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A modern behavioral treatment to address fetishism and associated functional impairments
Abstract
The clinical research and treatment options for sexual paraphilias are scant and have generally been limited to psychodynamic and early behavioral approaches. This article highlights the application of two existing evidence-based modern behavioral interventions, specifically behavioral activation and sensate focused therapy, to treat foot fetishism/sexual impulses and co-occurring mood/anxiety symptoms in a 57-year-old male Vietnam War veteran. This brief 6-week treatment addressed the patient’s complicating psychosocial factors and medical conditions, and focused on targeting behavioral avoidance symptoms associated with fetishism and depression (e.g., increasing socially and sexually appropriate and positive reinforcing behaviors in his environment). The patient no longer met diagnostic criteria for fetishism and endorsed significant reductions in depressed mood, anxiety, and stress at post-treatment and 1-month follow-up. This case illustrated how current behavioral treatments may be used to successfully treat patients with rare symptom presentations who may otherwise be neglected within a medical system.
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This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.
In recent years, behavioral activation approaches have been used to treat individuals with clinical depression. Extension of these strategies toward individuals presenting with coexistent depressive and anxiety symptoms may represent a parsimonious, practical, and time-and cost-effective treatment method. The present study outlines a case in which coexistent anxiety and depressive symptoms predominate, a clinical presentation made somewhat more complex given an Axis III diagnosis of colitis. A brief behavioral activation treatment for depression (BATD) is used to simultaneously incorporate activation and exposure strategies to ameliorate affective symptoms. Following a 10-session treatment protocol, the patient demonstrated notable decreases in self-reported anxiety and depressive symptoms and increased quality of life. Although these data are preliminary, they suggest some efficacy for BATD as a viable treatment alternative for individuals with a mixed anxiety-depressive disorder presentation.
Atypical sexual behavior is intriguing to many people, yet the empirical research on paraphilia and fetishism is relatively lacking. Nonetheless, clinicians are often called on to intervene in such cases, particularly when the paraphilia involves nonconsenting partners. This review article is structured around a brief historical overview of the diagnostic classification of atypical sexual behavior in the United States, descriptions of the types of atypical sexual behavior that receive clinical attention, an overview of the models that have been proposed to explain the development of atypical sexual behavior, and finally a summary of the most common treatments for these problems.
Background:
Sexual offenders continue to occupy the public's attention; a significant proportion of this population is diagnosed with paraphilias. Cognitivebehavioral treatment has been the mainstay of treatment for sex offenders and for the paraphilias for the past three decades. This article will review the history of cognitivebehavioral therapy, its techniques, and its efficacy.
Method:
A literature review was conducted of PubMed and PsychInfo Databases.
Results:
A significant literature exists describing cognitive-behavioral therapy and presenting outcome studies and meta-analyses evaluating its efficacy.
Limitations:
This study is based on a literature review and influenced by the knowledge and biases of the authors.
Conclusions:
Cognitive-behavioral therapy is the most prominent therapy for sexual offenders. Although reports from individual programs and meta-analyses support its efficacy, overall, the strength of the evidence base supporting this therapy is weak and much more empirical research is needed.
Major depression is the most common psychiatric disorder among breast cancer patients and is associated with substantial impairment. Although some research has explored the utility of psychotherapy with breast cancer patients, only 2 small trials have investigated the potential benefits of behavior therapy among patients with well-diagnosed depression.
In a primarily Caucasian, well-educated sample of women (age = 55.4 years, SD = 11.9) diagnosed with breast cancer and major depression (n = 80), this study was a randomized clinical trial testing the efficacy of 8 sessions of behavioral activation treatment for depression (BATD) compared to problem-solving therapy. Primary outcome measures assessed depression, environmental reward, anxiety, quality of life, social support, and medical outcomes.
Across both treatments, results revealed strong treatment integrity, excellent patient satisfaction with treatment protocols, and low patient attrition (19%). Intent-to-treat analyses suggested both treatments were efficacious, with both evidencing significant pre-post treatment gains across all outcome measures. Across both treatments, gains were associated with strong effect sizes, and based on response and remission criteria, a reliable change index, and numbers-needed-to-treat analyses, approximately ¾ of patients exhibited clinically significant improvement. No significant group differences were found at posttreatment. Treatment gains were maintained at 12-month follow-up, with some support for stronger maintenance of gains in the BATD group.
