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Generalization of therapeutic gain in the treatment of premature ejaculation
BEHAVIOR THERAPY 7, 355--358 (1976)
Generalization of Therapeutic Gain in the Treatment of Premature Ejaculation SERGIO YULIS University of Chile
Following treatment for premature ejaculation. 23 males provided reports of sexual intercourse with females other than the one who had been a treatment partner. Analysis of the data strongly suggests that concomitant assertive training in the treatment of sexual dysfunctions increases the probabilities of generalization of therapeutic gains. Reports on the treatment of premature ejaculation consistently show a high percentage of therapeutic success (Masters & Johnson, 1970; Luco, Busto, Rubio & Aguirre, 1974; Wolpe, 1969). Assessment of permanent change, however, has always been related to sexual performance with the treatment partner. Understandably, almost no evidence is available about the generalization of therapeutic results in the treatment of sexual dysfunction. For this purpose, generalization is defined as the adequate performance of coitus with a nontreatment partner, that is, a person other than the w o m a n who participated in the treatment program. Ethical reasons preclude research specifically designed to test hypotheses about the generalization of therapeutic benefits in the treatment of sexual dysfunctions. Nevertheless, information about its occurrence usually does b e c o m e available in the course of treatment and especially at follow-up. The data to be presented reflect information c o n v e y e d by 23 out of 37 males treated for premature ejaculation. This information was gathered during routine follow-up interviews 6 months after the end of treatment. Clients, self-referred or referred by psychiatrists and psychologists, were mostly middle- or upper-class persons with a mean of 14.3 years of education. Their mean age was 26.6 years, and the mean duration of the major complaint was 8.4 years.
TREATMENT PROCEDURE During the initial interview, a preliminary history was taken, with special reference to the major complaint. Also, the concomitant presence of other psychological or psychosocial disturbances and their possible role in the treatment program was assessed. Treatment was offered if there was no difficulty which would hinder treatment and if the individual had a Requests for reprints should be addressed to Sergio Yulis, Director, Psychology Department, Allan Memorial Institute, 1025Pine Avenue West, Montreal, Quebec, H3A IA1. 355 Copyright ~) 1976 by Association tel" Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
356
SERGIO YULIS
partner, either his wife or girl friend, who agreed to participate in the program. If these conditions were met, an appointment was arranged for the couple with one of the treatment teams, each of which was composed of a female and a male therapist. The diagnostic interviews followed the general pattern suggested by Masters and Johnson (1970). However, a concerted effort was made to obtain information about the variables controlling sexual performance and the client's ability to alter them. Thus, a detailed analysis of the unfolding of sexual anxiety was undertaken. Also, the client's assertive behavior, especially the ways he communicated his needs, wishes, and preferences, were thoroughly investigated. For this, in addition to the client's verbal report, role-playing as a diagnostic procedure in the fashion of Corsini (1966) was amply employed. The final diagnostic interview involved the two co-therapists and the two clients. This round table began with the therapists communicating their point of view about the genesis and maintenance of the sexual difficulty, illustrating it, as much as possible, with the information gathered in the previous days. At the same time, a treatment program, with careful consideration of details pertaining to time, space, and so on, was proposed. At all times, the clients were encouraged to participate with questions, comments, and if possible, with specific suggestions. Finally, specific treatment indications to be carried out before the next session were briefly reviewed. From then on, the couple was seen three times a week for a period of up to 18 sessions. The core of the treatment procedures involved features derived from Masters and Johnson, such as the sensate focus, Seaman's squeezing technique, and Wolpe's controlled intromission and thrusting. Additionally, if the therapist's assessment so indicated, clients received specific assertive training designed to broaden their repertoire for the skillful expression of their wishes, needs and preferences, especially in the area of social interaction, dating, and sexual contact. This training was conducted by means of modeling and role-playing with the assistance of a tape recorder. When behavior was modeled, either the therapists themselves or associates of them were the models. This use of additional personnel was introduced in order to broaden the sample of experience the patient might encounter in social interactions and dating.
