Journal of Sex Education and Therapy

ISSN: 0161-4576 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/wzjs20

Masters and Johnson's Contribution: A Response

to the Interview with Harold Lief and Arnold
Lazarus

Bernard Apfelbaum

To cite this article: Bernard Apfelbaum (1985) Masters and Johnson's Contribution: A Response
to the Interview with Harold Lief and Arnold Lazarus, Journal of Sex Education and Therapy, 11:2,
5-11

To link to this article: http://dx.doi.org/10.1080/01614576.1985.11074832

Published online: 22 Jan 2015.

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Download by: [UNIVERSITY OF ADELAIDE LIBRARIES] Date: 11 October 2017, At: 03:53
 FORUM: A DEBATE 5
MASTERS AND JOHNSON'S
CONTRIBUTION: A RESPONSE TO THE
INTERVIEW WITH HAROLD LIEF AND
ARNOLD LAZARUS
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Bernard Apfelbaum, Ph.D.

Director
Berkeley Sex Therapy Group
Berkeley, CA 94705

Editor's Note: In the Fall/Winter 1984 issue of JSET, Dr. popularizers rather than innovators. The only unam-
Julian Slowinski conducted an interview with Harold biguous published statement of this now widespread
Lief, M.D. and Arnold Lazarus, Ph.D. concerning their position has been made by LoPiccolo (1977, p. 1227).
views of sex therapy. In this response to that inter- He is openly skeptical about whether Masters and
view, Bernard Apfelbaum argues that the role of Mas- Johnson contributed anything new, and this is the
ters and Johnson was not adequately or fairly repre- totality of his comment on their work:
sented. This article was subjected to the same blind Effective direct approaches to sexual dysfunction were
review and evaluation process with consulting editors described by Semans, Hastings, Brown, and by a num-
as are all manuscripts submitted to JSET. Following ber of behavior therapists (Wolpe, Lazarus, Brady, Kraft
the Apfelbaum article are rebuttals by Drs. Lief and and Al-Issa) [before 1970]. It was, however, the publi-
Lazarus. Copies of all materials are being sent to Wil- cation of Masters and Johnson's unquestionable data
liam Masters and Virginia Johnson, with an invitation [in 1970] on the effectiveness of the direct approach that
to clarify the issues through their own written contri- led to its general acceptance.
bution.
In his discussion with Lazarus, Lief (p. 16) indicated
*** * ** * * ** that Masters and Johnson's work can be thought of as
limited, and that consequently it is not their model
Slowinski (1984) has done us all a service in con- but Helen Kaplan's "integrated" (behavioral-analytic)
ducting and reporting his interview with Lief and model that defines sex therapy:
Lazarus on "the state of sex therapy today." The dia-
We should emphasize what Helen Kaplan has added
logue form brings us the kind of inside view that is to the field by integrating the behavioral and psycho-
largely unavailable in published sources. Since I con- dynamic aspects. And I think that's what "the new sex
sider the view presented to be misleading in some therapy" has come to mean.
fundamental respects I would like to take this unique
opportunity to respond to it. Lief's statement reflects Kaplan's (1979) claim that the
What is most striking and most telling about the Masters and Johnson Institute (MJI) model is a simple
discussion is that Masters and Johnson's contribution behavioral approach that is ineffective in the treatment
is hardly mentioned. They are briefly referred to twice, of more difficult cases. The new sex therapy is there-
once by Lazarus (p. 13), questioning their outcome fore Kaplan's own approach, on the assumption that
data, and once by Lief (p. 16) in his remark that: her behavioral-analytic model has subsumed the more
limited MJI model.
Masters and Johnson had no real training in behavioral Lazarus' response was to restate his familiar posi-
techniques, in behavioral therapy. It's almost as if they tion that it is impossible to integrate behavior therapy
discovered this pari passu with behavioral therapy.
and psychoanalysis: "I feel that the integration of
The conception of Masters and Johnson as having divergent approaches is impossible if you take a look
simply re-invented behavior therapy defines them as at the fundamental assumptions that each one fol-
 6 journal of Sex Education and Therapy