BATD and problem-solving interventions represent practical interventions that may improve psychological outcomes and quality of life among depressed breast cancer patients. Study limitations and future research directions are discussed.
The historical definitions of sexual Fetishism are reviewed. Prior to the advent of DSM-III-R (American Psychiatric Association, 1987), Fetishism was typically operationally described as persistent preferential sexual arousal in association with non-living objects, an over-inclusive focus on (typically non-sexual) body parts (e.g., feet, hands) and body secretions. In the DSM-III-R, Partialism, an "exclusive focus on part of the body," was cleaved from Fetishism and added to the Paraphilia Not Otherwise Specified category. The current literature reviewed suggests that Partialism and Fetishism are related, can be co-associated, and are non-exclusive domains of sexual behavior. The author suggests that since the advent and elaboration of the clinical significance criterion (Criterion B) for designating a psychiatric disorder in DSM-IV (American Psychiatric Association, 1994), a diagnostic distinction between Partialism and Fetishism is no longer clinically meaningful or necessary. It is recommended that the diagnostic Criterion A for Fetishism be modified to reflect the reintegration of Partialism and that a fetishistic focus on non-sexual body parts be a specifier of Fetishism.
The place of long-term psychodynamic psychotherapy (LTPP) within psychiatry is controversial. Convincing outcome research for LTPP has been lacking.
To examine the effects of LTPP, especially in complex mental disorders, ie, patients with personality disorders, chronic mental disorders, multiple mental disorders, and complex depressive and anxiety disorders (ie, associated with chronic course and/or multiple mental disorders), by performing a meta-analysis.
Studies of LTPP published between January 1, 1960, and May 31, 2008, were identified by a computerized search using MEDLINE, PsycINFO, and Current Contents, supplemented by contact with experts in the field.
Only studies that used individual psychodynamic psychotherapy lasting for at least a year, or 50 sessions; had a prospective design; and reported reliable outcome measures were included. Randomized controlled trials (RCTs) and observational studies were considered. Twenty-three studies involving a total of 1053 patients were included (11 RCTs and 12 observational studies).
Information on study characteristics and treatment outcome was extracted by 2 independent raters. Effect sizes were calculated for overall effectiveness, target problems, general psychiatric symptoms, personality functioning, and social functioning. To examine the stability of outcome, effect sizes were calculated separately for end-of-therapy and follow-up assessment.
According to comparative analyses of controlled trials, LTPP showed significantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. With regard to overall effectiveness, a between-group effect size of 1.8 (95% confidence interval [CI], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups (P = .002). According to subgroup analyses, LTPP yielded significant, large, and stable within-group effect sizes across various and particularly complex mental disorders (range, 0.78-1.98).
There is evidence that LTPP is an effective treatment for complex mental disorders. Further research should address the outcome of LTPP in specific mental disorders and should include cost-effectiveness analyses.
Pavlovian conditioning of the human male sexual response may be involved in the ontogenetic development of sexual interests and may be responsible for individual differences. We attempted to demonstrate Pavlovian conditioning of sexual interests in a nonclinical sample of adult males. Ten participants were exposed to 11 pairings of a slide of a moderately attractive, partially nude female adult (TARGET) and a highly arousing videotape depiction of heterosexual sexual interactions (US). Ten other participants were exposed to 11 presentations of the TARGET alone. Participants exposed to the TARGET-US contingency showed a 10% relative increase in sexual arousal to the TARGET; participants exposed to the TARGET-ALONE contingency showed an 11% relative decrease in sexual arousal to the TARGET. This group difference is interpreted as resulting from both conditioning and habituation.
