THE EMPLOYMENT OF HYPNOTIC STRATEGIES IN A CASE OF ERECTILE DYSFUNCTION, VIEWED FROM A COGNITIVE-BEHAVORIAL PERSPECTIVE By Alberto Bemejo Mercader Clinical Psychologist Center for psychology EIDOS(Alicante) Luis Braille St 18 Esc.4-3rd B 03010 ALICANTE - Spain. Email abermejo@correo.cop.es Summary A clinical example of erectile dysfunction is presented. In the treatment we start with a functional analysis and use hypnotic strategies with a cognitive behavorial focus. These strategies are commented, and the use of hypnosis in sexual therapy is also commented. Abstract The abstract is in English and can be read in the original. Introduction Hypnosis is not a therapy in itself. It is a specialized technique that can be used as a catalytic agent for the cognitive-behavorial techniques used in Clinical Psychology. The work by Kirsch et al (Kirsch 1990; Kirsch, Montgomery and Sapistein 1995; Shoenberger, Kirsch,Gearan,Montgomery and Pastyrnak, 1994) show that hypnosis used as adjunct to psychoanalysis and cognitive-behavorial methods, can substantially improve the results. Until further research can show conclusively that there is a qualitative and quantitative change between two awake "states" that has been induced by hypnosis, we shall have to agree that the "hypnotic phenomena" are rooted in social and psychological characteristics, such as motivation, the expectations of entering trance, the believe and faith vested on the hypnotizer,the desire to please him, and a positive experience at the initial trance(subjectively interpreted by the subject as "very relaxing"). There exists a certain consensus about the fact that the aplication of hypnotic techniques encourages the emergence of psychological and physicopsychological phenomena that thus characterize the hypnotic state, and that have been accepted (sometimes with some reticence) by the mayority of the specialists. They include (Miguel Tobal y Gonzales Ordi,1988): * Increase in the aceptance of suggestions. * Augmentation of the capacity for mental "imagery" * Augmentation of the capacity for feeling the emotional implications of situations being imagined by the subject or that are suggested directly by the experimenter. * The capacity to focus attention on a restricted stimulus: verbal suggestions and/or accesorial dispensed by the experimenter. (I have trouble understanding this H.R.) * Distorsion of the psychological variables of space and time. * "Automatic" behavior. * Diminution of the capacity for logical/rational analysis and for the critical assesment of any situation. * Feeling of profound relaxation. * Psychophysiological alterations, related directly to the characteristics of the suggestions The first detailed reference regarding the use of hypnosis in sexual therapy was published by Erickson in 1935. His technique of indirect imagination was applied to a premature ejaculation case, apparently with good results. Since then, there have been diverse aplications of hypnosis to concrete sexual dysfunction cases. There is a multitude of hypnosuggestive procedure that can be used during therapy. Space does not permit us to develop the whole group of applications that can be used, so that we offer some examples of this set of therapeutic tools. * Instructions and direct suggestions * Specific visualizations and exercises of imagination * Procedures to reduce anxiety * Exercises promoting energy and activation *Exercises of cognitive restructurizing (modified for hypnosis) (? HR) * Modification of expectations * Exercises of personal autoafirmation * Use of metaphors and associations * Posthypnotic instructions * Techniques of stimulus transfer * Manipulation of the symptoms (Kroger and Fezler 1976) * Time distortion I now will present an erectile dysfunction case in which I have introduced various "hynosuggestion" techniques that have been, in my opinion, useful in the solution of the problem faced by my patient. A classical definition of impotence is that of Masters and Johnson (1970) according to which an impotent man is incapable of obtaining or mantaining an erection of sufficient quality to be succesful in coitus. Kaplan (l974) gives a quatitative characterization by stating that there is an impotence problem when the man does not reach erection in 25% of his sexual contacts. Thus the sporadic "impotencies" are not to be considered pathological, since at some point all men have had this problem. When the time comes to establish the possible causes there has to be determined if there is an organic etiology or if it just obeys psychological causes. In any case the erection problems are cause by an inadequate pumping of blood into the cavernous bodies of the penis or a failure of the temporary retention of the same. Many factors can alter this process: Fatigue, use of alcohol or drugs, some prescription drugs, some diseases, and many psychological factors of which anxiety is the most relevant. It is estimated that the majority of erection problems have a psychological basis. Anxiety over the sexual interaction, the autoobservation during the interaction, obsessive thoughts, excessive preocupation about the partner, fear of not obtaining an adequate erection, an exagerated preocupation with quality of execution or performance, lack of concentration on the enjoyment of the situation at hand, all this can block the erection. Clinical Case Personal Data J.Z. is a young student, age 20, an homosexual male with no stable partner. He has no brothers or sisters. Reason for Consultation Refered to me by an urologist who found no physical problem and suggested a psychologist. He