Stop Premature Ejaculation Now! 

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Psychological intervention for premature ejaculation

The treatment of choice for men with lifelong or acquired premature ejaculation is couples therapy during which both partners can understand the factors that have brought on the premature ejaculation as well as those which are maintaining it. It's also important for the therapy to investigate the effect that this sexual dysfunction has both the man and his female partner so that mutual understanding is achieved and the appropriate treatment method can be established. Clearly, this is only likely to succeed where both partners are psychologically and emotionally healthy and have a high level of motivation to pursue treatment.

Following the interest in pharmacological treatment of premature ejaculation, a combined therapy that involves both drugs and psychological interventions has been recommended by some authors. Drugs such as Dapoxetine do have an effect on the time between penetration and ejaculation and therefore serve to provide the man with sexual confidence if he has previously had no control whatsoever over his ejaculatory response. This is similar to the use of Viagra as a confidence boosting drug in the short term for men whose erectile dysfunction has its origin in performance anxiety.

Using the drug in this way as a short-term aid to increase the man's ability to control his ejaculation gives the therapist, so it is said, an opportunity to teach the man to attend to his bodily sensations and pace himself during sexual activity rather than becoming anxious about the rapidity of his sexual response. I would question how able a man is to learn these things whilst he is taking medication; moreover, even the proponents of treatment readily acknowledge that not all men can give up the pharmaceutical remedy.

The final option is psychotherapy alone, in whatever form this may take. Most likely these days is psychotherapy will be a mixture of behavioral therapy, cognitive therapy, and psychodynamic approaches. Clearly however, the most important aspect of treatment is that the man should learn to control his ejaculation, and that he and his partner should:

1 recover confidence in sexual activities
2 reduced performance anxiety during sexual activities
3 become more flexible in sexual behavior
4 establish greater intimacy
5 resolve the interpersonal issues which are maintaining the premature ejaculation and inhibiting emotional openness
6 come to terms with feelings/thoughts that interfere with sexual function
7 increase communication and improve the quality of communication.

The psychodynamic orientation of therapy is useful in understanding that the premature ejaculation may be a metaphor for deeper issues that are of primary importance to each member of the couple. A skilful therapist will be able to unearth these so that behavior therapy can then work on the condition aspects of sexual dysfunction. This would typically involve homework exercises such as the ones described on this site, exercises that enable a man in his partner to establish the qualities in relationship which are mentioned in the list above.

Many men think that if they pay attention to the level of sexual arousal or excitement there feeling it will cause them to ejaculate more rapidly than before, so they pay attention to physical factors such as desensitization ointment, repeated masturbation before intercourse, avoiding stimulation from their sexual partner, using two condoms, or distracting themselves with the relevant thoughts whilst making love. Unfortunately all of these strategies take the focus away from the physical arousal that the man is experiencing and make it even less likely that he will be able to control his ejaculatory response.

It's interesting to listen to men with rapid ejaculation because when they talk about their sexual experience what they tend to describe is a rapid movement from a point where they do not feel sexually excited to the point of ejaculatory inevitability. In other words the prima facie evidence suggests that they have a lack of awareness of their level of arousal between these points, or that they are perhaps unable to keep themselves in this mid-range of sexual arousal. Graduated exercises allow them to become familiar with their bodily sensations, starting with masturbation and moving on to foreplay and full sexual intercourse. This is gradual increase in levels of sexual arousal gives them the ability to stay in a mid range sexual arousal below the point of ejaculatory inevitability. It is also clear that anxiety plays a large part in this process, so that relaxation and sensate focus are invaluable tools in this treatment methodology.

But it is also necessary to teach men how they can resolve the relationship issues that may be supporting their premature ejaculation and the cognitive distortions which exist within the relationship in the interactions between the man and his partner. For example, Rosen et al listed eight forms of cognitive distortions that certainly interfere with the ability of a man to achieve normal sexual function:

http://linkinghub.elsevier.com/retrieve/pii/S1571891306000616 

These include:
1 all or nothing thinking, e.g. I am a sexual failure because I ejaculate quickly
2 overgeneralization, e.g. I know I will not be able to control my ejaculation because I have never been able to control in the past
3 disqualifying the positive, e.g. even though my partner say she's happy with our sex life she's only saying that because she doesn't want to hurt my feelings
4 mind reading, e.g. there is no need for me to ask how she feels about my rapid ejaculation because I know already
5 fortune telling. e.g. things have gone badly before so they will go badly tonight
6 emotional reasoning, e.g. I feel this is true therefore it must be true
7 categorical imperatives. i.e. I should be a better lover, I ought to be able to satisfy my partner, I must improve my sex life
8 catastrophizing, e.g. if I can't control my ejaculation she will leave me.

Clearly there is an important role here for an educational process during therapy which will enable a man to reconstruct a framework within which he sees his sexual performance, and which will also enable a couple to rewrite their sexual script (that's the behavioral repertoire of the couple in the field of their sexual activities).

There's always resistance at some point during therapy. It is not easy, and it's often not comfortable, for a man or his partner, or both, to give up the status quo because it represents some point of reference within the relationship which maintains the behaviors even if they are maladaptive ones. A skilful therapist will be able to break down these resistances using confrontation, interpretation, intervention, and perhaps a smattering of humor.