lows." Although the impossibility of integrating the value when the client is suffering from pleasure anx-
MJI model with Kaplan's model is a case in point, iety, in this case fear of arousal because of incestuous
Lazarus did not further take up this issue, perhaps associations:
because he considers the MJI model to be subsumed Let's say that I discover, in the course of my therapy,
under his own. that a patient's impotence seems to be a result of certain
My response is prompted by the fact that there is matters pertaining to the mother-son relationship. He
no way to recognize from this discussion that there is has unknowingly accepted various pejorative labels that
an alternative view of the MJI contribution, much less his mother has given him. He remembers an occasion
one that sharply contrasts with the one presented . when he discovered his mother in the nude and he
The alternative view is that Masters and Johnson's developed a number of myths about sexuality after this.
work represents a breakthrough, perhaps the first real No wonder the poor fellow is impotent. You could give
breakthrough in the history of thinking about sexual- him 'sensate focus' exercises till doomsday and noth-
ity. ing's going to happen until you can work through these
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Much of the difficulty in even recognizing that there fundamental issues.

is an alternative view arises from Masters and John- The idea here is that this man suffers from pleasure
son's way of presenting their work. Outside of partic- anxiety rather than performance anxiety. Lazarus' point
ipation in their full-time training program or atten- is that removing performance demands through the
dance at their training seminars, there is no way to use of sensate focus exercises and helping this man to
become familiar with many of the essentials of their see that he is indeed able to have spontaneous erec-
model, a novel and perhaps questionable method of tions wouldn't help much since as a consequence of
presentation in a scientific field. As a consequence, his experience with his mother he is afraid of having
their contribution has been evaluated, even by their erections rather than of not having erections.
peers in the field, on the basis of a reading of Human Similarly, Helen Kaplan argues that sensate focus
Sexual Inadequacy. This is what makes it all too easy to exercises are ineffective in treating more severe cases
subsume their contribution under the work of others. because performance concerns-if present-are
Subsequent MJI publications have offered little superficial, a cover for a deeper fear of arousal. Her
additional information. There are some additional key contribution is the conception of sexual disorders
details in Kolodny, Masters, and Johnson (1979, Ch. as phobias. She contends that sensate focus assign-
19), but only at the intended textbook level. Masters ments, by limiting arousal, may simply help clients to
and Johnson's (1979) major clinical work other than avoid the phobic stimulus and thus prolong treat-
Human Sexual Inadequacy, Homosexuality in Perspective ment. Thus, she and her colleagues at times prescribe
only refers back to the previous work for ''basic treat- "foreplay" or taking a shower together.
ment techniques," with the as-yet unrealized promise Kaplan's associate, Witkin (1980, p. 17) cites her to
that "there will be a detailed discussion of the ... the effect that "today we are seeing patients who come
therapeutic format in future publications" (p. 258) . to sex therapy with very complicated problems,"
Human Sexual Inadequacy lacks a formal presentation whereas "for ten years patients came because of lack
of the model and offers no comparisons with other of information or performance anxiety." Now "patients
approaches. Much of the presentation is limited to the consult us whose problems require a high degree of
assignments, but even the rationale for the assign- clinical expertise." Witkin asserts that although sen-
ments is given only the most limited coverage and the sate focus exercises were of value for the earlier type
way the results of the assignments are actually used of patient, an "intimate shower" is a more effective
in the therapy is entirely left to the reader's imagina- first step for particularly difficult patients.
tion. Of most relevance here is the fact that Kaplan does
This is what makes it easy for most sex therapists not suggest that her practices represent a radical break
to say that they base their therapy on Masters and with the Masters and Johnson model. Instead, she
Johnson's work. From the limited presentation in claims to have simply gone beyond Masters and John-
Human Sexual Inadequacy it would be difficult to find a son, adding psychoanalytic depth to their superficial
way to do more. behavioral model, thereby making it possible to extend
the range of sex therapy.
It may be of some relevance to note briefly here that
Performance Anxiety versus Pleasure Anxiety just as the MJI model is not a superficial behavioral
Performance anxiety is widely appreciated as being model, so is it misleading to think of the Kaplan model
central to Masters and Johnson's work. Central to an simply as "psychoanalytic," since it represents only
assessment of their model is a recognition of the way one among many psychodynamic models (Apfel-
therapists look at performance anxiety, the fear of not baum, 1977b). Kaplan is a follower and colleague of
becoming aroused, in relation to pleasure anxiety, the Sager's (1976), and what she has done is to apply to
fear of becoming aroused. Fortunately, in the discus- sex Sager's conception of destructive systems, espe-
sion under consideration Lazarus (p. 17) offered a cially as embodied in hidden relationship-contracts.
clinical example to illustrate his contention that reliev- Thus she is concerned with pleasure anxiety, both as
ing performance anxiety, as through the use of Mas- a fear of pleasure and as a self-defeating avoidance of
ters and Johnson's sensate focus exercises, is of little it.
 journal of Sex Education and Therapy 7
It is therefore clear that it is misleading for Kaplan sions that characterize dysfunctional and, I would add
