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Born Against
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Scott, you might want to do a little research, like check out Helen Kaplan's last book. At least you'll get a detailed view into the case histories of other couples, and an idea what the causes and successful treatments have been for them.
I haven't read Kaplan's book myself, but it sounds good from this review I found in Archives of Sexual Behavior. There are also some references at the end that might be worth checking out.
Quote:
The Sexual Desire Disorders: Dysfunctional Regulations of Sexual Motivation.
By Helen Singer Kaplan. Brunner/Mazel, New York, 1995, 332 pp., $39.95.
Reviewed by Barry W. McCarthy, Ph.D.
Washington Psychological Center, P.C., 4201 Connecticut Avenue, N.W., No. 602, Washington, DC 20008.
Helen Singer Kaplan was one of the founders of sex therapy. Her special contribution was the focus on sexual desire problems (Kaplan, 1977). The present volume was Kaplan's final book before her untimely death in 1995. Kaplan presents a comprehensive theory of sexual motivation combining medical, psychodynamic, family systems, and cognitive-behavioral understandings and interventions. The 10 chapters, with 32 case studies, explore detailed evaluation and treatment strategies and techniques.
The book has all the strengths and all the weaknesses of a clinically based as opposed to an empirically based presentation. It is rich in clinical detail, with regard to both assessment and treatment. It is both intriguing and frustrating for the reader - how to determine what is the "gold" from what might sound like a valid insight, but is actually misleading or could even be iatrogenic. For these reasons, it is a challenging book to read and review.
On the one hand, Kaplan tries to be eclectic, using diverse concepts, evaluations, and interventions. On the other hand, she presents a very strong clinically based theory and intervention program. Especially interesting, but theoretically and clinically controversial, is her emphasis on "superficial" and "deep" etiologies for sexual desire disorders.
Chapter 8, on treatment case studies, is the strongest, especially the descriptions of "Nick and Tony Black," a 10-session sex therapy case with one booster session a year later, and "Peter and Pearl Traveler," a 5-year treatment case. These cases demonstrate Kaplan's clinical work at its best with rich detail. The format is similar to that of Rosen and Leiblum's (1995) Case Studies in Sex Therapy, illustrating the integration of theoretical, assessment, and intervention techniques. Kaplan does not use her easiest cases, but shares with the reader complex cases where the sexual problems are multicausal and multidimensional. In addition, she cites cases where the outcome is mixed or unsuccessful. Discussing failure cases is of great value but seldom done in the clinical literature (McCarthy, 1995).
The theoretical core of the book is Chapter 2 - the dysfunctional regulation of sexual motivation. Her premise is that there are dual control elements in sexual motivation - physiological and psychological inciters and physiological and psychological inhibitors. She believes, and the reviewer concurs, that the majority of patients unwittingly "turn themselves off." The main treatment strategy is to help the individual and/or couple modify, reverse, or eliminate these countersexual behaviors. In terms of terminology, Dr. Kaplan prefers the term Hypoactive Sexual Desire, which has been adopted in the DSM-IV, although many question why this is superior to the traditional term, Inhibited Sexual Desire.
Kaplan's attempts to present a "deep" psychodynamic understanding of the evolution of sexual desire, especially very early erotic experiences and the meaning of sexual fantasies, are intellectually thought-provoking and controversial. Her explanation of sexual fantasies as the erotization of childhood trauma is particularly controversial. For example, Kaplan states that in over 7000 clinical histories, she did not find a single person with sadistic or masochistic sexual fantasies who had not been subjected to significant cruelty as a child. This cries out for objective scientific examination. In treatment recommendations, she suggests accepting variant fantasies and utilizing them to promote sexual desire. This permission-giving intervention can be very helpful in reducing guilt and shame. Kaplan's oft-stated clinical strategy of first trying "superficial" cognitive-behavioral interventions and then reverting to "deep" psychodynamic interpretations has not been empirically studied, much less verified. She and her clinical team who meet and discussed cases at a weekly training/supervision seminar have a wealth of clinical data but a dearth of scientific validation.
In the two chapters on evaluation, Kaplan discusses the importance of doing a comprehensive assessment and, at the same time, tailoring the evaluation dependent on individual and couple factors. This is good clinical advice. Assessments should not be done in a rigid standardized format, ignoring individual differences and clinical judgment. However, her statement that sometimes it is not necessary to see the person alone to explore his/her sexual history, but can be conducted as part of the couple assessment, flies in the face of clinical training and the empirical data, which show that most patients have sexual vulnerabilities or secrets that they are initially reluctant to share with the spouse. Not having this information risks the therapy contract being a sham or, at least, the assessment/intervention process being less effective.
The final pages of the book examine aging and changes in sexual desire and functioning. This is one of the strongest sections. Kaplan's emphasis on prevention of sexual dysfunction and how individuals and couples can make healthy adaptations to aging is of great value. Her optimistic stance about aging and sexuality is refreshing.
Two areas that are underemphasized by Kaplan are the importance of prevention and early intervention and understanding patterns which maintain nonsexual marriage. After all, prevention is the optimal strategy, followed by early intervention. It is much easier to treat an acute dysfunction than a chronic sexual problem. The Laumann et al. (1994) study demonstrates that if you define a nonsexual marriage as being sexual fewer than 10 times a year, one in five American marriages are nonsexual. Dealing with this within 6 months, when it is still an acute problem, is likely to be more successful than when the pattern of anticipatory anxiety, tense and failed sex experiences, and sexual avoidance is entrenched. Even more important, the couple is motivated to work as an intimate team before the pattern of guilt-blame, attack-counterattack, and seeing the spouse as the worst critic has been established. It is easier to rebuild intimacy, pleasuring, and eroticism as an intimate team before these negative factors control the marital and sexual relationship (McCarthy, 1995).
Kaplan's final book has a great deal to recommend it, especially the richness of clinical vignettes and interventions. The reader must carefully assess the material presented because of its lack of empirical validation.
REFERENCES
Kaplan, H. S. (1977). Hypoactive sexual desire. J. Sex Marit. Ther. 3: 3-9.
Laumann, E. O., Gagnon, J. H., Michael, R. T., and Michaels, S. (1994). The Social Organization of Sexuality: Sexual Practices in the United States, University of Chicago Press, Chicago.
McCarthy, B. W. (1995). Learning from unsuccessful sex therapy patients. J. Sex Marit. Ther. 21: 31-38.
McCarthy, B. W. (1997). Strategies and techniques for revitalizing a non-sexual marriage. J. Sex Marit. Ther. 23: 231-240.
Rosen, R. C., and Leiblum, S. R. (eds.) (1995). Case Studies in Sex Therapy, Guilford Press, New York.
Named Works: The Sexual Desire Disorders: Dysfunctional Regulations of Sexual Motivation (Book)
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