Mr. and Ms. Albert: Problems of Premature Ejaculation
17th Dec. 2012

Abstract
This paper reviews the problem of a couple who is experiencing premature ejaculation problems. Psychological ejaculation theories and treatment interventions are considered. Mr. Albert’s possible negative psychological effect is looked at as well as his partner’s. Successful psychological interventions are discussed that could minimize the problem of rapid ejaculation. Combined pharmacotherapy and psychotherapy are found to be the most effective in minimizing the problems of rapid ejaculation and psychological obstacles that arise from the problem. It is highlighted that the psychotherapeutic intervention, cognitive behavioral therapy is important in any case to reduce distress and negative affective thoughts along with the medical process.
Mr. and Ms. Albert: Problems of Premature Ejaculation Mr. and Ms. Albert have been married for 15 years. Mr. Albert works as a restaurateur and is a successful man, and Ms. Albert is a housewife who is committed to child rearing. Mr. Albert is 38 and Ms. Albert is 35 years old. Mr. Albert was always a perfectionist, and he always managed to achieve his goals. Additionally, it was important for Mr. Albert throughout his childhood to please his demanding father. Nevertheless, despite the fact that this couple seems to lead a decent life and are highly compatible, they are experiencing problems when they engage in sexual intercourse. The Presenting Problem This brings us to their presenting problem of Mr. and Ms. Albert’s. Ms. Albert states that she feels a constant frustration throughout their marriage, because Mr. Albert has been having a rapid ejaculation problem. This erectile dysfunction is a continuous disability to maintain an erection adequate enough to complete sexual activity (American Psychiatric Association, 2000). Specifically, Mr. Albert reaches orgasm either immediately upon entering his wife’s vagina or within one or two strokes, and this meets the criteria of premature ejaculation (Serefoglu, Cimen, Atmaca, & Balbay, 2010). As their problem has been happening every single time they engage in intercourse, Masters, Johnson and Kolodny (1994) stated that this is named premature or rapid ejaculation. Also, Mr. Albert does not have any control over when he ejaculates, which is another sign of premature ejaculation (Kaplan, 1974). Mr. Albert’s wife herself has no problems with becoming sexually aroused, and she believes that intercourse is the only method she could reach orgasm. This has resulted in Ms. Albert avoiding any mention of their problematic situation as she believes that rage would take over her, preventing her from properly expressing her feelings to Mr. Albert. For that reason, they have never tried other sexual techniques for pleasing each other and Ms. Albert completely blames Mr. Albert for his inability to control his ejaculation. Equally, it has been difficult for Mr. Albert to discuss his problem with his wife, because of the intense feeling of guilt and inadequacy he has. Communication is clearly lacking between Mr. and Ms. Albert, and so unresolved conflicts arise, further increasing both their stress levels.
Hypothesis
It is hypothesized that psychological factors are associated with Mr. Albert’s premature ejaculation. The problem is believed to be related to his previous experiences as a child. Specifically, Mr. Albert may have become accustomed to masturbating rapidly to avoid getting caught as a child because maybe masturbation was frowned upon by his parents. He also had a very demanding father, which may have contributed to the issue. Therefore, if during the first time he encountered sex he felt pressured to perform quickly, this could be the reason for rapid ejaculation now.
Assessment
If Mr. and Ms. Albert were to come and have a counseling session the question that would be addressed would be how Mr. Albert felt when he was younger and discovered his sexuality. Most boys usually experience their first ejaculation from a wet dream or masturbation. Conditioned rapid ejaculation is promoted by both personal and early sexual encounters, where foreplay may also be responsible for rapid ejaculation (Masters et al., 1994). Personal masturbatory experiences may be highly connected with Mr. Albert’s demanding father. It is likely that when he was a boy he had to speed up his ejaculation so that he would not get caught by any family members in the act. Therefore, talking about how Mr. Albert felt about his sexuality may help to identify a possible explanation for the condition.
