THE GOAL AND THE FUTURE DIRECTION OF COUPLE’S SEX THERAPY 부부성치료의 목표와 방향설정 THE GOAL AND THE FUTURE DIRECTION OF COUPLE’S SEX THERAPY 2005. 10. 22. 한국상담심리학회-성상담연구회 심포지엄 해암뇌과학연구소 정동철 정동철신경정신과의원

INTRODUCTION Sex Therapy in the Age of Viagra(Leiblum SR, 2000) Changing Perspectives and Practices The Viagra Revolution The Changing Social Climate Changes in Sex Therapy The new sexual pharmacology Female sexuality Technological changes in society: Effects of the Internet Future Concerns and Directions 해암뇌과학연구소 해암뇌과학연구소

CHANGING SOCIAL CLIMATE (정동철, 2000) DINK (Double Income No Kids, 맞벌이 무자녀 부부)족 ① 저 체중 → 출산력 떨어지고 생리불순 ② 저 출산 → 유방암.난소암 등 위험성-출산율은 1.26명이다. 미국 중앙정보국(CIA) 통계에 따르면 전 세계적으로 우리나라보다 출산율이 낮은 나라는 홍콩.마카오.싱가포르.리투아니아.체코.슬로베니아뿐이다. ③ 저 골 밀도 → 운동 못해 다른 병 불러 ④ 저 모유수유 → 아기 아토피 등 원인 ⑤ 저 쌀 소비 → 당뇨 등 성인병 많아져 Pre-marital Sex, Yes 76% [일간스포츠(연합)] 2003.07.31 Datemate 사귀기의 4대 원칙. 사랑하지 말 것, 스킨십은 키스까지만 할 것, 감정이 식으면 깔끔하게 헤어질 것, 사생활에 간섭하지 않을 것 등, 다감정의 교류 없이 만난다는 점에서 미국의 ‘퍽버디(fuck buddy)’와 유사하지만 섹스를 하지 않는다는 점에서 다르다. .(조선;05.09.28.) Abortion 낙태 年35만 건… 42%가 미혼.  기혼여성 3명중 1명이 수술 경험(조선; 2005.09.13.) Media & Entertainment Misconception and Abuse of Sex for Economic Performance Only 해암뇌과학연구소 해암뇌과학연구소

NATURE OF SEXUAL DYSFUNCTION Definition Sexual health is the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love. The concept of sexual health includes three basic elements(WHO, 1975) 1.   a capacity to enjoy and control sexual and reproductive behaviour in accordance with a social and personal ethic, 2.   freedom from fear, shame, guilt, false beliefs, and other psychological factors inhibiting sexual response and impairing sexual relationship, 3.   freedom from organic disorders, diseases, and deficiencies that interfere with sexual and reproductive functions. Triphasic Concept(Kaplan HS, 1987) DSM-IV and ICD-10 DSM-IV는 H.Kaplan의 영향(triphasic concept)을 받아 진단분류가 그 전과 달라졌으나, 진단기준은; 우선하는 정신장애, 의학적 장애, 물질장애 등에 해당되지 않아야 한다는 입장과 달리 분류를 세분화하여 포괄하고 있다. Epidemiology One third of Couples; Orgasm, M 10%, F 25% Pain Intercourse, M 3%, F 15%/극치장애;남 10%, 여 25%/Desire, F 33%/PE 27%/ Excite, F 20%/-Generally Marital Sex Dysfunction 30~50%. Resemble Rate of Divorce 50%. Prognosis 60~100% 해암뇌과학연구소

ETIOLOGIC DETERMINANTS (Kaplan HS, 1974) Psychological Determinants Immediate Causes/ Conflict-Intrapsychic Causes/ The Relationship-Dyadic Causes/ Learned Causes Biological Determinants Physical Illness; Hormonal/ Nervous/ Vascular/ Pain/AIDS(정) cardiovascular disease - high blood pressure, diabetes, high cholesterol, lack of exercise, obesity and smoking - are the same as those associated with impotence. Substances(Drugs); Aphrodisiacs/ Alcohol/ Marijuana/ Amphetamine/ Cocaine/ Androgen/ Anticholinergic (Anti-acid/ Antiadrenergic (Anti-hypertension)/ Anti-psychotics Age-Prolonged Refractory period and Potency(pre- Viagra, 정) Sociological Determinants Cultural/ Regional/ Religious View Points 해암뇌과학연구소

