Johan Verhulst

An interactional approach to sexual dysfunctions

Abstract This paper offers an interactional perspective as a broad and practical conceptual framework with which to understand patterns of sexual dysfunction. The theoretical model centers on the power of the sexual interaction as a critical focus for therapeutic change. The model is developed by presenting: the basic sexual interaction cycle, the individual and interactional variables that modify the sexual interaction cycle, and the creation of a continuously changing figure/ground configuration of sexual and nonsexual patterns. At various points in the discussion of the model, initial clinical strategies are derived to illustrate the applicability and advantages of an interactional perspective on sexual relationships.

The medical alliance: from placebo response to alliance effect.

Abstract The natural human response to illness is to seek to understand what is happening and to look for help from others. In all cultures, one finds healers, who provide explanations and offer care. Their interventions often have a placebo effect through activation of natural healing processes in the patient. Although placebo effects are relatively large and robust, physicians generally consider placebo treatment prescientific and deceptive. We review the determinants of the placebo response and show how a particular professional alliance between a patient and a caregiver is apt to equally affect treatment outcome. We distinguish the alliance effect from the placebo effect. We develop a comprehensive model of the medical alliance, on the basis of the concept of concordance, and review its relevance for clinical practice and medical education. The alliance effect represents a professional and ethical way of activating a patient’s natural healing mechanisms.

The psychotherapy curriculum in the age of biological psychiatry : mixing oil with water?

The field of psychiatry is characterized by tensions and philosophical differences. These tensions are described as a set of dilemmas facing the training director when designing the psychotherapy curriculum for residents. A solution to these dilemmas is presented. As a concrete example, the recently developed psychotherapy training program at the University of Washington in Seattle is described.

How Many Psychiatrists Do We Need

Projections of manpower needs based on population growth and possibly improving access are unconvincing because of rapid changes in psychiatric practice and because complex social and political forces are influencing the psychiatrist’s role in the mental health system. Given this basic uncertainty, attempts at filling residency positions at all costs are less than responsible. To serve our field well, efforts should be focused on recruiting “the best and the brightest” of our medical students and on providing quality training that stays in tune with the developments of the field and the evolution of the role of the psychiatrist.

Sexual Pharmacology: Love Potions, Pills, and Poisons

The human population is increasingly exposed to chemicals that affect sexual function, from industrial pollutants to life-saving pharmaceuticals. First, the products that can cause dysfunction, including endocrine disruptors, drugs of abuse, and prescription medications, are reviewed. A systemic perspective proves helpful in explaining the large variability in effects and side effects of medications. Secondly, the biological treatments of sexual dysfunction are presented in light of the age-old human wish to control desire and sexual response. It is proposed that the development of the phosphodiesterase type 5 inhibitors (PDE-5 inhibitors) constitutes a turning point in this search for control. They contribute markedly to a shift from seeing sexual dysfunctions as “problems of living” to approaching them as medical disorders. The advantages and pitfalls of this “medicalization of sex” are discussed, focusing in particular on the social roles and expectations that are inherent in the disease model. Finally, the need for a systemic approach to sexual pharmacology, involving the physiological, individual, relational, and socioeconomic levels, is emphasized. A majority of patients with sexual dysfunctions first consult their primary care physician. The tension between the need for a comprehensive, systemic approach and the physicians constraints of time and expertise represents a challenge, the resolution of which is likely to determine the future of the field of sex therapy.

Educating Psychiatry Residents to Practice in Smaller Communities: A Regional Residency Track Model

Psychiatrists in the USA are concentrated in population-dense major metropolitan and higher income areas, particularly in the Northeast [1]. Many areas, including rural communities but also smaller cities, experience a shortage and have difficulty recruiting psychiatrists. Indeed, more than three quarters of counties in the USA have a severe shortage ofmental health providers, especially prescribers [2]. Psychiatry residency programs are located primarily in major metropolitan areas and graduates most often choose to practice in the vicinity of where they have completed graduate medical education [3]. Here, we describe a regional track model of psychiatry residency education designed to increase rates of practice in smaller communities. The University of Washington School of Medicine and Psychiatry Residency Program serve a large geographical region (the WWAMI region: Washington, Wyoming, Alaska, Montana, and Idaho) with some of the lowest physician to population ratios and graduate medical education position to population ratios in the nation. For example, the communities sponsoring the regional tracks described here (Spokane, Washington and Boise, Idaho) are in the lowest quartile nationally for physicians per capita and have 5–6 psychiatrists per 100,000 people as opposed to the national average of 10.9 [4]. The average number of graduate medical education positions per 100,000 is 35.7 nationally, but 6.8 and 3.6 per 100, 000 in Spokane and Boise, respectively [5]. Both have a severe shortage of mental health providers, poor access to mental health care, and suicide rates 46–54 % above the national average [6]. Historically, the only psychiatry residents were based in the academic medical center in Seattle, Washington, a major metropolitan center and the largest city in the region. These residents rarely practiced elsewhere in the WWAMI region after graduation, despite selection of residents from and interested in practicing in the region and the availability of several 1–3month away rotations to explore practice in smaller communities. Thus, our psychiatry residency program established two regional tracks in smaller cities in our region, located in the midst of large, underserved areas, with the goal of preparing general psychiatrists to practice in these communities. The Spokane Track was founded in 1992 and the Idaho Track in 2007. Spokane and Boise have populations of 208,916 and 205,671 (2010 census) and are 280 and 495 miles from Seattle, respectively. These regional tracks were established with the goal of 50 % retention of graduates in the regional site community. Here, we report on this outcomemeasure and, secondarily, on rates of practice of these graduates in other underserved parts of our region.

