Lonnie Barbach on Sex Therapy

Lonnie Barbach on Sex Therapy

by David Bullard

Renowned author, psychologist and sex therapist Lonnie Barbach discusses the early days of discovery in the human sexuality field, her pioneering work with preorgasmic women, and addressing sexual issues in individual and couples therapy.
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Early Years of The Human Sexuality Program

David Bullard: Lonnie, as we start this interview I should acknowledge that we’ve known each other a long time as friends and colleagues.
Lonnie Barbach: Well, we met in late 1974 at the Human Sexuality Program at the University of California at San Francisco—that is a while ago!
DB: Yes, and you were one of my post-doctoral instructors, along with Jay Mann, Bernie Zilbergeld, Harvey Caplan, and Rebecca Black. Actually, you all were more important therapist role models to me than anyone I had encountered in graduate school.  And it was an exciting time to see how you all were bringing a kind of San Francisco humanism to sex therapy.
LB: That was an incredibly exciting time in human sexuality research and therapy and it led me to write my first book.
DB: Yes, For Yourself  was your timely and incredibly successful book that empowered women to take charge of their own sexual pleasure.  Not to linger too much in the past, but are there any impressions you can share when you think back to those days of the UCSF Human Sexuality Program, which for awhile was the largest training program in the country for psychotherapists, physicians and nurses in the newly-emerging field of sex therapy, post-Masters and Johnson.
LB: Well, for me, it changed my life; it was a pretty formative and important time. I didn't fully appreciate its significance at the time, but I knew that it was exciting.

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DB: You graduated with a doctorate in psychology from the Wright Institute.
LB: I had done everything but my dissertation when I began at UCSF. I ended up designing this format for pre-orgasmic women's groups at UC, Berkeley where I worked with a small group of UC students in women's consciousness-raising groups using masturbation as a learning technique, but no one believed this form of therapy could work with middle-class housewives! So I was challenged and had to find a different environment in which to do my dissertation research.  Jay Mann was a psychologist and director of the HSP at UCSF and he said, “Well, if you pay us rent to use the space, you can run your research groups out of here and be under the umbrella of UCSF.” Then, as part of recruiting subjects, I was a guest on Don Chamberlin’s radio talk show called “California Girls.”  Thereafter, whenever someone mentioned having an orgasm problem, he would refer them to me. Within a few months, I had hundreds of women on a waiting list at UCSF.
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Women’s Preorgasmic Groups

DB: So his show really jump-started your work with women’s preorgasmic groups.  Prior to your contributions, the professional diagnostic terms for a woman who had never or rarely had orgasm were “nonorgasmic” or “frigid.” Your use of “preorgasmic” instantly re-set more hopeful expectations and dropped the pejorative labels that almost all women had been oppressed by one way or another.
LB: Yes.  The semantics were oppressive, and we had to push over several years to get the medical and psychological establishment to drop those old labels. 
There was a great need in our society for people to drop shame about their sexuality in order to enjoy it….
There was a great need in our society for people to drop shame about their sexuality in order to enjoy it and for general self-acceptance. I learned a lot from the women in the groups--they were my teachers also. After completing three research groups with great results, I suddenly had this large number of women wanting help, so Jay Mann suggested we do a large group educational program. By then he realized that UCSF would earn more if they hired me and directly took in the money the women were being charged rather than my just paying them rent.  So I was brought on as co-director of clinical training in charge of their first women's program; later they added a men's program that Bernie Zilbergeld headed.
DB: You and I were both in graduate school in that era and I can remember what a powerful idea this was: empowering women to learn to take charge of and enjoy their own sexuality.  
LB: And I didn't realize that at first! All I knew was that I needed a job. It was actually a fluke that I even got into the field of sexuality. A woman came to a volunteer educational program I was leading for Planned Parenthood. At the end she said “you really should apply for my job because I'm leaving a position at UC, Berkeley as a sex therapist.” I was trying to finish my education at that point and really needed to earn some income. Two male colleagues of mine, Jim Purcell and Bob Cantor, both agreed they would do Masters and Johnson couples therapy counseling with me.  In that format, you needed both a female and male therapist for one couple. We got the job and I read the few books that were out and talked to everyone who knew anything about sex therapy, although there weren’t many of them at that time.  Shortly, Jim and Bob told me that they were too involved with their other jobs and graduate work and had no time to do the couples sex therapy. So I had a job I could not do as a single female. 
 