to speak of "integrating" her thinking with Masters (Apfelbaum, 1977a), functional or normal sexuality.
and Johnson's. In actuality her concern with pleasure When touched, kissed, or hugged, we feel the com-
anxiety is much more easily integrated with most other pulsion to respond in kind, what Masters and Johnson
approaches. The behavioral approach as represented (1970, p. 73) called the "rush to return the favor."
by Lazarus shares this concern, as illustrated by the Sensate focus exercises, if properly structured, block
clinical example just discussed. The only difference is this compulsion to reciprocate, through the method
that Kaplan thinks of pleasure anxiety as a product of of taking turns, resulting in enforced passivity.
Oedipal guilt whereas the behavior therapist thinks When Lazarus says that "you could give him 'sen-
of it as a conditioned response. This same focus on sate focus' exercises till doomsday and nothing's going
pleasure anxiety can be found in the sexual enrich- to happen until you can work through these funda-
ment or growth movement perspective, although there mental issues," he communicates a widely shared
it is thought to be a product of cultural and religious impression that Masters and Johnson intended the
taboos. sensate focus exercises to function as a training device
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In contrast, the MJI approach, while cognizant of that either succeeds or fails, and that can be taken out
pleasure anxiety, emphasizes performance anxiety, of the context of Masters and Johnson's therapy.
the compulsive drive toward pleasure. As Masters and In fact, within the context of their therapy, the sen-
Johnson (1970, p. 12) put it, in italics, in their original sate focus exercises cannot fail, or at least when they
work: "Fear of inadequacy is the greatest known deterrent fail they also succeed-succeed that is in pinpointing
to effective sexual functioning." What I am suggesting is the anxiety that should be the target of treatment. As
that many sex therapists disagree with this formula- a set-breaking device the sensate focus exercises can
tion, thinking that the greatest deterrent is the fear of undo sexual compulsions and thereby liberate spon-
adequacy, but they resolve this disagreement by taneous sexual feelings, but a more common effect is
assuming that Masters and Johnson must have been to liberate the anxiety that the compulsions had bound.
referring to less difficult cases. These therapists are A man whose compulsion to be the dominant partner
also able to assimilate Masters and Johnson's therapy is blocked may luxuriate in this first experience of
by interpreting it in such a way as to fit their own being required to be passive and to receive pleasure.
approaches. The way these therapists assimilate the However, he is at least equally likely to feel anxious
sensate focus exercises is a case in point. about not being allowed compulsively to manage the
encounter, given his worry that nothing will happen
Sensate Focus unless he makes it happen. His anxiety is then out in
For some sex therapists it fits their own model to the open and available for therapeutic intervention.
think of the sensate focus exercises as simply a way The sensate focus exercise has succeeded in its diag-
for partners to communicate their likes and dislikes. nostic function. As Masters and Johnson (1985, p. 7)
Sex therapists working from a different model think have recently put it:
of the sensate focus exercises as a crude approximation The judicious use of sensate focus exercises has multiple
of the desensitization procedures developed by Wolpe, clinical applications. For example sensate focus exer-
Lazarus, and other behavior therapists. It is entirely cises are now initially used to identify and evaluate
understandable that therapists who look at sensate levels of inhibited sexual desire and/or states of sexual
focus exercises in either way would not think of the aversion. Thus, sensate focus techniques are employed
both as diagnostic and as therapeutic modalities.
MJI approach as a major breakthrough, but both ways
reflect these therapists' own models and consequently Sensate focus exercises in the context of Masters
seriously misconstrue the MJI approach. and Johnson's therapy are an elegant diagnostic and
From within the MJI context the sensate focus exer- exploratory device, but when taken out of this context
cises might best be thought of as a set-breaking strat- (although often still done in Masters and Johnson's
egy that blocks performance compulsions, determi- name) and viewed simply as a training device, there
nants of sexual relating that had not been previously is only one way for them to succeed. Consequently,
recognized by either laypersons or professionals: the failure is likely. Indeed, looked at this way the sensate
compulsions to reciprocate, to penetrate, to reach male focus exercises can seem like an exercise in futility, as
orgasm, and for the man to be the dominant partner. can be seen from Witkin's (1982, p. 112) argument
Thus, a principal objective of the exercises is method- against their use:
ically to block these compulsions in order to make Since each partner in sensate focus is assigned a defined
spontaneous responses possible. role, it is relatively easy to avoid relating to the other in
The compulsion to reach orgasm, especially male a spontaneous way; in fact, couples have been known
orgasm, was first isolated and named by Masters and to perform the exercise in the dark, and as if it were a
Johnson ("goal directedness"). Their immediate pre- massage to firm up muscles rather than to relax them.
decessor, Van de Velde, had referred to orgasm as Avoidance is furthered by the fact that the patient being
"the aim, the summit, and the end of the sexual act," pleasured will often keep his (her) eyes closed, so that
in effect the partners do not really look at each other.
a formulation that was up-ended by Masters and John-
son. They recognized that making orgasm the aim of Clearly, for Witkin the sensate focus exercises are
the sex act was, in effect, the linchpin of the compul- needlessly restrictive, making it too easy for partners
 8 journal of Sex Education and Therapy