One hundred and twenty consecutively evaluated outpatient males with paraphilias (PAs; n = 88, including 60 sex offenders) and paraphilia-related disorders (PRDs; n = 32) were systematically assessed for certain developmental variables and DSM-IV-defined Axis I comorbidity. In comparison with the PRDs, the PA group was statistically significantly more likely to self-report a higher incidence of physical (but not sexual) abuse, fewer years of completed education, a higher prevalence of school-associated learning and behavioral problems, more psychiatric/substance abuse hospitalizations, and increased employment-related disability as well as more lifetime contact with the criminal justice system. In both groups, the most prevalent Axis I disorders were mood disorders (71.6%), especially early onset dysthymic disorder (55%) and major depression (39%). Anxiety disorders (38.3%), especially social phobia (21.6%), and psychoactive substance abuse (40.8%), especially alcohol abuse (30%), were reported as well. Cocaine abuse was statistically significantly associated with PA males (p = .03). There was a statistically significant correlation between the lifetime prevalence of Axis I nonsexual diagnoses and hypersexual diagnoses (PAs and PRDs). The prevalence of retrospectively diagnosed attention deficit hyperactivity disorder (ADHD) was 35.8%, the third most prevalent Axis I disorder. ADHD (p = .01), especially ADHD-combined subtype (p = .009), was statistically significantly associated with PA status. ADHD was statistically significantly associated with conduct disorder, and both of these Axis I disorders were associated with the propensity for multiple PAs and a higher likelihood of incarceration. When the diagnosis of ADHD was controlled, the differences reported above between PAs and PRDs either became statistically nonsignificant or remained as only statistical trends. Thus, ADHD and its associated developmental sequellae and Axis I comorbidities was the single most common nonsexual Axis I diagnosis that statistically significantly distinguished males with socially deviant sexual arousal (PAs) from a nonparaphilic hypersexual comparison group (PRDs). Sex offender paraphiliacs were more likely to be diagnosed with conduct disorder, alcohol abuse, cocaine abuse, and generalized anxiety disorder. The prevalence of any ADHD in the sex offender paraphiliacs was 43.3%, and nearly 25% of offenders were diagnosed with ADHD-combined subtype.
This therapist guide of prolonged exposure (PE) treatment is accompanied by the patient workbook, Reclaiming Your Life from a Traumatic Experience. The treatment and manuals are designed for use by a therapist who is familiar with cognitive behavioral therapy (CBT) and who has undergone an intensive training workshop for prolonged exposure by experts in this therapy. The therapist guide instructs therapists to implement this brief CBT program that targets individuals who are diagnosed with posttraumatic stress disorder (PTSD) or who manifest PTSD symptoms that cause distress and/or dysfunction following various types of trauma. The overall aim of the treatment is to help trauma survivors emotionally process their traumatic experiences to diminish or eliminate PTSD and other trauma-related symptoms. The term prolonged exposure (PE) reflects the fact that the treatment program emerged from the long tradition of exposure therapy for anxiety disorders in which patients are helped to confront safe but anxiety-evoking situations to overcome their unrealistic, excessive fear and anxiety. At the same time, PE has emerged from the adaption and extension of Emotional Processing Theory (EPT) to PTSD, which emphasizes the central role of successfully processing the traumatic memory in the amelioration of PTSD symptoms. Throughout this guide, the authors highlight that emotional processing is the mechanism underlying successful reduction of PTSD symptoms.
This paper has three topics. The first concerns some features of the treatment of a boy with a hair and fur fetish. The second concerns the concepts 'phallic' and 'castrated' employed by Freud. The third concerns phantasies of transsexual events according to which boys can turn into girls, and vice versa. To begin with, the author describes several themes and some variations on them that emerged during the psychotherapy of Sam, an 11-year-old boy. This clinical material may be understood in terms of the influence of a specific sort of intrusive and oppressive object. Such an object exerts its influence through super-ego qualities, projected and re-introjected in sense perception, and the author suggests that it shares its influence with features of a fetish. Next, the author selects from these themes and variations Sam's dreams and daydreams about a girl with a penis. The author discusses some claims that Freud made about children imagining each other to be 'phallic' or 'castrated'. The author reconsiders Sam's dreams and Freud's claims, by distinguishing two kinds of castration phantasy. Finally, the discussion is extended to include descriptions of some patients who experience transgender identity. In explaining fetishism, Freud's account implies that a child can imagine 'castration' could turn a boy into a girl. Like fetishism, transgenderism also involves phantasies of transsexual events, of which castration is one kind.