SEX THERAPIST Orientation and Experience becoming as a; Proper Sexo-sophist Individual Psychotherapist Marital Therapist Behavior Therapist Rational Emotive Psychotherapist (정동철, 2002) 해암뇌과학연구소

AN OVERVIEW OF THE VARIOUS TREATMENT APPROACHES Blends of Psychodynamic, Behavioral, Cognitive Therapies 1. psychoeducational remediation, 2. reduction of sexual & performance anxiety, 3. script modification tech., 4. relationship enhancement & conflict resolution strategies, 5. relapse prevention procedures. THE PLISSIT Model(Annon, 1976) Permission-Limited Information-Specific Suggestion-Intensive Therapy 해암뇌과학연구소 해암뇌과학연구소

SEXUAL CRUCIBLE THERAPY (Schnarch, 1991) Sexual Desire is a Systemic Process 1. High & Low Positions in a System 2. The Least Desire Always controls Sex Differentiation: Alternative Paradigm Why is Differentiation Important? 3. Couples’ Foreplay 4. Emotional Gridlock 5. Dependence on Empathy, Accommodation 6. Anxiety Reduction in the Natural System 7. Poorly Differentiated Monogamy Relationships 8. Continued Personal Development(Differentiation) 해암뇌과학연구소 해암뇌과학연구소

THE FOUNDATION & FRAMEWORK OF PSYCHOTHERAPY The Therapeutic Contract-Fees, frequency, rule for canceling, length, pt’s expect, therapist expect, focus of tx. Therapist Active Level-Short-term>Long-term Importance of Empathy-Stand inside patient’s Shoes Engendering Hope- Positive therapeutic climate eliminating Wallowing following by sadness and frustration/ Role play Too Much, Too Soon-Too much inform, too early interpret The Illusion of Rapid Cure-Working through Cognitive Aspects of Treatment-Contextual, emotional> cognition; Myths(6) & Cognitive distortions(8) Alienation from the Self-the Penis is attached to the Heart The Dysfunction as Friend or Solution-Symptom may be his/their friend 해암뇌과학연구소 해암뇌과학연구소

THE GOALS OF PSYCHOTHERAPY (정동철, 1982, Kleinplatz PJ, 2001) Men with ED often feel puzzled disgraced weakened frightened Men’s Potency to the optimal Level possible, so 1. You have to be willing to make love 2. You have to be relaxed 3. You have to be concentrate on your sensations 해암뇌과학연구소 해암뇌과학연구소

MEDICAL AND SURGICAL TREATMENTS Oral Erectogenic Agents Phosphodiesterase Type-5 Inhibitors(Sildenafil), Cialis(Tadalafil), Levitra(Vardenafil HCL);80% Dopamine Agonists-Apomorhine HCL(sublingual Uprima, only one centrally active agent);60% Alpha-1/ Alpha-2 Blockers-Phentolamine mesylate (Zorgniotti) or Doxazosin;50% Local Therapies Intracavernosal Injection Therapy(Caverject);70~80% Intraurethral Alprostadil(Muse);50~65% Vacuum Constriction Device(VCD) Therapy;60~80% Surgical Treatments Prosthesis Implantation;5~20% complications 해암뇌과학연구소 해암뇌과학연구소

CURRENT RESEARCHS ON NEUROBIOLOGICAL DEVICES Central Nervous System Excitatory Systems Inhibitory Systems 1. Fear of Performance Failure 2. Threat of Performance Consequences Interaction of Cognition and Emotion Neuro-Imaging Devices Molecular Biology and Immunology Genetics 해암뇌과학연구소

BRAIN AND SEX(Emotion) Drives from Basic Drives: Feeding, Sex, Reproduction, Pleasure, Pain, Fear, Aggression. Emotion has three major aspects: Integration and Correlation of Sensory Stimuli with Memory Autonomic reactions to Sensory Stimuli Perception and evaluation of Sensory Stimuli Memory Consolidation Circuits appear to be especially important. They are found: In the Limbic System most prominent area/ Papez Circuit In the Amygdala intergrating gate of internal & external stimuli In the Frontal L-lift, R-depression and Temporal Cortex TLE-personality(viscosity)/ L-humorless R-excessive LH-Analytic, Limited Emotion RH-Affect, Socialization, Body Image In the Hypothalamus hormonal control 해암뇌과학연구소