to avoid spontaneity (note again that it is the fear of beyond them because, as in the words of one well-
responding spontaneously that the Kaplan group known sex therapist: "Unless he can touch her ten-
focuses on, rather than the fear of not responding derly in front of us, how can we be sure that he will
spontaneously). As Witkin sees it, partners who do be able to do that back at the motel?"
the assignment in the dark, as a massage, and with To such therapists it looks like a needless restriction
eyes closed, have thwarted the purpose of sensate for Masters and Johnson not to be more aggressively
focus . Thus, they can benefit from the "intimate sex positive, not to use sex films and other sexual
shower," in which they are allowed no such easy out, enhancement devices and even to downplay the use
since they cannot shower in the dark, and "must look of vibrators. It looks this way to these therapists because
at each other, talk to each other, reveal themselves to they see clients as primarily suffering from sex-nega-
each other, and, in other words, relate to each other." tive propaganda, hence requiring an unreserved
To say that partners who do the assignment in the counter-propagandistic approach. They are uncon-
dark with their eyes closed are not relating to each cerned about the performance pressure generated by
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other is only to say that they are not relating to each their position of advocacy because, like Kaplan and
other in the expected way. However, they are relating Lazarus, their target is pleasure anxiety.
to each other in the way that creates their difficulty. The least well known but most crucial aspect of the
If the sensate focus exercises have failed in the Witkin/ Masters and Johnson model is their emphasis on ther-
Kaplan sense, they have succeeded in the Masters and apeutic neutrality. This creates the abstinent approach
Johnson sense, that is, they have succeeded in their to treatment that to Witkin and others appears to be
diagnostic function. needlessly limited. However, it is precisely this seem-
For Witkin, diagnosis is not a purpose of the sensate ing limitation that constitutes their breakthrough. For
focus assignments. Her position is understandable example, with regard to the risk of sending the couple
given her view that: "Sensate focus is intended pri- off without instruction in technique, at MJI patients
marily to acquaint the couple with his (her) own and are initially instructed to touch their partners in what-
the partner's specific sensual likes and dislikes." If ever way they find pleasing or interesting, rather than
this sounds familiar it is because this is one impression in a way designed to please or turn on their partners,
created by a reading of Human Sexual Inadequacy, and another piece of set-breaking and another departure
Witkin is not alone in thinking that this conception of from the commonsense approach and another effort
sensate focus represents the Masters and Johnson to reduce performance pressure .
model. Kolodny (1985) wryly comments: "It is unfor- Perhaps Masters and Johnson's most striking inno-
tunate that MJI therapists can be seen as simply cheer- vation was to radically depart from the general expec-
leaders urging couples to get back into the sensate tation that the only way to treat sex problems is to
focus game to 'win one for the Gipper'." create an especially erotic environment and to have a
It is this version of the MJI model that Kaplan has patient and skillful partner. For example, no one had
"integrated." Understood this way, Masters and questioned the practice, universal in the sex manuals,
Johnson's contribution hardly looks like a major of treating frigidity in women only by giving advice
breakthrough in our thinking about sex. Indeed, this to their male partners, advice designed to make the
makes their claimed success rates look especially puz- husbands more patient and skillful. There had been
zling. The now popular answer to this puzzle, noted no way to see the performance pressure created by
above and first put forth by Kaplan (1979), is that their this approach since people who did not respond to it
patients (like those treated in the first ten years follow- were simply thought of as being either unwilling to
ing the publication of Human Sexual Inadequacy) simply change or as having problems so deep-seated as to
did not suffer from serious sexual difficulties. This require more comprehensive psychiatric help.
answer overlooks the fact that current outcome statis- Until the Masters and Johnson breakthrough no one
tics reported by MJI (Kolodny, 1981) are consistent considered the possibility that an erotic environment
with those reported in Human Sexual Inadequacy. and a patient and skillful partner can create intense
Although from Witkin's point of view Masters and performance pressure, which in turn can create the
Johnson appear to be lax in not requiring partners to impression of a deep-seated inhibition. Thus the sen-
relate to each other in the right way, this misses the sate focus exercises are not to be done in a romantic
point that Masters and Johnson quite deliberately do setting, an aspect of the Masters and Johnson approach
not take the position that there is a right way to do that is not always noted or is often considered to be a
sensate focus. limitation. Its systematic significance is easily over-
For example, although it has been generally over- looked.
looked, Masters and Johnson generally do not give It is true that Wolpe's gradualist approach bears
instruction in techniques of touch. Some sex therapists some resemblance to the Masters and Johnson
who have noted this think of it as an oversight or as approach, but the purpose is different. Wolpe wanted
simply a matter of personal style. When these thera- to avoid overwhelming the client with erotic stimu-
pists give instruction in technique they think of them- lation, and thus introduced it gradually. This was a
selves as going beyond Masters and Johnson. They breakthrough of its own. No one previously had sug-
typically comment that Masters and Johnson were the gested that sexual stimulation should be interrupted
pioneers and we owe them a debt, but we have to go at the first sign of anxiety. However, this was simply
 Journal of Sex Education and Therapy 9

