.845446 T o t a l 26 76.296296 Intercour se A 2 8.554402 4.277201 5.548397 0.0193* E r r o r 23 17.730460 .7708895 T o t a l 26 51.851852 *When s i g n i f i c a n t ANCOVA r e t e s t e d a g a i n s t i t s own c o v a r i a t e only: APPENDIX XI (Continued) Means and Standard D e v i a t i o n s ( i n Parentheses) of Pretreatment, F i r s t Three Weeks of Treatment, Last Two Weeks of Treatment and Three Week Follow-Up on Female Items of the Sexual Behavior Inventory ( A l l Data Except Pretreatment Are Adjusted f o r C o v a r i a t e Assessment Period I n d i v i d u a l Group C o n t r o l X SD X SD X SD Pretreatment massage 0 .900 (1 .853) 2 .182 (1 .940) 1 .667 (1 .862) sensate focus i Tiale g e n i t a l s 2 .600 (3 .565) 2 .727 (3 .409) 1 .685 (2 .251) orgasm through masturbation 0 .100 (0 .001) 1 .000 (1 .612) 1 .000 (1 .265) orgasm through f o r e p l a y • 0 .100 (0 .316) 0 .273 (0 .647) 0 .667 (1 .211) i n t e r c o u r s e 2 .200 (2 .044) 1 .182 (1 .471) 1 .667 (1 .506) orgasm through i n t e r c o u r s e 0 .010 (0 .213) 0 .000 (0 .000) 0 .500 (0 .837) F i r s t Three Weeks of Treatment massage 2.749 (2.273) 1.322 (1.128) 1.828 (1.602) sensate focus male g e n i t a l s 4.010 (3.028) 1.328 (1.348) 1.883 (2.000) orgasm through masturbation 1.389 (1.059) 0.962 (2.014) 0.588 (1.095) orgasm through f o r e p l a y 0.349 ( .316) 0.258 (0.647) 0.613 (1.549) Assessment P e r i o d L a s t Two Weeks of Treatment massage se n s a t e f o c u s male g e n i t a l s orgasm t h r o u g h m a s t u r b a t i o n orgasm t h r o u g h f o r e p l a y i n t e r c o u r s e orgasm t h r o u g h i n t e r c o u r s e Three Week Follow-Up massage se n s a t e f o c u s male g e n i t a l s orgram through m a s t u r b a t i o n orgasm t h r o u g h f o r e p l a y i n t e r c o u r s e orgasm t h r o u g h i n t e r c o u r s e APPENDIX XI I n d i v i d u a l X SD 3.180 (2.658) 4.501 (2.263) 1.157 (1.889) 0.652 (0.972) 2.292 (1.317) 0.381 (0.675) 2.892 (2.369) 3.755 (2.669) 1.837 (1.567) 1.248 (1.101) 2.614 (1.287) 0.546 (1.075) ( C o n t i n u e d ) Group X SD C o n t r o l X SD 1.535 (1.578) 3.132 (1.328) 2.533 (1.695) 0.463 (0.820) 1.230 (1.272) -0.005 (0.302) 1.991 (1.902) 2.488 (1.662) 2.047 (2.272) 1.206 (1.079) 2.479 (1.293) 0.336 (0.505) 1.719 (1.211) 0.756 (1.211) 0.429 (0.518) -0.102 (0.010) 0.593 (0.516) 0.041 (0.015) 1.531 (1.211) 1.013 (1.602) -0.6449 (0.000) -0.292 (0.000) 0.941 (0.516) 0.309 (0.408) 169 APPENDIX XI (Continued) M u l t i v a r i a t e A n a l y s i s f o r Sexual Behavior Inventory Female -Pretreatment Data Source Wilks Lambda df Approx. F. df Prob. A 4.4031E-01 6,2,24 1.5633 12.00, 37.00 0.1459 Analyses of Covariance f o r Sexual Behavior Inventory Female -F i r s t Three Weeks of Treatment Source d f SS MS F Prob. Non-Sexual Massage A 2 8.185611 4.092805 1.4704 0.2530 E r r o r 20 55.669037 2.783451 T o t a l 26 76.962963 Sensate Focus Male G e n i t a l s A 2 29.388778 14.694388 4.4058678 0.0383* E r r o r 23 76.709274 3.3351858 T o t a l 26 138.66667 Orgasm Through Masturbation A 2 1.811297 9.056485E-01 0.7407 0.4933 E r r o r 20 24.452446 1.222622 T o t a l 26 58.962963 *When s i g n i f i