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SEXUAL PROBLEMS AS PHOBIAS
Once the target behaviors are identified, a further step in the behavioral analysis is required: to formulate the psychological organization of that specific behavior. The disturbed sexual behavior may be a blind habit, a product of assertive difficulties, the result of incorrect cognitive patterns or inappropriate learning, or a straightforward phobic response. Each of these requires a different treatment strategy and a different therapeutic technology. The phobic organization is emerging as the most frequent elicitor of sexual disturbance. Masters and Johnson, for example, cite the fear of sexual inadequacy as the greatest single cause of actual inadequacy. Hence, the remainder of this essay will focus on the examination and treatment of sexual phobias.
The word “phobia” is an unfortunate choice. It directs behavior therapists as well as other clinicians to limiting their search to areas of fear or perhaps of anxiety and tension. By so limiting himself or herself, the therapist often misses other clinically important reactions. Actually, phobic reactions may take many different forms.
Following Salter, Fensterheim defines a phobia as any disturbed reaction of the autonomic nervous system conditioned to a specific stimulus or class of stimuli. Although usually experienced as Year, these reactions may also be experienced as anger, depression, withdrawal, or in many other ways. One patient described his phobic reaction as “a dull feeling of nothing.” It is not the quality of the experience that makes it phobic but rather the automatic, persistent, and out-of-control response of the autonomic nervous system.
Once we realize that feelings other than fear or anxiety can constitute a phobic reaction, some otherwise difficult cases become relatively easy to treat. A man complained of intermittent sexual impotency. Periodically he was able to attain and maintain an erection but under those conditions, was usually disappointed in sex. At other times, he was unable either to attain or to maintain an erection. At these times he was aware of feelings of irritability and resentment, and often there were sharp words and fighting between the couple. Closer examination revealed that the more actively the wife behaved in the sexual situation, the more apt the husband was to be impotent. Although such a pattern is usually associated with a fear of premature ejaculation, this did not seem to be true in this instance. Rather, the husband interpreted the wife’s level of activity as demands being placed on him, and he responded to these “demands” with resentment. Further examination showed a similar—although a much lower response—to demands in nonsexual situations.
The first treatment attempt was assertiveness training. His rights and his wife’s rights were discussed with him. He practiced saying “no” to demands in life situations as well as in role-playing situations with the therapist. He also practiced responses to possible “put-downs” by his wife if he did not meet her expectations. These procedures yielded only a slight and transitory change in the problem area.
The problem was then formulated as a phobic reaction. His wife’s activity was the stimulus that set off an automatic and persistent reaction experienced as resentment and irritability. The interpretation of her activity as a demand was, at this point, not an essential part of the reaction but rather an attempt to define this unreasoning, automatic response. Reduction of the phobia through a classic systematic de-sensitization with relaxation (Wolpe) made a rapid and apparently lasting change in the sexual problem.
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