APPROACHES OF BEHAVIORAL THERAPISTS
Although the irrelevance of intrapsychic considerations to the treatment of disturbed sexual behaviors that are now blind habits is especially clear, this same behavioral perspective may be applied to all sexual disturbances. Many behavioral therapists take any sexual problem, break it down into its component behaviors, and systematically change each behavior in turn. With this approach they have achieved some excellent results.
Barlow, Reynolds, and Agras, for example, have used just such a behavior-by-behavior approach in the successful treatment of a transsexual young man, an area generally considered to be highly refractory to any kind of treatment. First the patient was trained in “masculine” motor and social behaviors. He was taught to sit, stand, and walk in a male-appropriate (as determined by community standards) role, to deepen his voice, and to converse appropriately. Next, using sexual fantasies combined with social reinforcers, he was trained to identify himself as male rather than as female. Finally, a classical conditioning method known as fading was used to establish heterosexual arousal, and aversive methods were used to decrease homosexual arousal. Through the sequential, successful modification of these component behaviors, the patient changed from a person desiring sex transformation surgery to one on the brink of leading a full heterosexual life. The power and limits of such a completely behavioral approach to complex sexual problems, what it can and cannot do, has not yet been fully tested, but it does have great promise.
In clinical practice, however, there are times when the exploration of intrapsychic processes seems necessary to identify the target behaviors. Even under these conditions, behavioral technology may be used to bring about the actual change. To illustrate this approach, we will describe the treatment of a twenty-four-year-old homosexual man who complained of compulsive masochistic sexual behavior. He was not attracted to lovers who would show him tenderness and consideration but rather to “bastards” who would mistreat and even physically abuse him. He received no pleasure from this and experienced only disgust with himself and a feeling of intense frustration. He rather quickly broke off each such relationship, only to be caught up again just as quickly in a similar one. A variety of behavioral methods was attempted unsuccessfully: desensitization to tenderness, assertive training, aversion to “bastards,” and various behavioral assignments.
A series of sessions using quasi-free association methods revealed that he had experienced similar feelings of self-disgust and frustration as a child in relation to his father. The memories of specific incidents, however, were sparse and vague and the feelings were almost conjectural. A nonsystematic desensitization (Fensterheim) to the vague memories was attempted. The first result of this procedure was more vivid memories and a heightening of the disturbed reaction to them. Eventually the disturbed reactions diminished and then disappeared. At that point, without any further behavioral recommendations or treatment, the masochistic pattern was replaced by a series of more satisfactory relationships. An almost two-year follow-up (he returned to discuss an unrelated career problem) showed this adaptive change to persist.
These illustrations have stressed the importance of identifying target behaviors. It must also be noted that the behavior therapist, as a clinician, is well aware that the sexual problem may not be primary but may derive from other problems. Depression, poor inter-personal relations, a generally high level of anxiety, physiological malfunctions – all may influence sexual behavior.
In these instances, even though the person has a sexual problem, nonsexual target behaviors may have to be selected for change. Many times the modification of these nonsexual behaviors will relieve the sexual problem; other times, further and more sexually-oriented treatment is necessary to resolve the problem.
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