exhibits dificulty in mantaining erection on masturbation (about twice a week), which is his only activity at this time, ever since he detected this problem. He fears ridicule if he has any contact with a male that attracts him. He has had this problem for 4 weeks, during which time he has had to reduce his masturbation because of some pains that develop when trying to force an erection, which he does not reach anyway, in the majority of cases. Periodicaly he tries again to try to resolve the problem but all he manages to do is to get more and more preocupied, increase his pains and be more disgusted. His sexual interest has diminished. What used to stimulate his sexuality does not do so any more (there has been a reduction of his sexual fantasies, and he does not fixate on males). In spite of all, sometimes he does reach orgasm, in spite of the pain or tension, in several minutes of "forcing" it. He appears apathetic and "blue". Some of his verbalizations are "I am turning impotent" "I am very unfortunate". History of the problem His sexual learning has been done with his friends, classmates, films, magazines, and "autodiscovery". His parents do not known about his homosexuality, which they would not accept. In his family the subject of sex is not treated publicly, although he does not think that his family encourages repressive or negative feelings on this matter. When J.Z. disclosed partially his problem (by complaining about "pain" or "bother") his mother immediately suggested consultation with an urologist. Before his problem emerged, he conducted sexual activities (masturbation or sexual contact without penetration -and with protection-) 3 times a week approximately. He has never had a stable partner. Two years ago he had coitus with a girl, which he liked, but not as much as with boys. He accepts his homosexuality and does not consider that any trauma has resulted from wanting boys instead of girls, or that this preference has caused his present troubles. He considers himself a normal and well adjusted person, has never consulted with a psychologist, has a pleasant life with his family and friends, works hard at this studies, but he regards himself as a somewhat nervous person, easily prone to excessive preocupation when confronted with any kind of problem. Since November he has studied intensely for his exams at the University, working long hours each day and worrying about the results of his exams. Some months back, J.Z. entered into a weight reduction regime and managed to shed 40 pounds. (This information was offered later into the therapy, after a relapse) Evaluation The evaluation phase took the first two sessions, but since the very beginning the patient was already required to do certain exercises at home. The evaluation procedures consisted in: ---The interview ----A dairy was kept by the patient ( see its structure separately) ----Sexual History ----Sexual Opinion Survey (SOS) of Fisher et al (1988). Spanish version by Carpintero E. and Fuentes A. (1994). J.Z. had a mark of 93 (decil 6) in the area of erotophobia-erothofilia. ----Sexual Pleasure Questionaire: Men (Annon,J.S.) ----STAI A/R from Spielberger ( This was administered again at the end of the therapy) Before therapy his marks were 35 on A/E and 26 on A/R with centiles of 85 and 77 respectively. After therapy his marks were 4 in A/E and 20 in A/R with centiles of 4 and 55 respectively. --- 16PF Marks in "decatypes": A7,B6,C4,E4,F4,G4,H4,I5,L4,M7,N5,O9,Q1-5,Q2-4,Q3-4,Q4-7. in centiles MI-57,IN-64,AQ-73. Note that the highest mark corresponds to the dimension of APPREHENSION Note also that this test was administered after his relapse. ASIDE: THE FORMAT OF THE DAIRY Day/time Concrete experience Physical sensations Feelings Associated thoughts Other observations END OF ASIDE Summary of the functional analysis Problem conduct: Erectile dysfunction. Analysis of the responses. MOTOR AREA: Reduction of masturbation frequency, avoidance of sexual encounters. PHYSIOLOGICAL AREA: genital pain or bother on masturbation ( like "pinching") Aumentation of body tightness, Sweating, Acelerated breathing when no erection is forthcoming. Few frequency of orgasms. EMOTIONAL AREA: Much nervousness, Stress, Disgust, Fear. COGNITIVE AREA: Anxious and depressing thoughts related to his problem: "I am getting to be impotent". "I am very unlucky" "what will happen when I am with somebody" "I am afraid I will never recover" "I am good for nothing" "how long?" Analysis of the antecedent stimuli Any place and time when he decides to masturbate, but above all note that the erections are practically non existent when doing this in the afternoon or at night. Analysis of the consequent stimili Genital "bothers". Irritability, Preocupation,Confusion. Fear of remaining impotent Lack of sexual desire. Avoidance of sexual encounters. Organimistic variables(?) ORGANIC OR PHYSIOLOGICAL CAUSES : Absent PERSONALITY OR HISTORY OF SEXUAL LEARNING: Positve attitude towards sex. Agreeable sexual experiences. High marks on the APPREHENSION dimension on the 16PF HABILITIES IN SOCIAL ROLES OR IN INTERPERSONAL RELATIONS: Not relevant. Explaining Hypothesis High anxiety levels, a product of the preparation for examinations (dedicates many hours daily to studies and visits to the University, and says he is nervous and preocupied by that). The cumulative fatigue is the basis for the problem but with the following complications: 1) J.Z. detects his erections problems as being progressive ( they get worse with each masturbation) which reveals the additional problem of anxiety about his sexual performance. Every time he tries masturbation he remembers the problems encountered in the previous ones, thus having the anxiety of thinking that he will never have a complete erection. In this situation, in which the sympatic system is being activated , an erection will not occur or it will be necesary to "force it" 2) The absence of desire ( he does things in a "mechanical" manner with no fantasies of sexual excitation) makes it more difficult arrive at orgasm, since there is an absence of any type of pleasant sensations during masturbation. 