There has been increasing interest in using video telehealth to deliver evidence-based psychotherapies (EBPs). Telehealth may have numerous advantages over standard in-person care, including decreasing patients’ and providers’ costs and increasing system coverage area. However, little is known regarding the effectiveness of EBPs via video telehealth. This review had two goals, including a review of the existing literature and ongoing research on using video telehealth technologies to deliver EBPs as well as an informal survey of telehealth experts to discuss the special considerations and challenges present in adapting practices to video telehealth. Together, findings suggest that telehealth practices could represent an important component of the future of psychotherapy and clinical practice, especially in dissemination and implementation of EBPs in traditionally underserved areas and populations.
Studies which investigate the impact of treatment on subjects with singular and multiple sexual paraphilias (exhibitionism, fetishism, pedophilia, transvestism, voyeurism) are reviewed. A methodological evaluation was conducted with attention to six categories: design, subjects, therapists, treatment, time periods, and outcome measures. Subjects included sexual offenders and non‐offenders. Most of the studies were single‐case reports. The methodological shortcomings in the literature included the failure to control for social desirability factors, especially in the case of sex offenders, and the reliance upon verbal self‐reports in the evaluation of outcome. Almost all of the studies found positive treatment effects, either immediately after treatment or at various follow‐up periods. However, periodic booster treatment sessions sometimes were necessary with paraphilias of long duration. Across the paraphilias reviewed, the literature offered tentative support for the efficacy of a multiple behavioral treatment package specifically tailored to aspects of the patient's sexual arousal pattern. The elimination of variant sexual responses in conjunction with fostering appropriate, non‐variant sexual behavior is a relevant treatment strategy in some cases. Future research should use homogeneous experimental and control subjects, obtain a pre‐therapy assessment of sexual and social functioning, specify treatment goals, and use multiple outcome measures. The importance of specifying subject variables for the goal of successful subject‐treatment matches is also suggested. As a step in that direction, a checklist which noted the psychological and situational correlates of the five predominant sexual paraphilias was derived from the literature.
Treatment of paraphiliacs in North America has met with long—term success. As a result, the treatment, especially of exhibitionism, frotteurism (scopophilias) voyeurism, and fetishism, in terms of fiscal responsibility, is estimated at over $169.000 per offender. Our experience using Chinese Style Psychoanalysis has been more positive and the success rate is very high. This paper describes our methods and includes case histories of our work with sexual paraphiliacs, from which readers should find useful ideas. Our Chinese Style Psychoanalysis focuses on analyzing the patient's infantile behaviors. We use their easily remembered experiences, which happened in their childhood as evidence. Then we keep moving until our patients achieve insight and understand that their paraphilic behaviors and impulses are molded by their childhood psychology and behaviors, are using childhood amusement to meet adult sexuality. They give up the paraphilic behavior on their own initiative. We propose that using our methods for the treatment of certain paraphilias would greatly enhance methods now in use in the West.
The work described in this article was based on the long-term treatment approach developed by Jacques Lacan, the French psychoanalyst (1901-1981). It provides a first formulation (after about 4 years) of an ongoing case, which has been conducted exclusively by telephone. The myriad significations of a particular fetish object are drawn out and tied to the participant's history, and evolution of the fetish during the course of the analysis is described.
This article introduces strategies for deepening the understanding of paraphilias and the therapeutic process of treating them. The case study explores a young man's compulsive sexual fantasies over the Internet, his compulsive masturbation, and his pedophilic and paraphilic fantasies as adaptations from early developmental conflicts. A therapeutic process supports this young man's understanding of his rejection of himself and promotes acceptance of developmentally appropriate and integrated sexual expression. In particular, this case discussion addresses three aspects in them ultiplicity of one's sexuality: the sexual self, the “voices” of sexuality, and the “dance” of sexuality. Additionally, management of transference and countertransference are discussed as means of strengthening the therapeutic alliance.
This paper discusses sexual fetishism as a factor contributing to sexual dysfunction. Help-seeking is triggered by the effects of the fetishistic desires and related behaviours on normal sexual functioning. The paper discusses the nature and management of these problems. Clinical case material is provided to illustrate some of the ways in which fetishism manifests as a clinical problem in this context. A treatment approach is described, which draws upon several techniques.