A Neural Circuit for Emotion James Papez & Paul MacLean Thick Line is Papez, Fine Line, MacLea 해암뇌과학연구소

EARLY TREATMENT CONSIDERATIONS process-of-care(POC) model 1 EARLY TREATMENT CONSIDERATIONS process-of-care(POC) model 1. Identification & recognition/ 2. Goal directed, stepwise process/ 3. Patient & partner education/ 4. Clear guideline for follow-up The Therapist’s Illusion: Evaluation, Not Treatment-Initiated with the First Handshake Attend to the Therapeutic Relationship before Attending to the Data-Gathering data is secondary<respectful, comfortable, healing relationship Look for the Early Resistances-Resistance before Conflict, when talking sexual problems, interior(bed) The Secret: The Pitfalls from Collusion-Secrets from 1) Oneself, 2) the Partner, and 3) to Both 해암뇌과학연구소 해암뇌과학연구소

THE FIRST DECISSION Therapist’s Ideology and Treatment Modality Guidelines for Recommending Treatment- Life long=individual, Acquired=conjoint, With extra=individual because of ethic Some Heuristic Guidelines for When to Recommend an Adjunctive Medical Intervention- Medical; 1. Life long, 2. Low confidence with Partner, 3. Significant medical factors, 4. Past Hx of psychotherapy Not medical; 1. Recent acquired, 2. Couples with severe discord, 3. Young men with performance anxiety, 4. Patients don’t want alternative intervention 해암뇌과학연구소 해암뇌과학연구소

THE PRESCRIPTION OF BEHAVIORAL TASKS Behavioral tasks are employed to 1) overcome performance anxiety, 2) aid with diagnostic assessment and clarification of underlying dynamics, 3) alter the previously destructive sexual system, 4) confront resistance in each partner, 5) alleviate couple’s anxiety about physical intimacy, 6) dispel myths and educate patients regarding sexual function and anatomy, 7) counteract negative body image concerns, 8) heighten sensuality Sensate Focus I(pleasuring), II(genital pleasuring), and III(vaginal containment without active movement)(Kaplan HS, 1983) Other Behavioral Tasks-masturbate, squeeze, Quiet Vagina(Master & Johnson, 1970) Relapse Prevention-booster maintenance session 6mos later. 70% better, 56% initial gains The Role of Adjunctive Medical Interventions-oral medications, self-injection therapy 해암뇌과학연구소 해암뇌과학연구소

LOVE CYCLE (Masters, Johnson, & Kolodny, 1985) 해암뇌과학연구소 해암뇌과학연구소

CONCLUSION-1 但有生死心 造作趣向 皆是汚染. 若欲會其道 平常心是道. Sex therapy should aim for more than remediation of symptoms of sexual dysfunction. Sexual Problems can provide opportunities to aim for profound change for the individual or the couple. The kinds of sexual issues that concern our clients may be much broader than what currently exists or is envisioned in our taxanomies. Sexual dysfunctions must be understood in the contexts in which they arise and come to be seen as problematic. Sex therapists can and should assume a greater role in shaping the public discourse surrounding sexuality, in helping the client to mobilize resources that already lie within, and in looking beyond the medical to see the whole person. Technical solutions may be useful for treating technical difficulties. However, in order to help individuals and couples optimal sexual development, we need more innovative methods. (Kleinplatz, 2001) 해암뇌과학연구소

CONCLUSION-2 何謂平常心. 無造作無是非無取捨無斷常無凡聖. Interaction between Cognition and Emotion in the Brain Questions of Medicalization and Surgicalization Treatment Methods only Innovative Tools of Sex and Marital Therapy Therapist’s Ideology and Orientation Sex Therapy as a Proper Marital Life Feminist sex therapy in the age of Viagra Recognition of 1. Social & Cultural Gender Inequality 2. The Influence of Power Differential 3. Traditional Sex Roles 4. The Unique Experiences of Men & Women regarding Sexual Socialization, Sexual Coercion, Sexual Decision Making & Relational Factors and 5. Valuing Equally the Subjective & Affective Aspects of Sexuality Sex therapy with HIV status and Mass Media 해암뇌과학연구소

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