The second question that arises is if Mr. Albert is anxious about something that has not been brought to the fore yet. Anxiety may contribute to Mr. Albert’s rapid ejaculation, such as performance anxiety, and excessively focusing on pleasing his partner (Frank, Anderson, & Kupfer, 1976; Muntjack & Kanno, 1976; Perelman & Rowland, 2006). It has been suggested that anxiety sustains sexual dysfunction in men (Strassberg, Mahoney, Schaugaard, & Hale, 1990). This is related to Mr. Albert as throughout his childhood he has been used to and learnt to constantly please his demanding father and he may have wanted to do the same to Mrs. Albert. And continuously failing to do so causes the increased stress within him every time. Nevertheless, the anxiety response may only be as a result of the initial dysfunction (Bancroft, 1989). Thus, his anxiety may have been prolonged because of his constant fail and blame from his wife for his dysfunction.
Model of Treatment An appropriate model of treatment is the psychotherapeutic approach. Traditionally, psychotherapy for rapid ejaculation focused primarily on improving ejaculatory control. It enabled men to reduce performance anxiety, clear out barriers of intimacy, and learn methods to postpone ejaculation, increase communication, and solve feelings or thoughts interfering with the dysfunction (Althof, 2003; Althof & Wieder, 2004). This psychotherapy helps men focus on their sexual excitement, which is something they are afraid doing. For example, they may try to distract themselves by solving mathematical computations during intercourse. This has been proven to be unsuccessful (Althof, 2006).
Interventions
Individual therapy would be essential to start with. In the presenting problem, the couple does not seem to communicate about the dysfunction at all. They both seemed to want to avoid talking about it and Mr. Albert’s wife is holding a grudge towards her husband, making Mr. Albert’s psychological state worse. Hence, individual therapy can address any issues from childhood that are unresolved (Althof, 2006). This is related to Mr. Albert and being one on one with the counselor can help him open up about his feelings and talk more about what else might be disturbing him without the presence of his wife. This is because Mr. Albert’s guilt and stress continuously pile up over time as he sees that his wife becomes frustrated whenever the subject of his dysfunction comes up. Moreover, it would be helpful to recommend Mr. Albert to get a check up from an urologist to see if there are any other biological problems Mr. Albert may have (Rowland & Cooper, 2011), if he has not gone to one already. As Mr. Albert’s dysfunction is life-long, conjoint therapy is necessary (Althof, 2006). However in this case, both partners have to be willing to pursue treatment. During this type of therapy, the therapist can clearly explain the maintaining factors and what effect Mr. Albert’s dysfunction has on both of them. Following that, the appropriate interventions can be carried out. It is important for both of the Alberts to be psychoeducated, and especially Ms. Albert, to see what her husband’s problem is about and that it is rather common among men (Dunn, Jordan, Croft, & Assendelft, 2002; Laumann & Rosen, 1999; Mercer, Fenton, Johnson, Wellings, Macdowall, McManus, et al., 2003). As behavioral techniques of Masters and Johnson (1970) showed that early success was reported (97%) for reducing rapid ejaculation, it was found that their study could not be replicated and overall, their evidence was inconsistent and weak (Melnik, Althof, Atallah, Puga, Glina, & Riena, 2011). Therefore, a recommended psychotherapeutic technique for Mr. Albert would be Cognitive Behavioral Therapy (CBT). CBT has proven to be effective for resolving a variety of emotional problems (Hoifodt, Strom, Kolstrup, Eisemann, & Waterloo, 2011; Soltanizadeh, Neshatdoust, Kalantari, & Salehi, 2012). The theory that underlies CBT is that what we think directly affects our feelings. So, the therapist’s aim is to help Mr. Albert recognize that his thoughts of inadequacy and guilt are very unhelpful and untrue. These are the