An overview and demographic description of each of the current DSM-IV-TR paraphilias (i.e., Pedophilia, Transvestic Fetishism, Exhibitionism, Fetishism, Voyeurism, Sexual Masochism, Frotteurism, Paraphilia Not Otherwise Specified) are provided. Most of these are medical descriptions of sexual offenses. Discussion is provided regarding a paraphilic description of rape (i.e., Paraphilic Coercive Disorder) that may appear in DSM-5. The effectiveness of current treatments (behavioral, cognitive–behavioral therapy, chemical/physical castration; and the use of selective serotonin re-uptake inhibitors) for each of these paraphilias is examined. It was found that there are too few well-designed studies to provide support for evidence-based practice with any of the paraphilias, based on Chambless and Hollon (1998) criteria (i.e., evidence should be based on: two + well conducted studies/two + independent researchers, three + small experiments reporting data from at least nine participants). It is suggested that more high quality research studies need to be conducted into the treatment of paraphilias. This work is contrasted with the growing body of evidence for the effectiveness of sex offender treatment for child molesters and exhibitionists (typically without a paraphilic diagnosis); current evidence is equivocal regarding the efficacy of treatment for rapists.
The main theoretical position on fetishism remains that outlined by Freud, the splitting of the ego and castration anxiety being central to the establishment of the fetish. The dangers and attractions of an oedipal resolution are outlined in the case of 'Stanley', an older adolescent whose nappy wearing, transvestism and obsession with pregnant mothers and their babies brought him to therapy. The paper demonstrates some of the technical difficulties in such work, the slow ego-structuring that is necessary, the patient's swift perception of danger at any failure of attunement by the therapist and subsequent flight to the perverse defence, and the impetus that acceptance of oedipal gain may bring to development.
This review updates a similar paper published in this Journal in 2000. It presents evidence from meta-analyses, systematic literature reviews and controlled trials for the effectiveness of couples and family therapy for adults with various relationship and mental health problems. The evidence supports the effectiveness of systemic interventions, either alone or as part of multimodal programmes, for relationship distress, psychosexual problems, domestic violence, anxiety disorders, mood disorders, alcohol abuse, schizophrenia and adjustment to chronic physical illness.
A 27-yr-old male was treated for fetishism with masochism by electrical aversion and aversion relief on a twice per day basis for 8 days. To increase heterosexual responsiveness, sexual retraining was combined with the above procedure. After this active treatment, the patient was discharged from hospital to continue sexual retraining exercises at home for 1 month. The latency to imagine the deviant fantasies and to evoke sexual arousal while fingering his fetishistic objects increased progressively as the treatment evolved. At 1 and 3-month follow-ups, the subject reported that his masochistic and fetishistic fantasies had completely disappeared, and at a 4-month follow-up, he considered his sexual problems solved. The improvement was maintained 1 yr after treatment.
Recent controlled studies demonstrate that aversion therapies can be effective treatments for certain behaviour disorders such as alcoholism (Ashem and Donner, 1968) and sexual deviation (Feldman and MacCulloch, 1971). However, the mechanism of action in the various forms of aversion therapy has not been determined. As one form of aversion therapy, covert sensitization employs descriptions of noxious scenes as aversive stimuli.An earlier study (Barlow, Leitenberg and Agras, 1969) suggested that pairing descriptions of noxious scenes with scenes of the undesired behavior was the critical procedure in covert sensitization. There, a single case design was used with two sexual deviates. Sexually arousing scenes were paired with descriptions of nausea and vomiting during the first phase, while in a second phase the same sexually arousing scenes were presented alone, and finally, pairing was reinstated. Put another way, these phases represent acquisition, extinction and re-acquisition respectively.During the pairing of scenes in the first phase, deviant arousal declined, rose again when the pairing of scenes was removed, and dropped in the final phase when pairing was reinstated. This appeared to demonstrate the effectiveness of pairing in the procedure. It is possible, however, that therapeutic instructions and the resulting expectancy of improvement present in both covert sensitization phases, were responsible for the effectiveness of the treatment, since the patient may have viewed the middle extinction phase as non- therapeutic.To test this notion, the procedure of the first experiment was changed somewhat. Four homosexual Ss were told that the acquisition procedure (covert sensitization) with pairing would temporarily worsen their sexual deviation and that the extinction procedure (no pairing) was therapeutic. The experiment began with the no pairing procedure with therapeutic instructions to create the desired expectancies at the outset and to test for an initial placebo effect. In addition, an objective measure of sexual arousal, penile circumference change, was recorded.If pairing is the necessary and sufficient procedure in covert sensitization, then deviant sexual arousal should decrease during covert sensitization despite instructions to the contrary and, conversely, no improvement should occur during the no pairing, placebo phase.
