Far too many therapists with a superficial knowledge of sex therapy techniques (e.g., sensate focus exercises, the "squeeze" technique) have been willing to treat dysfunctional patients. An elementary knowledge of traditional sex therapy or hypnosis techniques that has been gleaned from a book or brief workshop is inadequate preparation for ethical practice. The hypnotherapist wishing to treat sexual dysfunctions must first master an extensive and complex body of literature on the evaluation of sexual disorders (Kaplan, 1983; Kolodny, Masters & Johnson, 1979; Krane, Siroky & Goldstein, 1983; Schover & Jensen, 1988; Wagner & Green, 1981). Afterwards, NIMH sponsored ethical standards mandate 50-100 hours of advanced supervision in sex therapy (Masters, Johnson, & Kolodny, 1977; Masters, Johnson, Kolodny, & Weems, 1980) to hold oneself out to the public as qualified to work with such referrals.
It should be noted that even well trained sex therapists are now finding the successful treatment of sexual disorders to be much more challenging than was originally believed. Initial reports (e.g., Masters & Johnson, 1970) in the field of sex therapy suggested an extremely high success rate. But recent effectiveness studies of behaviorally oriented sex therapy (DeAmicis, Goldberg, LoPiccolo, Friedman, & Davies, 1984) and surveys of certified sex therapists (Kilmann, Boland, Norton, Davidson, & Caid, 1986) have documented lower success rates than were originally suggested (Heiman & LoPiccolo, 1983). Methodological flaws have also been pointed out (Zilberg-eld & Evans, 1980) in the work of Masters and Johnson (1970; Schwartz & Masters, 1988) that cast further doubt on the validity of the high success rates reported for their traditional approach. Sex therapists are struggling with difficult cases and finding that their traditional approaches are, in many cases, unsuccessful or only partially successful.
This seems due, at least in part, to the increased incidence of cases of inhibited sexual desire (ISD). This is a term originated by Lief (1977) to describe a syndrome that he and others (Frank, Anderson, & Rubinstein, 1978; Kilmann, et al., 1986; Lief, 1985; LoPiccolo, 1980; Schover & LoPiccolo, 1982) find is the most widespread sexual dysfunction. Recent estimates suggested that 50% or more of sex therapy clinic patients have the diagnosis of ISD (Shover & LoPiccolo, 1982). And yet this is perhaps the most complex and least successfully treated sexual complaint (Kaplan, 1979; Leiblum & Rosen, 1988; Zilbergeld & Ellison, 1980), typically requiring a greater number of treatment sessions than other dysfunctions (Kilmann et al., 1986; Leiblum & Rosen, 1988). It seems often to involve problems with communication and intimacy, traumatic sexual experiences, and negative parental models (Stuart, Hammond & Pett, 1986, 1987).
Since ISD is exceptionally widespread and traditional sex therapy highly limited in treating this problem, we perceived an increasing need for more effective treatment protocols. Hypnosis has been used in the treatment of sexual problems for a long time. Almost 50 years ago, Erickson and Kubie (1941) provided us with the earliest known case of the successful treatment of ISD with hypnosis. Hypnotic interventions with sexual dysfunctions (Araoz, 1980, 1982; Crasilneck, 1979, 1982; Hammond, 1984b, 1985c; Zilbergeld & Hammond, 1988) seem to hold considerable promise in sex therapy, although the literature consists exclusively of case studies and outcome reports on series of patients. However, a recent survey (Kilmann et al., 1986) indicates that the potential of hypnosis remains largely untapped by certified sex therapists, only 7% of whom use hypnosis in their clinical work.
advantages of hypnosis in sex therapy. The use of hypnosis in sex therapy has several unique strengths to recommend it. Hypnosis may be used in the treatment of the individual patient without a partner. Relatively few treatment options have typically been available for the single patient or those without cooperative partners, particularly if the therapist does not use sexual surrogates. Interestingly, the largest and most extensive follow-up reports on the use of hypnosis with sexual dysfunction have been on individual patients suffering with erectile dysfunction (Crasilneck, 1979, 1982). Crasilneck reported follow-ups on a larger number of impotent patients than any other sex therapy researchers, including Masters and Johnson, and with comparable outcome rates to those of Masters and Johnson (1970).
Hypnosis also offers techniques that allow rapid exploration and identification of underlying conflicts, unresolved feelings about past events, and factors beyond conscious awareness. For example, many patients have reported in an initial sex history that they had never experienced incest or sexual molestation. Later, however, early childhood sexual abuse was uncovered through the use of hypnosis. There are additionally times when adaptive functions are being served by sexual dysfunctions, of which the patient has only limited or no conscious awareness. A dysfunction, for instance, may serve as a way of protecting the patient against a fear (e.g., of infidelity), of punishing the self for past misbehavior, or of expressing anger toward a partner.
Learning self-hypnosis may provide patients with a sense of self-control and a technique for stress management. Physical and mental tension and fatigue often inhibit sexual interest and performance capacities. Some patients need a method for mentally "changing gears" and making a transition from a hectic day to being able to focus on sensual involvement. Self-hypnosis provides them with such a skill for anxiety reduction and decompression, as well as for the arousal of sexual passion through sexual imagery prior to sexual involvement.