Negative Automatic Thoughts (NATs) one creates for themselves (Neenan & Dryden, 2004). NATs are what cause anxiety and distress (emotional problems) and these are eventually replaced as part of the method with other helpful, more positive ways of thinking about the situation. In this case of Mr. Albert’s situation, NATs can help him increase his sexual confidence. Furthermore, because of Mr. Albert’s life-long problem, it would be more effective if pharmacological and psychological therapy were combined (Althof, 2010; Porst, 2011), and of course with the motivation of both partners. Pharmacotherapy has the ability to delay ejaculation effectively. This in turn can increase Mr. Albert’s sexual confidence over time and possibly reduce the bitterness Ms. Albert feels towards her husband. The medicine can help Mr. and Ms. Albert build up some courage to try engaging in intercourse again and psychological therapy can help the couple pass the psychological obstacles that might prevent them from using the medical intervention effectively. The kind of medicine that is usually prescribed is off-label administration of selective serotonin reuptake inhibitors (SSRIs) and these are usually prescribed to postpone ejaculation (Waldinger, Zwinderman, Schweitzer, & Oliver, 2004). The first choice of medication is commonly Dapoxetine, which has been found to have the greatest efficacy compared to other medication, such as Fluoxetine and Citalopram (Porst, 2011). However, because it is quite expensive and has lack of recognition for ejaculatory dysfunction, it is still not used very much yet (Porst, 2011). It is expected that the therapy will trigger some resistance at least from the patient or the couple (Mitchell, 2005). Specifically, it is quite difficult for the individual to get out of their comfort zone, even though their behavior is maladaptive. Nonetheless, this can be overcome gradually by the therapist changing the technique of trying to influence the client instead of directly fighting with them. This is to avoid energy wasting of disagreeing with what should be done, and figure out a more ideal technique of what should be followed (Mitchell, 2005). Because Mr. Albert’s premature ejaculation case if life-long, he may never be able to drop pharmacological therapy, but Mr. and Ms. Albert can somewhat feel they can more or less return to a more ‘normal’ way of having sexual intercourse. This intervention is directive, provides the couple with advice while educating them about the problem and the couple uses certain techniques to help them overcome the issue.
Conclusions
Psychological treatment is still important for treating men and couples who experience problems of rapid ejaculation. The man who has the problem of rapid ejaculation becomes very stressful and anxious, and this is the same for their partner. Sexual and relationship satisfaction can be improved through psychotherapy and combined pharmacotherapy with psychotherapy. For Mr. Albert’s life-long premature ejaculation problem, medical therapy needs to be done as psychotherapy alone would not improve the dysfunction. CBT can help along with the medication to change Mr. Albert’s negative thoughts about himself and increase his sexual confidence.

References
Althof, S. E. (2003). Therapeutic weaving: The integration of treatment techniques. In S. Levine, C. Risen, & S. Althof (Eds.), Handbook of clinical sexuality for mental health professionals (pp. 359-376). New York, NY: Bruner-Routledge.
Althof, S. E. (2006). The psychology of premature ejaculation: Therapies and consequences. The Journal of Sexual Medicine, 3(4), 324,331. doi: 10.1111/j.1743-6109.2006.00308.x
Althof, S. E. (2010). What’s new in sex therapy. Journal of Sexual Medicine, 7(1), 5-13. doi: 10.1111/j.1743-6109.2009.01433.x
Althof, S. E., & Wieder, M. (2004). Psychotherapy for erectile dysfunction: Now more relevant than ever. Endocrine, 23(2-3), 131-134. doi: 10.1385/ENDO:23:2-3:131
American Psychiatric Association: DSMIV-TR. (2000), Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Association.
Bancroft, J. (1989). Human sexuality and its problems. Edinburgh, UK: Churchill Livingstone.