RESULTS Treatment Results O f t h e 37 m e n s e e n f o r t h e t r e a t m e n t o f p r e m a t u r e e j a c u l a t i o n , 33 rep o r t e d a v e r y s a t i s f a c t o r y s e x u a l r e l a t i o n s h i p at 6 m o n t h s f o l l o w - u p . I n t h e majority of cases, this report was also substantiated by information from t h e i r t r e a t m e n t p a r t n e r s . V e r y s a t i s f a c t o r y s e x u a l a d j u s t m e n t is d e f i n e d as between 80-100% ejaculation-controlled sexual encounters. This represents a success rate of 89%, which probably reflects not only the efficacy of the treatment, but also the relative youth of the clients and relatively short duration of the dysfunction.
Generalization Data T h e i n f o r m a t i o n a b o u t g e n e r a l i z a t i o n c o n c e r n s 23 p a t i e n t s w h o r e p o r t e d s e x u a l c o n t a c t w i t h at l e a s t o n e n o n t r e a t m e n t p a r t n e r ( T a b l e 1). N i n e o f t h e s e 23 s u b j e c t s e x p e r i e n c e d p e r s i s t e n t d i f f i c u l t i e s in e j a c u l a t o r y c o n t r o l when having intercourse with a nontreatment partner. Therefore, they are c o n s i d e r e d f a i l u r e s as f a r as g e n e r a l i z a t i o n o f t h e r a p e u t i c g a i n is c o n -
357
GENERALIZATION OF EJACULATION CONTROL TABLE 1 INCIDENCE OF GENERALIZATION OF THERAPEUTIC GAIN IN RELATIONSHIP TO MARITAL STATUS AND TYPE OF TREATMENT Treatment
Generalization results
Marital status
Unsuccessful generalization
Married Single
3 4
2 --
5 4
Successful generalization
Married Single
1 2
2 9
3 11
10
13
23
Total c o l u m n s
Sex therapy
Sex therapy and assertive training
Total rows
cerned. Fourteen of the 23 clients can be considered as having achieved successful generalization for ejaculatory control. It is of note that the nine males (five married and four unmarried) who experienced persistent difficulties in ejaculation control with a nontreatment partner also reported episodes of premature ejaculation with their treatment partners following these unsuccessful encounters. Furthermore, 22 of the 23 males who have reported experience with a nontreatment partner indicated having had difficulties in controlling their ejaculation on the first of these encounters. Thirteen of the 23 clients had had conjoint assertive training in addition to the specific treatment for sexual dysfunction. Eleven of them (84%) experienced successful generalization of ejaculatory control, whereas two were considered failures in this respect. Of the l0 subjects who did not receive conjoint assertive training, three were successful and seven unsuccessful in terms of generalization. Statistical analysis indicates that assertive training is associated with successful generalization of therapeutic gain. Fisher's (1935) Exact Probability Test yields a probability of .011, demonstrating a statistically significant gain in generalization when assertive training is added to the sexual treatment. These results, strongly suggesting the utility of assertive training procedures, are similar to Serber's (1972) conclusion with reference to the role of assertive training in the treatment of sexual deviances. REFERENCE NOTE 1. Luco, A., Busto, M. A., Rubio, C., & Aguirre, M. A. Las tecnicas de Masters y Johnson en la incompatibifidad sexuah Adaptation a la realidad Chilena y su aplicacion experimen-
358
SERGIO YULIS
tal. Paper presented at the Fifteenth Interamerican Congress of Psychology, Bogota, Colombia, December 1974.
REFERENCES Corsini, R. Role-playing in psychotherapy. Chicago: Aldine, 1966. Fisher, R. A. The design of experiments. Edinburgh: Oliver & Boyd, 1935. Masters, W. H., & Johnson, V. E. Human sexual inadequacy. Boston: Little, Brown & Company, 1970. Serber, M. Shame aversion therapy with and without heterosexual training. In R. D. Rubin, H. Fensterheim, J. D. Henderson, & L. P. Ullmann (Eds.), Advances in behavior therapy. New York: Academic Press, 1972. Pp. 115-119. Wolpe, J. The practice of behavior therapy. London: Pergamon Press, 1969.