Major depressive disorder (MDD) is highly prevalent and impairing and highly likely to present in primary care settings. Recent efforts by the Department of Veterans Affairs (VA) have sought to integrate mental health services into primary care settings, leading to new specialty pharmacotherapy and psychotherapy treatment options for primary care patients. However, little is known about the effectiveness of these new services in primary care patients with MDD. The present study investigated the effectiveness of a brief, easy-to-administer, evidence-based psychotherapy behavioral activation in an integrated mental health/primary care setting in a southeastern VA medical center during the first year of the program.
Thirty-five veterans with MDD (DSM-IV criteria) completed an initial clinical intake, were given the Mini International Neuropsychiatric Interview, and began a 4-week behavioral activation program. Patients also completed the Hospital Anxiety and Depression Scale (HADS) at intake, posttreatment, and at 1-month follow-up. The study was conducted from November 2009 to November 2010.
Sixty percent (n = 21) of patients completed the brief behavioral activation. Treatment completers demonstrated significant reductions in symptoms of both anxiety and depression on the HADS at posttreatment (t values > 5.2, P values < .001, d values > 1.16, g values > 1.02) and follow-up (t values > 4.0, P values < .01, d values > 1.74, g values > 1.67) when compared to pretreatment levels.
The present findings support the use of behavioral activation as an effective treatment for patients with MDD in a primary care setting. These findings suggest that new integrated primary care settings should incorporate behavioral activation to offer brief, evidence-based treatments that provide reliable symptom reductions in addition to possible reductions in treatment needs and better management of related physical health conditions.
Recent research has focused on the effectiveness of evidence-based psychotherapy delivered via telehealth services. Unfortunately to date, the majority of studies employ very small samples and limited predictor and moderator variables. To address these concerns and further replicate and extend the literature on telehealth, the present study investigated the effectiveness of 12-session exposure therapy delivered either via telehealth (n=62) or in person (n=27) in veterans with posttraumatic stress disorder (PTSD). Findings demonstrated that although older veterans and Vietnam veterans were more likely to complete the telehealth treatment, telehealth findings were not influenced by patient age, sex, race, combat theater, or disability status. Exposure therapy delivered via telehealth was effective in reducing the symptoms of PTSD, anxiety, depression, stress, and general impairment with large effect sizes. Interestingly, exposure therapy via telehealth was less effective than exposure therapy delivered in person; however, lack of random assignment to condition limits conclusions of differential effectiveness. Overall, these findings support the utility of telehealth services to provide effective, evidence-based psychotherapies.
Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as "empirically supported" and "evidence based." In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings.
A common pattern of women who were sexually molested as children and seek treatment for sexual dysfunction is described. The arousal, rather than the orgasmic, component is involved. The reasons for the evolution of this particular dysfunction are discussed. Treatment should extend the period of sensate focus and address the issues of the woman's anger, her need for control, and her guilt. Excellent results can be achieved in helping the patient to experience physical intimacy and the pleasure of sexual arousal.
This paper traces the course of a child foot fetishist from infancy to early adolescence. The role of parental pathology is noted as creating the symptom and in forcing the child to evolve specific defense mechanisms which were later maintained and served to avoid developmental tasks, resolve ambivalence, and preserve body integrity. The purpose of the symptom at varying stages of development is discussed as is the transformation from symptom to character trait in adolescence. This case history may help to clarify the role of infantile and childhood experience in the development of adult perversions.
Fetishism, defined as the obligate need for inanimate or part objects for sexual arousal, may be viewed from multiple perspectives. Sociocultural, biological, psychodynamic, and behavioral issues may all contribute to its etiology. Although psychoanalytic investigations offer much data to explain fetishism, behavioral treatments have been primarily reported as a treatment approach. Problems remain, however, in understanding the natural clinical course, etiology, and best treatment for this paraphilia.