the behavioral approach to any threatening stimulus, position of advocacy, in contrast to Masters and John-
whereas the Masters and Johnson approach is an effort son's sex-neutral position, because they have a narrow
to identify and undo specific sexual compulsions. view of performance anxiety. If these therapists do
not recognize all the ways we feel compelled to per-
Response Anxiety form in sex, how can patients be expected to recognize
Sex therapists who disagree with the MJI model of it?
sensate focus are nevertheless able to assimilate it by I have elsewhere suggested that Masters and John-
interpreting it in such a way as to fit their own son's conception of performance anxiety might better
approaches. The result is that the MJI model is tri- be called "response anxiety" because this more ade-
vialized . I mentioned that many sex therapists dis- quately conveys its meaning (Apfelbaum, 1984a).
agree with Masters and Johnson's formulation that "Performing" appears to refer only to the physical
"fear of inadequacy is the greatest known deterrent expression of sex, whereas "responding" more clearly
to effective sexual functioning." These therapists believe refers to all the compulsions that Masters and John-
that fear of inadequacy, i.e. performance anxiety, is son's therapy has isolated (compulsions to recipro-
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the pathogenic factor only in less difficult cases. They cate, to please the partner, to accelerate, to effectuate
conclude that to arrive at such a formulation Masters male dominance, etc.) as well as to respond in all the
and Johnson must have treated only the less difficult ways we feel called upon to respond. For example, if
cases, although there is no evidence for this. it is true that many women have at one time or another
The reason that these therapists believe perfor- faked an orgasm, we can say with even more confi-
mance anxiety to be the pathogenic factor only in less dence that all women and men have faked feelings.
difficult cases is that their conception of performance This need not be confined to sex. A faked orgasm is
anxiety is relatively superficial, making it genuinely like a social smile or like laughing at the boss's joke.
difficult for them to see how it deserves the emphasis Perhaps performance anxiety is all the more subtle
Masters and Johnson have given it. Thus, Kaplan (1979, for seeming obvious. In his "Three Decade Retro-
p. 29) refers to "deeper" sexual fears which, "in con- spective of the Masters and Johnson Institute," Mas-
trast to performance fears ... are not usually recog- ters (1983) stated that:
nized by patients." Also, in Witkin's citation from
Our greatest failure has been the failure to convince
Kaplan (above), performance anxiety is lumped together medicine first and the behavioral sciences second, that
with lack of information ("for ten years patients came sex is a natural function. Everyone of you know it, but
because of lack of information or performance anxi- none of you live it and very few of you practice it.
ety"). Inevitably, given this conception, Kaplan then
treats performance fears as a relatively trivial deter- This despairing statement must have mystified the
minant of sex problems. audience, all of whom did indeed think that they knew
It is easy to overlook the more subtle and pervasive sex was a natural function. It seemed to them obvious
forms of performance anxiety. Recall my example of to begin with. Since we all"know," in Masters words,
the person suffering from a sex problem who has the that sex is a natural function, what prevents us from
opportunity to receive the ministrations of a patient "living" this knowledge? One answer is performance
and skillful partner in an erotic setting. Neither the anxiety. But of course this does not refer to the simple