A typical source of resistance would be the fact that rapid Ejaculation and the disharmony that arises from it can maintain a sexual equilibrium within a relationship and disguise the female partner's concern about sexual activities.

Psychotherapy outcome studies

There is a regrettable lack of control and methodology in reported studies on the treatment of this sexual dysfunction. This led to a large amount of literature producing apparently compelling conclusions which are in fact mostly anecdotal.

In the 1960s, however, Masters and Johnson reported on 186 men studied in their quasi-residential setting who received intensive treatment including the squeeze technique, sensate focus, both individual and couples therapy, as well as training in sexual skills and communication. Masters and Johnson is achieve greater success was extraordinarily high for they reported only 2 to 3% failure rate for five years after treatment. It has to be said that this level of effectiveness has never been achieved since.

For example, only 64% of men in Hawton et al.'s study and 80% of Kaplan's cohort appeared to be successful in overcoming their rapid ejaculation, and that was immediately after therapy. Moreover almost all studies that have invested in long-term follow-up showed that men suffered from relapses, in as many as 75% of cases. Interestingly enough, 34% were not even bothered by this which strongly suggests that the treatment methodology they had received had improved the quality of their relationship and sexual satisfaction. This emphasizes that treating the couple as a unit can produce improvements in intimacy communication which may outweigh in importance the increase in intra-vaginal ejaculatory latency time.

Nonetheless, modern therapists have begun to look at the question of preventing relapses. This can be done by scheduling regular sessions at regular intervals after the termination of main therapy. Knowing that there will be a six-month follow-up session motivates patients to keep up with the work and gives them the opportunity to discuss any problems that have arisen.

Combined treatment coaching

Clearly there are major differences where treatment is a combination of pharmaceutical intervention and psychological approaches. For one thing, the psychological aspects of treatment have been referred to as coaching rather than therapy: they are more directive, the focus on giving advice and education and the improvement of technique. They also directly target behaviors that are maladaptive or unhelpful such as the avoidance of foreplay, inhibited sexual behavior, and destructive sexual patterns which are established with the relationship including the ability to communicate about problems.

In summary, the objectives of such coaching are:

1 Being able to identify and to work through any resistances that occur and which could potentially stop the treatment being effective or the man or his partner discontinuing treatment
2 reducing or indeed eliminating altogether any sexual performance anxiety
3 improving and the sexual confidence and self-esteem
4 putting the sexual dysfunction of the whole context in which the sexual activity takes place
5 assisting a couple in changing maladaptive sexual scripts

It's possible that the best focus of combined treatment is when pharmacological therapy has not proved effective. However that is a matter of opinion, and I would always go for psychological approaches before pharmaceutical solutions.

Conclusion

What can be said in a field so vexed by differing opinions? One thing is clearly the treatment needs to be tailored to the requirements of the man and his partner. Premature ejaculation is, or at least can be, a very distressing condition which affects the relationship between a man and his partner in every way. It is therefore arguable that every approach that can be brought to bear on the situation should be brought to bear to ensure that a couple achieves greater sexual satisfaction, emotional intimacy and a better relationship which is more harmonious and satisfying to them.

[1] Althof S. Psychological treatment strategies for rapid ejaculation: Rationale, practical aspects and outcome. World J Urol 2005; 23:89-92.

[2] Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: A systematic review and metaanalysis. Int J Impot Res 2004-13.

[3] Waldinger MD, The neurobiological approach to premature ejaculation. J Urof 2002 68(6):2359-67.

[4] Althof S:  When an erection alone is not enough: biopsychosocial obstacles to lovemaking. Int J Impot Res 2002;4(Supp l): 599-104.

[5] Abraharn K. Selected Papers, (5, 10) Institute of Psychoanalysis. London. Hogarth Press; 1927.

[6] MeMahon CG, Abdo C, Incrocci L, Perelman M, Rowland D, Stuckey 8, et al. Disorders of Orgasm and Ejaculation in Men. In: Lue IT, Basson R, Rosen, Giutiano F, Khoury 5, Montorsi F, editors. Sexual Medicine Sexual Dysfunctions in Men and Women Edition, 21. 20U; p. 411-68.

[7] Schapiro B. Premature ejaculation, a review of 1130 cases. J Urol 1943;50: 374-9.

[8] Masters W, Johnson V. Human Sexual Inadequacy. Boston: little Brown; 1970.

[9] Perelman M, MeMahon C, Barada J. Evaluation and Treatment of the Ejaculatory Disorders. In: lue T, editor. Atlas of Male Sexual Dysfunction. Philadelphia, Pennsylvania. Current Medicine, Inc.; 2004p. 127-57.

[10] Kaplan H. PE: How to overcome premature ejaculation. New York: Bruner/Mazel; 1989.

[11] Symonds T, Roblin D, Hart K, Althof S. How does premature ejaculation impact a man's life? J Sex Marital Ther 2003;3(29):361-70.

[12] Hartmann U, Schediowski M, Kruger THC. Cognitive and partner-related factors in rapid ejaculation. World J Urology 2005; 23:93-101

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