c a n t ANCOVA r e t e s t e d a g a i n s t i t s own c o v a r i a t e o n l y 170 APPENDIX X I ' (Continued) Source A E r r o r T o t a l df SS MS F Prob. Orgasm Through F o r e p l a y 2 7.827352 3.913675 4.4502 0.0229* 23 20.226995 8.794345E-01 26 28.666667 A E r r o r T o t a l I n t e r c o u r s e 2 22.115030 23 28.972690 26 58.666667 11.057514 8.7780 1.259682 0.0015* A E r r o r T o t a l Orgasm Through I n t e r c o u r s e 2 1.950267E-01 9.751332E-02 0.1383 0.8682 18 12.688484 7.049156E-01 26 14.518519 Analyses of Covariance f o r Sexual Behavior Inventory Female • Last Two Weeks of Treatment Source df SS MS F Prob. Non-Sexual Massage A 2 10.534655 5.267327 1.3068 0.2952 E r r o r 18 72.550550 4.030585 T o t a l 26 102.074074 *When s i g n i f i c a n t ANCOVA r e t e s t e d a g a i n s t i t s own c o v a r i a t e only 171 APPENDIX XI (Continued) Source df SS MS F Prob. Sensate Focus Male G e n i t a l s A 2 34.433775 17.216873 6.9145 0.0045 E r r o r 23 57.269550 2.489980 T o t a l 26 116.666667 Orgasm Through Masturbation A 2 15.952634 7.976316 3.5339 0.0450 E r r o r 23 51.912672 2.257072 T o t a l 26 80.66667 Orgasm Through F o r e p l a y A 2 1.307926 6.539630E-01 1.0095 0.3859 E r r o r 18 11.660167 6.477870E-1 T o t a l 26 16.518519 Int e r c o u r s e A 2 7.285159 3.642579 3.0608 0.0705 E r r o r 18 21.421323 1.190073 T o t a l 26 42.740741 Orgasm Through I n t e r c o u r s e A 2 5.778053E-01 2.889026E-01 1.8724 0.1881 E r r o r 18 2.777319 1.542955E-01 T o t a l 26 5.407407  *When s i g n i f i c a n t ANCOVA r e t e s t e d a g a i n s t i t s own c o v a r i a t e o n l y 172 APPENDIX XI (Continued) Analyses of Covariance f o r Sexual Behavior Inventory Female Three Week Follow-Up Source df SS MS Non-Sexual Massage A 2 4.849964 2.424981 E r r o r 18 78.136504 4.340917 T o t a l 26 96.666667 0.5586 Prob. 0.5864 Sensate Focus Male G e n i t a l s A 2 17.003969 8.601984 E r r o r 18 70.984848 3.943603 T o t a l 26 122.296296 2.1559 0.1431 Orgasm Through Masturbation A 2 20.100191 10.050096 3.4451 E r r o r 18 52.509859 2.917214 T o t a l 26 92.296296 0.0531 Orgasm Through Fo r e p l a y A 2 7.827352 3.913675 E r r o r 23 20.226995 8.7943 T o t a l 26 28.666667 4.4502 0.0229-*When s i g n i f i c a n t ANCOVA r e t e s t e d a g a i n s t i t s own c o v a r i a t e o n l y 173 APPENDIX XI (Continued) Source df SS MS F Prob. I n t e r c o u r s e A 2 22.115030 .11.057514 8.7780 0.0015^ E r r o r 23 28.972690 1.259682 T o t a l 26 58.666667 Orgasm Through Int e r c o u r s e A 2 1.950267E-01 9.751332E-02 0.1383 0.8682 E r r o r 18 12.688484 7.049158E-01 T o t a l 26 14.518519 *When s i g n i f i c a n t ANCOVA r e t e s t e d a g a i n s t i t s own c o v a r i a t e o n l y 174 APPENDIX XII Correlations.. For Male and Female Responses to the Sexual Behavior Inventory at B a s e l i n e and Three-Week Follow-Up Item B a s e l i n e Three Week ] .366 .049 *2 .239 .051 3 .874 .893 4 .783 .934 5 .822 .971 6 .753 .897 7 .768 .911 8 .789 .930 9 .726 .899 10 .814 .950 11 .795 .920 12 .819 .835 *13 .275 .561 *14 .385 .508 Follow-Up ^Disca r d e d Items 

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