A Review of “Male Sexuality: Why Women Don't Understand It—And Men Don't Either”

couples that if they are going to engage in sexual intercourse, they should not begin until they are aroused; the way to arousal is to understand one’s own sexual fantasies and convey to the partner what type of activity would elevate arousal. Such lessons are not generally made explicit in other sex manuals, making this volume as much a “why to” as a “how to” book. Part III, “Surmounting Sexual Challenges,” includes information on overcoming sexual inhibitions; incorporating sexual medications such as Viagra or sexual aids such as lubricants into sexual play; and dealing with sexuality, aging, and illness. As in other chapters, the McCarthys incorporate detailed amalgamated case histories that demonstrate how real-life couples have navigated such challenges, making positive changes so that their sex life could remain vital. All in all, Discovering Your Couple Sexual Style is a solid contribution to mainstream literature. Although the idea of a “couple sexual style” may seem a bit gimmicky, it can draw in readers who can then understand that sex isn’t about acrobatics, but rather it is about having mainly pleasurable, enjoyable, satisfying encounters, about being “sexual friends,” rather than sexual adversaries most sex therapists see in their offices. There are two caveats. One is that the reading level and writing style is somewhat lofty, for example, the McCarthys write, “Rather than being totally dependent on partner interaction arousal, some soulmate couples purposefully utilize role enactment arousal scenarios to spice up their sexual repertoire and introduce mystery and eroticism to their relationship” (p. 39). Pages of such language may be daunting to average readers. Alternatively, the phrase “good enough sex” doesn’t have much zing to it; most American readers will find themselves wishing for something that sounds zippier. With those criticisms aside, the McCarthys have created an even, nonsensationalized sex manual that therapists, counselors, and educators can recommend without fear of offending a client. Discovering Your Couple Sexual Style is a refreshing, inspirational book for average couples looking for good information to help them have the sex they seek and deserve.

Impotence: A Cultural History

behaviour not as deviant per se, but as culturally defined and interpreted based upon socioeconomic status, the treatment program described could offer a new set of tools to clients. This book is most appropriate for clinicians working in secure custody facilities or with a team of clinicians within institutional settings. It would also be informative for clinicians interested in learning more about the treatment of sexual offenders within a prison environment, and who have the experience to adopt the strengths of the program and modify them to deal with a non-incarcerated population. Overall, Treating Sexual Offenders outlines a program that is designed around a substantial literature review of empirical research on sexual offenders. The authors readily identify the flaws of existing research and help the reader understand that the field is a rapidly evolving one in which treatment and therapies are in their infancy. Consequently, clinicians must be cognizant that a great deal of discretion and flexibility in the treatment approach is required when dealing with persons who have offended sexually as the research has not borne out conclusively what the successful elements of treatment are for all types of offenders. As such, this book is directed at a very specific audience, and other clinicians would struggle to adopt such a program in their private practice.

The Role of the Psychiatrist

This essay proposes that the division between biological and psychotherapy-oriented psychiatry originates in the discipline’s reliance on two fundamentally different methods of inquiry, that is, the medical-biological and the empathic-narrative. These terms are defined and distinguished from psychotherapy and psychodynamic psychiatry, as well as from general humanistic qualities in medicine. The division within the field may be fueled by a lack of clarity with respect to these concepts. The author argues that the essence of psychiatry is defined by a balanced combination of both methods. Psychiatry does not consist only of basic methods, but also of rules and guidelines for clinical practice, and of knowledge and theories used in the application of the methods. The role expectations for psychiatry in the managed care environment are examined and their effects upon methods, theory, and practice are analyzed. Some suggestions for dealing with the challenges of health care reform are offered.