Describes a behavioral analysis of an unusual case of trouser fetishism in a young adult male that revealed a complex of fetish-related problem behaviors. These behaviors could be grouped into 3 categories: (a) the use of trousers in physical contact during masturbation, (b) fetishistic fantasies that occurred during and apart from masturbation, and (c) overt behavior aimed at procuring trousers for masturbation. A simple aversive conditioning program using the masturbation-related activities as target problems had some limited therapeutic value, but it was necessary to employ further behavioral treatments before the goals of therapy were achieved. Because of the design it was not possible to infer effects specific to each of the treatment components. However, the case was useful in demonstrating both the need for an adequate behavioral analysis and the value of combining various therapeutic programs in treating the individual case. (20 ref)
Pedophilic behavior in a 25-yr-old married male and homosexual behavior in a 32-yr-old married male were decreased, increased, and once again decreased by introducing, removing, and reintroducing the noxious scene in covert sensitization, a form of aversion therapy. Results indicate that verbal description of a nauseous scene was an effective aversive stimulus, and that pairing this scene with scenes of the undesired behavior was responsible for declines in deviant sexual behavior during covert sensitization. (17 ref.)
The effect of systematic desensitization upon snake fearful subjects was compared in two conditions. In the first, relaxation was paired with imagined scenes of the snake, and in the second with a real snake. The second group improved more in a behavioral approach test and evidenced less anxiety as measured by GSR than the first group. The results point to an inefficiency of the imaginative process, and the possibility that behavioral change is enhanced by contact with the feared object.
An operant conditioning measure is described, which showed that faradic shocks were aversive in a patient whose fetishism was associated with masochism. The patient's response was in keeping with expectations drawn from the initial measures, since faradic aversion produced rapid improvement of the masochism with subsequent improvement of the fetishism, and increased enjoyment of normal sexual relations. The operant conditioning and semantic differential measures accurately reflected clinical changes after treatment, and are useful to assess progress. Masochism does not necessarily contra-indicate aversion treatment.
New methods of treatment often prove to be valuable tools of clinical investigation. The advent of antidepressant drugs enhanced knowledge about depressive disorders, while the introduction of psychoanalytic techniques yielded a rich harvest from the field of psychopathology. Yet another technique which can throw fresh light on psychopathology is electric aversion, a method now used increasingly in the treatment of certain sexual disorders. With this method separate symptoms can be treated in turn, and their interrelations can thus be changed and studied. With careful clinical control and measurement we can examine the importance of various aspects of sexual disorders hitherto open to observation but not to detailed modification.
This study surveys the discharge register of a large London teaching hospital over 20 years and presents data on its 48 cases of clinical sexual fetishism. An attempt was made to answer two questions: (1) What are the clinical problems these patients present? They have more to do with the perception of fetishes as personally or socially unacceptable than with 'objective' restrictions placed on sexual activity. (2) What is the classification used to describe? The data have not enabled any conclusions to be drawn about the existence of particular fetishist syndromes. Certainly, a fifth or more of the sample had fetishes for clothes or rubber or rubber items, or wore or stole a fetish or fetishes; but this information is insufficient to allow one to assume that these patients had something significant in common, and leaves open the question of what more precisely each individual was attracted to.
Meta-analyses were performed on 12 studies of treatment with sexual offenders (N = 1,313). A small, but robust, overall effect size was found for treatment versus comparison conditions (r = .12). The overall recidivism rate for treated sexual offenders was .19 versus .27 for untreated sexual offenders. Treatment effect sizes across studies, however, were heterogeneous. Effect sizes were larger in studies that had higher base rates of recidivism, had follow-up periods longer than 5 years, included outpatients, and involved cognitive-behavioral or hormonal treatments. Cognitive-behavioral (p < .0005) and hormonal treatments (p < .00005) were significantly more effective than behavioral treatments but were not significantly different from each other.
The psychometric properties of the PTSD Checklist (PCL), a new, brief, self-report instrument, were determined on a population of 40 motor vehicle accident victims and sexual assault victims using diagnoses and scores from the CAPS (Clinician Administered PTSD Scale) as the criteria. For the PCL as a whole, the correlation with the CAPS was 0.929 and diagnostic efficiency was 0.900 versus CAPS. Examination of the individual items showed wide ranging values of individual item correlations ranging from 0.386 to 0.788, and with diagnostic efficiencies of 0.700 or better for symptoms. We support the value of the PCL as a brief screening instrument for PTSD.