Dunn, K. M., Jordan, K., Croft, P. R., & Assendelft, W. J. J. (2002). Systematic review of sexual problems: Epidemiology and methodology. Journal of Sex and Marital Therapy, 28(5), 399-422. doi: 10.1080/00926230290001529
Frank, E., Anderson, C., & Kupfer, D. J. (1976). Profiles of couples seeking sex therapy and marital therapy. American Journal of Psychiatry, 133(2), 559–562.
Hoifodt, R. S., Strom, C., Kolstrup, N., Eisemann, M., & Waterloo, K. (2011). Effectiveness of cognitive behavioral therapy in primary health care: A review. Family Practice, 1(1), 1-16. doi: 10.1093/fampra/cmr017
Kaplan, H. S. (1974). The classification of the female sexual dysfunctions. Journal of Sex and Marital Therapy, 1(2), 124-138. doi: 10.1080/00926237408405280
Laumann, E. O., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. Journal of the American Medicine Association, 281(2), 537-444.
Masters, W. H, & Johnson, V. (1970). Human sexual inadequacy. Boston, MA: Little Brown.
Masters, W. H., Johnson, W. E., & Kolodny, R. C. (1994). Heterosexuality. New York, NY: HarperCollins.
Melnik, T., Althof, S., Atallah, A. N., Puga, M. E., Glina, S., & Riera, R. (2011). Psychological interventions for premature ejaculation. Cochrane Database of Systematic Reviews, 10(8), 81-95. doi: 10.1002/14651858.pub2
Mercer, C. H., Fenton, K. A., Johnson, A. M., Wellings, K., Macdowall, W., McManus, S., Nanchahal, K., et al. (2003). Sexual function problems and health seeking behavior in Britain: A probability survey. The Lancet, 365(9466), 1246-1255. doi: 10.1016/S0140-6736(05)74813-3
Mitchell, C. W. (1999). Understanding and managing client resistance: Letting go to gain control. Retrieved from http://www.cliftonmitchell.com/Articles2.html
Muntjack, D. J., & Kanno, P. H. (1979). Retarded ejaculation: A review. Archives of Sexual Behavior, 8(2), 138-151.
Neenan, M., & Dryden, N. (2004). Cognitive therapy: 100 key points and techniques. New York, NY: Routledge.
Perelman, M. A., & Rowland, D. L. (2006). Retarded ejaculation. World Journal of Urology, 24(6), 645-652. doi: 10.1007/s00345-006-0127-6
Porst, N. (2011). An overview of pharmacotherapy in premature ejaculation. Journal of Sexual Medicine, 8(4), 335-341. doi: 10.1111/j.2011.02451.x
Rowland, D., & Cooper, S. (2011). Practical tips for sexual counseling and psychotherapy in premature ejaculation. Journal of Sexual Medicine, 8(4), 342-352. doi: 10.1111/j.1743-6109.2011.02367
Serefoglu, E. C., Cimen, H. I., Atmara, A. F., & Balbay, M. D. (2010). The distribution of patients who seek treatment for the complaint of ejaculating prematurely according to the four premature ejaculation syndromes. Journal of Sexual Medicine, 7(2), 810-815. doi: 10.1111/j.1743-6109.2009.01570
Soltanizadeh, M., Neshatdoust, H. T., Kalantari, M., Salehi, M., & Izadpanahi, M. H. (2012). Effectiveness of cognitive behavioral therapy on premature ejaculation in an Iranian sample. Interdisciplinary Journal of Contemporary Research in Business, 4(6), 491-503.
Strassberg, D. S., Mahoney, J. M., Schaugaard, M., & Hale, V. E. (1990). The role of anxiety in premature ejaculation: A psychophysiological model. Archives of Sexual Behavior, 19(3), 251-257. doi: 10.1007/BF01541550
Waldinger, M. D., Zwinderman, A. H., Schweitzer, D. H., & Oliver, B. (2004). Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: A systematic review and meta-analysis. International Journal of Impotence Research, 16(1), 369-381. doi: 10.1038/sj.ijir.3901172