3) When he tries this in the afternoon or night the erection problems and the genital bothers are worse, which is explained by his higher level of fatigue at those times. 4) His tendency of being excessively preocupied by any type of problem, whatever its nature, and his "nervous" nature, are other factors that maintain the problem. TREATMENT: For a better understanding of the hypnosuggestions that were introduced, and their function in the squeme of the treatment, I will present the interventions that were realized, session by session. The therapeutic objectives that I set out for myself were: -- Provide J.Z. with sexual information and education needed for a correct sexual functioning, together with the manner in which certain psychological variables can affect our sexuality. -- Complete resolution of his erectile problems. --Recuperation of the levels of "sexual desire" that he had previous to his erection problems. since his fear of not "desiring" as he did before (not to get excited in the presence of a certain boy), has been a constant theme over the whole therepy. -- Reduce his anxiety ( in particular the anxiety of sexual performance) to its adaptative value or less (he has always considered himself somewhat "nervous") __ Help him to recuperate his confidence on being able to have complete sexual relations with people of his "type", and with an optimal functioning in the loving-sexual sphere. Session 1(Note that this session was preceeded by two evaluation sessions so this is not the first sessionHR) Information and sexual education In the preceding evaluation sessions we had already discussed the matters explained above and sexual information had already been provided. Also, in addition, he had been instructed to do at home, alone, a program of sensual focus (self applied, with prohibition of stimulus of the genitals, and done every day)directed to know and locate the parts of his body that are most agreeable, to recoup the pleasure of feeling his body with no requirements, to serve as a reductor of his anguish and to realize that with an abandonment to these pleasant feelings, erections might spontaneously reapear (even when this is not the object). This exercise is combined with a simple training on the control of breathing to facilitate the necessary relaxation. Session 2 Revamping of the previous exercises. Clarification of doubts on sexual matters. Restructuring of a cognitive matter: We dedicate some minutes to discuss his "fear of becoming impotent", a fear that can interfere with the therapeutic process. He is now instructed to include his genital area in the focus exercise without their direct excitation or inducing orgasm: I encourage him to appreciate arousal sensations, should they appear, but in any case no orgasm is to be reached. He is instructed not to think in his fear of impotence but to try to include a larger number of fantasies of a sexual content during the exercise. We introduce an hypnotic induction starting with some simple abdominal respiratory exercises with the addition of suggestions of calm and relaxation. The idea is to prepare him for subsequent inductions in later sessions. Sessions 3 4 and 5 The focus exercises are satisfactory to him with greater feeling of calm and tranquility. Notices some erection respons. However, his fear of becoming impotent is still there. Sessions 2 and 3 are dedicated to a Systematic Desensitization in hypnosis to his fears of becoming impotent. The relaxation induced earlier is substituted by an induction of deeper relaxation. A hierarchy of 5 items is established (Whatever that means, HR) At the end of session 3, J.Z. is intructed to combine the focus exercises with the "stop and go" technique of Seamans. In sessions 4 and 5 he says he had adquired full and rapid erections including some orgasms. He is feeling better and more relaxed but still asks himself "for how long?" and still has his doubts about a full recovery. He complains about his feelings of "lack of sexual desire" and low arousal with respect to past standards. During the 5th session I introduce an exercise of positve dynamic imagery in hypnosis consisting in: --- Corresponding hypnotic induction --- Deepening the exercise of relaxation with direct suggestions of calm and relaxation, with some elements of the autogenous training of Schultz and the imagining of a relaxing beach scene. --- Guided imagining of sexual content: J. Z. meets an attractive fellow in a bar. He is encouraged to perceive the feelings of desire and arousal that results from the encounter, ending with a succesful sexual relation. --- This exercise is recorded and he is asked to listen to it during the week. He is asked to continue with the stop and go technique, feeding of fantasies of sexual content, and masturbation to orgasm is so desired. Session 6 RELAPSE ! J.Z. arrives very pessimistic. In spite of the recent advances he is anxious, sad and confused. Three day ago he completely failed to get an erection/orgasm on masturbation. He thinks that his problem may be organic. He