"Concrete" patients manifest resistance to interpretation per se. Their apparently primitive thinking is the result of complex psychodynamics, explicable in terms of the mechanisms of wish fulfillment and a revised theory of fetishism. The general thesis is that an unconscious equation of differentiation with overwhelming tension leads to a global process of defense against the differentiating function of the analytic frame. The wider implications of this theory can be integrated with Freud's mostly unknown late attempt to generalize the theory of fetishism.
The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.
The respondent (classical) conditioning of male sexual arousal was investigated, employing penile plethysmography and 2 control procedures. Nine participants participated in three sessions, for three consecutive weeks. Each session consisted of fifteen stimulus periods and fifteen detumescence periods. Three participants participated in each of three different experimental conditioning procedures. Sexually explicit visual stimuli preselected by each participant were utilized as the unconditioned stimuli (US), and a neutral slide of a penny jar was employed as the conditioned stimulus (CS). In the first procedure, short delay conditioning, the CS was presented for 15 seconds, followed immediately by the US for 30 seconds. The second procedure was a backward conditioning procedure. In the third procedure, a random control condition, the presentation of CS and US was determined randomly. Results indicated that participants showed systematic maximum increases in penile tumescence from baseline in the short delay conditioning procedure, but not in the other two control procedures. Implications of these results to behavior therapy strategies which are based upon the conditioning of human sexual arousal are examined and discussed.
This article reports on an evaluation of a cognitive behavioral program for the treatment of sexual dysfunction. Frequency data are provided on the sexual dysfunction of 95 males (mean age = 41.6 years) and 105 females (mean age = 36.4 years). The effectiveness of a cognitive behavioral program among 45 sexually dysfunctional males (mean age = 39.9 years) and 54 sexually dysfunctional females (mean age = 36.2 years) was assessed. The results demonstrated that, after therapy, respondents experienced lower levels of sexual dysfunction, more positive attitudes toward sex, perceptions that sex was more enjoyable, fewer affected aspects of sexual dysfunction in their relationship, and a lower likelihood of perceiving themselves as a sexual failure. The implications of these findings for the treatment of sexual dysfunction are discussed.
In the past decade, there has been renewed interest in the feasibility and efficacy of purely behavioral treatments for clinical depression. Emphasizing the functional aspects of depressive and nondepressive behavior, these treatments focus on the concept of behavioral activation, which guides implementation of procedures aimed at increasing patient activity and access to reinforcement. Although researchers have provided positive preliminary support for behavioral activation-based interventions, many fundamental issues concerning strategies, principles, and change processes involved in behavioral activation have yet to be addressed. In this paper, we compare and contrast contemporary behavioral activation interventions, explore strategies and process of change issues, clarify the basic behavioral principles underlying activation strategies, and outline questions that need to be addressed to improve outcomes and better understand the potential significance of behavioral activation as it pertains to the future of behavior therapy for depression.
An account is given of the available results of behavior therapy in the treatment of sexual disorders. To date attempts have been made to treat impotence, frigidity, voyeurism, exhibitionism, transvestism, fetishism and homosexuality. The results suggest that the methods of behavior therapy can be applied with success in treating sexual disorders. Some additional suggestions are made.
Negative conditioning or aversion therapy is most frequently thought of in relation to the treatment of alcoholism. The article by Franks (1958) gives an excellent review of the general principles involved. However, Eysenck (1960) includes several papers in his book to illustrate the effectiveness of such treatment in cases of homosexuality, writer's cramp (Liversedge and Sylvester, 1955) and fetishism (Raymond, 1956). A suggestion made in the latter was that the fetishist may well become such because of an unusual capacity for quickly forming conditioned responses, and therefore by the same token might equally easily respond to a de-conditioning technique. For this reason, the following case was treated by behaviour therapy by a psychiatrist and clinical psychologist in collaboration, and is reported in support of Raymond's (1956) advocacy of this technique of treatment in similar cases.