helper nor the afflicted person has any idea that they fear of performance failure but to all the ways we feel
are in a sexual pressure cooker. If the person only gets compelled to perform in sex, the ways we all (sex
more anxious, the inevitable conclusion is that the therapists included) feel proud of being able to respond
problem must be too deep-seated for such brief treat- easily and fully, or humiliated when we cannot.
ment. Similarly, when Van de Velde urged the hus- Let us return to the contention made by Lazarus
band to attend to his frigid wife, he had no idea that that sensate focus exercises would not work with the
he was writing a prescription for performance anxiety. man who had developed deep-seated anxieties "per-
If she did not respond despite her husband's deter- taining to the mother-son relationship." I would argue
mined efforts, the conclusion had to be, before Mas- that sensate focus exercises might be the treatment of
ters and Johnson's insight, that she really was frigid. choice in such a case. First, we should consider the
What Masters and Johnson refer to as the fear of likelihood that this man's impotence makes him feel
inadequacy must be understood as the fear of being inadequate-makes him feel that he should be able to
inadequate in all the ways that adequacy is measured respond more positively to sex.
in sex. It refers not only to fears of orgasmic or erectile In other words, the "pejorative labels that his mother
difficulties, but to the fear of not being able to meet has given him" may well be a source of difficulty
all the expectations implicit in the standard sexual because of the pressure on him, as on all of us, to
scenario and in standard gender-role stereotypes. In respond positively to sex. His anxiety about seeing
a word, it is the fear of not responding. his mother in the nude may be a source of difficulty
In effect, sex means always saying yes, and the because, again as is true for all of us, he thinks that
pressure to perform is just that broad. Sex therapists he should not be anxious in sex. These forms of per-
who take a sex-positive position dearly are not con- formance anxiety are easy to miss when performance
cerned about the risk of intensifying the pressure to anxiety is thought of as a simple fear of performance
respond in a sex-positive way. They can take this failure.
 10 journal of Sex Education and Therapy
The virtue of the sensate focus exercises is that his that is limited to the treatment of superficial, conscious
anxiety about his anxiety would be brought out anxieties. Also, the expectation that Masters and John-
(Apfelbaum, 1984b). He could then be helped to express son's success rates will be consistent with the results
some of his insecurity with his partner, an experience found by others is inevitably created by the belief that
that might in itself be quite relieving. In other words, all sex therapists base their treatment on Masters and
rather than requiring him to get over his anxiety by Johnson's therapy. Given the assessment of Masters
working with a therapist, he could learn how to get and Johnson's contribution presented by Lief and Laz-
reassurance in the sexual encounter itself. arus, there is no conceivable reason why Masters and
Lazarus commented early in the interview on his Johnson's therapy would be more effective than that
use of hypnosis (p. 16): offered by others.
One clue to a different answer to the outcome ques-
My assumption is that if a person says, "I am going to
be very relaxed during lovemaking," and then just says tion is provided by the marked discrepancy between
this over and over, it will have less of an impact than if the estimate of the success of Masters and Johnson's
therapy with desire disorders made by MJI and that
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the client shuts his/her eyes and feels a kind of heavy,