now tells me that he had shed 40 pounds in recent months and he thinks that that is at the root of his problem. We spend part of the session discussing his thoughts on performance and his fears., together with a discusion about his thoughts about an organic cause. I suggest that a test be made of his testosterone and his prolactin, to discard the weight loss as a cause of an hormonal imbalance I propose a new exercise of dynamic imagery similar to the last one, introducing, after the deepening, an exercise of attention, concentration,and strengthening of his personal resourses and positive qualites. I use the image suggested by A.M. Pelletier's (1979), of a majestic oak that represents him in its grandeur, its beauty and in all the details I suggest to him: Thick foliage., singing birds in the branches, strong and deep roots. "You are like this majestic oak... you are stronger for having coped with the vicissitudes of life... full of energy and health. In fact, you are much more than this oak, since you can think,move,make decisions, love and be loved...Feel your power, your strength, your habilities, your capabilities... show your gratitude for being yourself. YOU ARE YOU, full of energy... now rest profoundly and contemplate your strength. Later I associate the majesty of the tree with his erections on completing a sexual encounter. I suggest ending with sex on the beach (something that he finds exciting based on the questionaire he filled previously). This process is taped and he is asked to listen to it during the week, while continuing with his focus exercises/stop and go/masturbation-orgasm. Session 7 J Z, arrives more relaxed. He is still thinking that "he does not function". His levels of erections are "scarse". He is still preocupied thinking that his problem is not psychological ( the next day he will receive the results of his hormone tests). But now his main worry is the absence of desire and arousal. He also failed (he did not get an erection) in a sexual encounter he had with a friend ( an encounter he did not really want). The session was centered in the discussion of all these ideas: His lack of desire comes from his erectle problems, let us wait for the medical results, no point in being obsessed by the slow advance ("recuperation will take time") as worry interferes with the therapy ("better to downplay the importance of the problem") .I encourage him to continue with his exercises and with last week recording. Session 8 The endocrinologist dismissed any hormonal problems. As soon as he found out he felt better, as he now knows that his problem is "all in the head". He does the exercises and perceives advanges in his erections. He is less obsessed or preoccupied, more relaxed. and thinks he will succeed. He practiced sex with a friend, and had an erection, but did no reach orgasm (he has no idea why). In general his lack of desire persists. Under hypnosis, I propose another exercise that I call relaxation+activation. The relaxation is similar to the previous ones, and the activation part consists in imagining little balls or capsules of energy that emanate from the base of the brain, the hypothalamus. ( this represents any cerebral stimulant secreted by his own organism). These capsules are distributed over the whole body by the blood, giving him energy and activating him, filling him with life. (what matters in this is the metaphor we suggest, independent of whether it corresponds to reality). We ask J.Z. to visualize how he is loaded with this "organic electricity" from all his pores,specially his genitals, and to perceive the sensual feelings produced by them and the corresponding arousal. This energizing fills him with life, is very pleasing and sensual and affects all his organism. I encourage him finally to give free rein to all this arousal by imagining a sensual objective ,and letting himself during several minutes to let his imagination fly by imagining all kinds of pleasant arousing situations. His home exercises would be: ---- To listen the new tape with relaxation-activation, daily. ---- To engage in sexual activities only if he really wants to. ---- To help in restoring desire we encourage him to visit a sex shop, rent or buy some tapes of erotic character and look at then alone or with company. Also purchase erotic books and magazines. ------Avoid sexual encounters with friends, that is, with persons for which he has no sexual feelings that would be sufficient to have a sexual relation. Until now, he was afraid to deal with an unknown person because of ridicule. I encourage him, that if he meets an unknown person with which there is the possibility of a sexual encounter, to do it if he really likes the idea. J.Z. does think that to have sex with an unknown person would be highly arousing. Session 9 J. Z. arrives at session saying that everything is going well. He has complete erections and arrives at orgasm without difficulty. This week he had relations with two unknowns without any trouble. He claims that he has felt very aroused during his two experiences and hopes to increment more his capacity to be aroused. His fears have disappeared, and now assumes that his improvement will be complete shortly. Prevention of relapses. We reinforce his acceptance of his advances so far and his expectations of a complete recovery. However he is warned about the possibility of a relapse. but he is advised that an isolated incident does not represent pathology. Using a diagram, he is made to understand that, just like his problem grew over time, its resolution will also take time, improving day by