Generalization of Therapeutic Gain in the Treatment of Premature Ejaculation SERGIO YULIS University of Chile
Following treatment for premature ejaculation. 23 males provided reports of sexual intercourse with females other than the one who had been a treatment partner. Analysis of the data strongly suggests that concomitant assertive training in the treatment of sexual dysfunctions increases the probabilities of generalization of therapeutic gains. Reports on the treatment of premature ejaculation consistently show a high percentage of therapeutic success (Masters & Johnson, 1970; Luco, Busto, Rubio & Aguirre, 1974; Wolpe, 1969). Assessment of permanent change, however, has always been related to sexual performance with the treatment partner. Understandably, almost no evidence is available about the generalization of therapeutic results in the treatment of sexual dysfunction. For this purpose, generalization is defined as the adequate performance of coitus with a nontreatment partner, that is, a person other than the w o m a n who participated in the treatment program. Ethical reasons preclude research specifically designed to test hypotheses about the generalization of therapeutic benefits in the treatment of sexual dysfunctions. Nevertheless, information about its occurrence usually does b e c o m e available in the course of treatment and especially at follow-up. The data to be presented reflect information c o n v e y e d by 23 out of 37 males treated for premature ejaculation. This information was gathered during routine follow-up interviews 6 months after the end of treatment. Clients, self-referred or referred by psychiatrists and psychologists, were mostly middle- or upper-class persons with a mean of 14.3 years of education. Their mean age was 26.6 years, and the mean duration of the major complaint was 8.4 years.
TREATMENT PROCEDURE During the initial interview, a preliminary history was taken, with special reference to the major complaint. Also, the concomitant presence of other psychological or psychosocial disturbances and their possible role in the treatment program was assessed. Treatment was offered if there was no difficulty which would hinder treatment and if the individual had a Requests for reprints should be addressed to Sergio Yulis, Director, Psychology Department, Allan Memorial Institute, 1025Pine Avenue West, Montreal, Quebec, H3A IA1. 355 Copyright ~) 1976 by Association tel" Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
356
SERGIO YULIS
partner, either his wife or girl friend, who agreed to participate in the program. If these conditions were met, an appointment was arranged for the couple with one of the treatment teams, each of which was composed of a female and a male therapist. The diagnostic interviews followed the general pattern suggested by Masters and Johnson (1970). However, a concerted effort was made to obtain information about the variables controlling sexual performance and the client's ability to alter them. Thus, a detailed analysis of the unfolding of sexual anxiety was undertaken. Also, the client's assertive behavior, especially the ways he communicated his needs, wishes, and preferences, were thoroughly investigated. For this, in addition to the client's verbal report, role-playing as a diagnostic procedure in the fashion of Corsini (1966) was amply employed. The final diagnostic interview involved the two co-therapists and the two clients. This round table began with the therapists communicating their point of view about the genesis and maintenance of the sexual difficulty, illustrating it, as much as possible, with the information gathered in the previous days. At the same time, a treatment program, with careful consideration of details pertaining to time, space, and so on, was proposed. At all times, the clients were encouraged to participate with questions, comments, and if possible, with specific suggestions. Finally, specific treatment indications to be carried out before the next session were briefly reviewed. From then on, the couple was seen three times a week for a period of up to 18 sessions. The core of the treatment procedures involved features derived from Masters and Johnson, such as the sensate focus, Seaman's squeezing technique, and Wolpe's controlled intromission and thrusting. Additionally, if the therapist's assessment so indicated, clients received specific assertive training designed to broaden their repertoire for the skillful expression of their wishes, needs and preferences, especially in the area of social interaction, dating, and sexual contact. This training was conducted by means of modeling and role-playing with the assistance of a tape recorder. When behavior was modeled, either the therapists themselves or associates of them were the models. This use of additional personnel was introduced in order to broaden the sample of experience the patient might encounter in social interactions and dating.