warm relaxation" [which he suggests is what is accom- made by Kaplan. As I indicated in my review of Dis-
plished through the use of hypnotically induced imag- orders of Sexual Desire:
ery].
Much of Kaplan's justification rests on her "impres-
This effort to have the client work at relaxing, whether sion" of a 10-15% success rate for Masters and John-
by trying to talk himself into it or by using hypnotically son's therapy in cases of sexual apathy, especially since
induced imagery, seems likely to increase perfor- her own success rate, though not specifically given, is
mance pressure. Therefore, my guess is that Lazarus' apparently no better than 50%. One wonders where
readiness to risk making a performance demand (to Kaplan got her impression since Kolodny (1979) reported
a provisional success rate of 80% with such cases at the
relax) and thereby intensifying the client's anxiety about Masters and Johnson Institute.
not being able to relax is generated by his view that
the problem is pleasure anxiety rather than perfor- Further, Kolodny (1985) states that:
mance anxiety. The performance demand is even clearer A review of dozens of cases done in the early 1970s,
in Hartman and Fithian's (1972, p. 193) use of hyp- using MJI tapes and case notes, identified many cases
nosis with "about one half of all couples in therapy," which would be diagnosed today as "low sexual desire"
to suggest, for example, "a firmer and longer lasting but were then called impotence, since this was the pre-
erection." senting symptom. However, we managed to treat these
Kaplan provides much more striking examples of cases fairly successfully, obtaining at least a 75% success
the same approach since, as I pointed out in a review rate. Just because they were not given the diagnostic
of Disorders of Sexual Desire: label now in vogue doesn't mean that we didn't rec-
ognize what was going on and what should be done
Kaplan asserts that in all but the simplest cases Masters about it.
and Johnson's strategy of nondemand pleasuring and
the avoidance of goal directedness is likely to fail because, I have since learned that Kaplan's impression of a
underneath, the person "does not want to" per- 10-15% success rate for Masters and Johnson's ther-
form .. . . apy in cases of sexual apathy was based on Kaplan's
By declaring performance anxiety to be a cover for (and her co-workers') own application of Masters and
the wish to fail sexually and by insisting on successful Johnson's therapy, and specifically refers to the effi-
performance and advocating working at sex, Kaplan caciousness of the sensate focus exercises. However,
has reversed all the essentials of Masters and Johnson's as I have tried to demonstrate, Kaplan's impression is
thinking (Apfelbaum, 1981). therefore based only on a narrow construction of the
sensate focus exercises, one taken out of the context
Outcome of Masters and Johnson's therapy. Indeed, I would
Early in the discussion Lazarus raised a question venture to say that the way sensate focus exercises are
about Masters and Johnson's outcome data, specifi- understood and presented is a good way to identify a
cally their relapse rates. This, of course, echoes Zil- given sex therapist's treatment model.
bergeld and Evans' (1980, 1983) critique of the way It cannot be assumed that Masters and Johnson's
Masters and Johnson reported their data, especially innovative strategy is faithfully represented by others
in view of the fact that the reported success rates are in the field. The fact that their model is not considered
so much higher than those found by many other sex by many to be innovative indicates this. What has
therapists. Although this critique has been misinter- happened is that the Masters and Johnson approach
preted as raising a question about the therapy itself, is assimilated to whatever model a sex therapist uses,
in fact it was entirely concerned with methodological and may even then be considered an inadequate ver-
flaws in the collection and analysis of outcome data. sion of that model. My proposition is that Masters and
In other words, Masters and Johnson's high success Johnson's therapy is truly revolutionary, a radical
rates have yet to be explained. What makes these departure from all previous approaches and perhaps
success rates especially suspect is the belief that Mas- still from many contemporary approaches. However,
ters and Johnson's therapy is merely an unsophisti- that has yet to be completely presented in published
cated version of the behavioral approach and even at form. The concepts are sufficiently elusive and subtle
 Journal of Sex Education and Therapy 11

to have as yet escaped fullest appreciation. Thus any Kolodny, R.C. Personal communication, 1985.
difference in success rates between Masters and John- Kolodny, R.C., Masters, W.H. & Johnson, V.E. Textbook of
son's work and that of others in the field may reflect Sexual Medicine. Boston: Little, Brown, 1979.
a real difference in treatment approaches. LoPiccolo, J. Direct treatment of sexual dysfunction in the
couple. In Money, J. and Mustaph, H. (Eds) Handbook of
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