day. To complement this area of relapse prevention, we completed a training in autoinstructions to confront his anxiety (should it reappear) or to handle an episode of "situational impotence". He is asked to continue, during the upcoming follow up period, with the exercises he has been doing all along Sexual education provided The sexual routine of a couple. The rol of fantasies in sex. Each encounter will be different and our degree of arousal and satisfaction will be different depending on the circumstances. Session 10 Follow up J.Z. does not show up for the first two sessions of the follow up, for various reasons (conflict with his examination schedules). Via the telephone, he informs us that his problems have disappeared, and that he now is ready to face any unexpected eventuality, should it show up, Three months later, J.Z. comes in for consultation and says the same thing: He feels well, his problems have disappeared, is more relaxed, including when facing his examinations. His worries are now focused on other matters. He did adquire erotic material to integrate with his sexual activities. We dedicate the rest of the therapy to resolve various doubts about human sensuality. We train him in problem resolution, so as for him to have a systematic manner to confront his preocupations. At the present time the case is in follow up. DISCUSSION J.Z.'s recuperation has been complete in every sense, with all the therapeutic objectives accomplished. This conclusion is based only on the testimony (and the diary) of the patient, since no objective study/valoration was done pre and post therapy. (We do count, however, on the reduction of his marks in ANXIETY-STATUS of the patient in the STAI). The interventions that were done have facilitated the behavorial, emotional and cognitive changes that were necessary for the patient to become conscious of the fact that his problem was caused by the stress in which he was immersed (exams). The advance of the treatment was marked by some reverses caused by small failures, excessive preocupations and fears. His "perfectionist character" did not help either: In his view, the advances were always insufficient, and when one problem was solved (erections) a new one surfaced to worry about (lack of desire). It was necesary to use all available therapeutic resources to resolve his fears, relate his erection responses to moments of relaxation and sensual abandon, recoup his "desire" and his capacity for feeling aroused, and to make him understand how much a situation of emotional instability can affect our sensual life. The hypnotic interventions were done under a cognitive-behavorial squeme and inserted in the functional analysis of the problem faced by the patient. The DS was applied and it obtained optimal results in just two therapeutic sessions, since hypnosis facilitates relaxation, increments notably the capacity for visualization of the patient, and is a potent tool to focus his attention, without distraction, onto the items to which he is exposed. Hypnotic relaxation,present in many interventions, was a determining factor in managing the anxiety in the patient. Indeed, J.Z. ,exhibiting a high grade of sugestivity, has benefit by attaining profound relaxation in less time that what would have been required by other habitual techniques for relaxation, but in this case, at the price of being less autonomous (he was helped by recordings). It is, however, true that the objective was to solve his erection problem, and not to instruct him on how to relax voluntarily without any artifacts. Nevertheless, once the treatment was finalized, he was instructed not to use the tapes (unless necessary) and to do breathing exercises instead, or else to try to relax daily without the use of the tapes. Hypnosis has been crucial in those exercises based on dynamic imagery: Lazarus(1978) says: "Visualizing any pleasant scene, real or imagined, past present or future has many benefits: Positive imagery can have an important role in reducing tension, inhibit anxiety and as a direct activator of enjoyment. The power of positve mental imagery to cure physical alterations is begining to draw attention. It can help to control pain (sadness), or induce an optimistic sentiment that overcomes boredom." In this concrete case we have used positive imagery, metaphors and associations of interest for the therapy. To visualize, as an imagined behavior test, a satisfactory sexual encounter in which the patient is his own model, gives confidence to the patient that, should it become reality, he can predict that he will succeed. As we said earlier, hypnosis is a potent catalist, in this imagery because it enriches those images and makes them more real by endowing them with a quasireal character. The same with metaphors,associations and symbolisms being used in therapy As human beings we have the capacity to abstract,use symbolisms and representations. Our abstractions are intended to give significance to our daily experiences, given that our internal sensual representations are just symbols of manifest reality. Thus, our conduct and thoughts, if inadequate, can be modified with a clear image of ourselves as models of health projected over time, or by symbols of health that adequately represents us (the tree, the little capsules of organic electricity...) I wanted to show in this work the possibility of using hypnosis as a therapeutic tool in the area of sexuality. More controlled studies are necessary to definitely establish the efficacy of hypnosis as an adjoint to the therapy of sexual disfunctions. ALBERTO BERMEJO MERCADER