Discouragement is a factor too often overlooked in sex therapy. Many patients simply no longer believe that they will ever be able to experience passion and interest or to perform adequately. However, perhaps due to the popularized images of hypnosis as mystical, some patients come to therapy with a belief that hypnosis can do for them what they cannot do for themselves: promote change. Hypnosis may be used to provide hope, increased feelings of self-efficacy (Bandura, 1977), and confidence that change can occur. "Trance ratification" procedures can convince patients of the power of their own mind and of hypnosis to help them. When patients feel an arm levitate and float up involuntarily, they are often convinced that this thing called hypnosis may, in fact, be capable of doing something for them. Similarly, when a glove anesthesia is created in a hand so that a needle may be painlessly put through a fold of skin on the back of the hand, patients are convinced that they have more potentials than they realized and that perhaps their mind is powerful enough to stir sexual desire, facilitate orgasm, or create erections.
We are well aware that some patients are endowed, either through heredity and/or early life experiences, with exceptional hypnotic capacity. For individuals with these native capacities, hypnosis can be an extremely powerful tool. When patients possess the capacity to focus and use their minds so powerfully, it seems a shame not to utilize their unique talents.
Hypnosis also offers us a variety of techniques for altering problematic emotions and increasing desired emotional states. Symbolic imagery techniques often allow patients to release pent-up feelings like anger and resentment, without further harming the relationship with the partner. For example, such a patient may experience himself gradually smashing a huge boulder in the mountains while simultaneously venting his angry feelings. Other patients may imagine breaking through a barrier, discarding old parental messages that evoke negative emotions, or placing feelings of guilt in the gondola of a hot air balloon and watching it float away. The chronically fatigued patient may imagine an energy transfusion or withdraw to a serene place in self-hypnosis. The master control room technique, found at the beginning in this chapter, has proven surprisingly effective in stimulating feelings of sexual desire, particularly after roadblocks to desire (e.g., relationship problems) have been removed.
In the treatment of secondary dysfunctions (e.g., inhibited sexual desire, erectile dysfunction), hypnotic age regression may revivify memories that help rekindle and recapture positive sexual and affectional feelings. Hypnosis and self-hypnosis can enhance the patient's ability to focus attention and increase sensory awareness, thereby facilitating increased arousal and pleasure. Hypnotic techniques can also aid in elucidating internal (cognitive, imagery) processes that are impossible to observe and difficult to explicate through discussion alone. Occasionally, for instance, spouses report a very unpleasant experience with assigned tasks like sensate focus, but they are unable to explain why or provide details about thoughts or images that may have interfered. Through hypnosis patients may be regressed to the sexual date several days earlier; as they mentally relive the experience, the suggestion may be offered, "Everything that you are thinking, mentally picturing, and experiencing, just say out loud." Patients are often able to provide details of what were elusive and unavailable internal processes.
limitations of hypnosis. Despite the many advantages of hypnosis, hypnosis is not a panacea and is frequently most effective when combined with other therapeutic methods. Although I use hypnosis with considerable frequency, I do not rely on or advocate the unitary use of hypnosis. As with any single treatment modality, there are also some limitations and cautions in the use of hypnotic techniques in this area.
First, hypnotherapists may experience the temptation to overemphasize an individual focus for treatment, neglecting important relationship factors that may be involved. Individual psychotherapy has been known for many years to have the potential to evoke pathological reactions in the untreated spouse (Kohl, 1962), and deterioration in the marital relationship appears to be a greater risk in individual marital therapy (Gurman & Kniskern, 1978a, 1978b). We find in sex therapy that, unless individually focused hypnosis is used in a context that involves the partner in assessment and in at least part of the treatment, there is a risk that some patients may feel singled out as the "identified patient," and relationship factors may be neglected. It is recommended, therefore, that the partner be included from the beginning in assessment. When I do individual hypnotic work, the mate is typically involved in behavioral assignments afterwards. If the individual work requires more than three or four sessions, it is further recommended that a conjoint session occur for one-half hour or an hour each month to maintain the spouse's feeling of involvement and input. The temporarily uninvolved partner is also encouraged to call between conjoint sessions if an individual or conjoint session is desired and/or to send feedback through the spouse.
It should also be noted that spouses may sometimes be present during hypnotic work. Some patients will feel self-conscious, as though they have an audience, and prefer not to have the spouse in attendance. However, occasionally a patient will feel more secure having his/her mate present. Inquire about this matter and respect the feelings of the patient. When a partner witnesses an age regression to a negative past experience(s), he/she will generally be more empathic and supportive of the mate. Some hypnotic techniques also focus on both partners simultaneously, such as mutual hypnosis. Both mates may also be age regressed to a wonderful experience, or the technique of pseudo-orientation in time into the future may be used to have them share a fantasy of having beautiful sexual experiences together. On the other hand, if the patient is being taught to enter a self-hypnotic state and create sexual fantasies to facilitate sexual desire, and the fantasies are about partners other than the spouse, an individual session will be desirable.
Variations in the native hypnotic talent level of patients provide an inevitable limitation to hypnotic work. Thus the 5%-10% of patients who either cannot or will not be hypnotized and realistically the other 10%-15% of patients who enter only very light trance states will be limited in their hypnotic capacity and unlikely to benefit from such treatment. Furthermore, even after being educated about the nature of hypnosis, a very small number of patients will not want to be hypnotized because of the widespread misconceptions about hypnosis. Thus hypnosis is like any other therapeutic technique: it will not be effective with everyone. Finally, we should note, once again, the need for controlled research in this area to accurately investigate the potentials of hypnotic treatment of sexual dysfunction.
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