RESULTS Treatment Results O f t h e 37 m e n s e e n f o r t h e t r e a t m e n t o f p r e m a t u r e e j a c u l a t i o n , 33 rep o r t e d a v e r y s a t i s f a c t o r y s e x u a l r e l a t i o n s h i p at 6 m o n t h s f o l l o w - u p . I n t h e majority of cases, this report was also substantiated by information from t h e i r t r e a t m e n t p a r t n e r s . V e r y s a t i s f a c t o r y s e x u a l a d j u s t m e n t is d e f i n e d as between 80-100% ejaculation-controlled sexual encounters. This represents a success rate of 89%, which probably reflects not only the efficacy of the treatment, but also the relative youth of the clients and relatively short duration of the dysfunction.
Generalization Data T h e i n f o r m a t i o n a b o u t g e n e r a l i z a t i o n c o n c e r n s 23 p a t i e n t s w h o r e p o r t e d s e x u a l c o n t a c t w i t h at l e a s t o n e n o n t r e a t m e n t p a r t n e r ( T a b l e 1). N i n e o f t h e s e 23 s u b j e c t s e x p e r i e n c e d p e r s i s t e n t d i f f i c u l t i e s in e j a c u l a t o r y c o n t r o l when having intercourse with a nontreatment partner. Therefore, they are c o n s i d e r e d f a i l u r e s as f a r as g e n e r a l i z a t i o n o f t h e r a p e u t i c g a i n is c o n -
357
GENERALIZATION OF EJACULATION CONTROL TABLE 1 INCIDENCE OF GENERALIZATION OF THERAPEUTIC GAIN IN RELATIONSHIP TO MARITAL STATUS AND TYPE OF TREATMENT Treatment
Generalization results
Marital status
Unsuccessful generalization
Married Single
3 4
2 --
5 4
Successful generalization
Married Single
1 2
2 9
3 11
10
13
23
Total c o l u m n s
Sex therapy
Sex therapy and assertive training
Total rows
cerned. Fourteen of the 23 clients can be considered as having achieved successful generalization for ejaculatory control. It is of note that the nine males (five married and four unmarried) who experienced persistent difficulties in ejaculation control with a nontreatment partner also reported episodes of premature ejaculation with their treatment partners following these unsuccessful encounters. Furthermore, 22 of the 23 males who have reported experience with a nontreatment partner indicated having had difficulties in controlling their ejaculation on the first of these encounters. Thirteen of the 23 clients had had conjoint assertive training in addition to the specific treatment for sexual dysfunction. Eleven of them (84%) experienced successful generalization of ejaculatory control, whereas two were considered failures in this respect. Of the l0 subjects who did not receive conjoint assertive training, three were successful and seven unsuccessful in terms of generalization. Statistical analysis indicates that assertive training is associated with successful generalization of therapeutic gain. Fisher's (1935) Exact Probability Test yields a probability of .011, demonstrating a statistically significant gain in generalization when assertive training is added to the sexual treatment. These results, strongly suggesting the utility of assertive training procedures, are similar to Serber's (1972) conclusion with reference to the role of assertive training in the treatment of sexual deviances. REFERENCE NOTE 1. Luco, A., Busto, M. A., Rubio, C., & Aguirre, M. A. Las tecnicas de Masters y Johnson en la incompatibifidad sexuah Adaptation a la realidad Chilena y su aplicacion experimen-
358
SERGIO YULIS
tal. Paper presented at the Fifteenth Interamerican Congress of Psychology, Bogota, Colombia, December 1974.
REFERENCES Corsini, R. Role-playing in psychotherapy. Chicago: Aldine, 1966. Fisher, R. A. The design of experiments. Edinburgh: Oliver & Boyd, 1935. Masters, W. H., & Johnson, V. E. Human sexual inadequacy. Boston: Little, Brown & Company, 1970. Serber, M. Shame aversion therapy with and without heterosexual training. In R. D. Rubin, H. Fensterheim, J. D. Henderson, & L. P. Ullmann (Eds.), Advances in behavior therapy. New York: Academic Press, 1972. Pp. 115-119. Wolpe, J. The practice of behavior therapy. London: Pergamon Press, 1969.