At the same time six women who also had no partners applied for sex therapy at the student health service. Some were single, some had partners but the partner wasn’t willing to come into therapy.  And one woman was faking orgasm and didn’t want her partner to know. Women’s consciousness-raising was really big at the time.  It seemed to me that Lo Piccolo and Lobitz's nine-step masturbation program could be used in a consciousness-raising group format.  So I tried it and led the first group with Nancy Carlson. Our first group was ten sessions long and we only had five weeks in order to fit it in between midterm and final exams! They were all “primary pre-orgasmic” women (never having experienced an orgasm by any means); by the end of this group they were all orgasmic by themselves and most of them were also orgasmic during sex with a partner. That was the beginning…. and if I had been on the East Coast, I probably never would have done anything more because, as I learned later, other professionals couldn't believe what I was doing out here--there was really a negative, critical reaction to working with women in groups and teaching them masturbation. But I was in California! So it all grew and developed.
DB: LoPiccolo and Lobitz had used this behavioral approach only in individual therapy?
LB: Yes. And then Jay Mann said I should write a book about this approach.  “But this stuff is so basic,” I said, and while he agreed, he believed that women needed permission to approach it so simply. So he was entirely responsible for my writing career. 
DB: Well, many therapists have ideas and talk about writing books, but actualizing it is quite a different matter!
LB: The power of the book is that it gives permission to women and to their partners to explore themselves. I did not realize that this was so needed because I did not come from a particularly sex negative or repressive family or religious background, so sex seemed natural and normal to me.
DB: And you were a couple of years ahead of the publication of Jack Annon’s book, in which he spoke about the PLISSIT (Permission, Limited Information, Specific Suggestions, and Intensive Therapy) model. 
LB: Yes, his wonderful book, The Behavioral Treatment of Sexual Problems, came out in 1976.
DB: How many copies of For Yourself have sold and in how many languages?
LB: It has been translated into 8 languages and a couple of million copies have been sold worldwide. I don't keep track of the numbers, but I do know that I’ve sold over 4 million copies of the total of my books in the United States.
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A Career in Human Sexuality

DB:  I hope you don’t mind if I repeat a comment made at a professional meeting, when you were introduced as the person who has been responsible for more female orgasms than anyone else in human history!
LB: Yes that was either Bernie Zilbergeld or Jay Mann; it was very funny.
DB: That has led to a long career and interest in couples and sexuality, as well as in individual therapy. You do everything in your private practice.
LB: You can't separate out sex from a person’s life context. So we go into the psychological issues, the relationship issues, and perhaps the medical or physiological and neurophysiological issues.  Half the time it's not just a sexual issue but also a relationship issue. So that is the majority of my work.
DB: I don't imagine you've done a women's group in a long time.
LB: Probably not for 25 years. Group therapy is not as popular as it used to be and it's difficult to get a group together around one particular sexual issue. And it is not as needed. More basic information and permission about sexuality is now out there in every Cosmopolitan issue and in many books and the media in general. The culture is more open to the topic of sex.
DB: It's interesting to see how psychological issues evolve over time as a result of the culture changing, not just from research findings and technical changes.
LB:  
Yes, for example, trans-gendered, gay and lesbian issues are being discussed in high schools and now most people have a friend or cousin in one of these sexual minority groups because people are more open about it so it has become more natural. Look at the opportunities given to all of us to learn about other ways of being human that television and the internet have brought to us.  The culture is more accepting and it's infiltrating into the job market and the military.
DB: You wear several hats that I know of:  you have a partner and colleague of 26 years in David Geisinger, you are a mother of a wonderful daughter, you are a therapist with a private practice, you are a lecturer and workshop leader, and are an author and writer….
LB: And I used to be a producer of educational as well as erotic films.  I was a consultant for K-Y [a manufacturer of personal lubricants]. And a teacher at UCSF and at Antioch West.
DB: You then focused on male sexuality and couples sexuality as well.
LB: One thing just naturally led to another.
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Couples Therapy

DB: Switching to your couples work and sexuality, are there any particular influences other than your own ongoing work with clients?
LB: I’m process oriented. For example, there can be a negative kind of power or withholding.
Not wanting sex and/or not having orgasms can be powerful ways of impacting the relationship, especially if there is a power imbalance in the relationship.
Not wanting sex and/or not having orgasms can be powerful ways of impacting the relationship, especially if there is a power imbalance in the relationship. If the man seems more powerful and has a larger personality, this negative withholding may be a way for her to balance out the power. So I tend to look at and work with the system in a relationship although power may be only one aspect of it. If one person is more forward, talking a lot, I may have them talk less and have the partner talk more. You have to move the process of the relationship in therapy. David and I wrote a book together called Going the Distance, Finding and Keeping Lifelong Love and in that we described our theory of working with couples and it has deepened over the years. Since then, other therapists have come up with similar approaches, such as Sue Johnson’s Emotionally Focused Therapy. The main premise is that intimacy is no better than the dialogue between two people and the dialogue has to be one based on vulnerability, so an important task is to help couples learn to be vulnerable and to make it safe to be vulnerable in their relationship. You look underneath anger for the more vulnerable feelings and help them express what's going on at that level so that people can hear each other and really respond without being pushed away and without getting defensive. It works really well.
DB: When you give a talk to graduate students who are interested in couples therapy, what particular ideas do you suggest, especially for dealing with any sexuality component their clients may be struggling with?
LB: One reason I think couples therapy is fascinating is that there are so many parts: each partner has his or her relationship history, each has their own personality issues, and then there are the ways they fit together. This is true for all aspects of their relationship including their sexual relationship. So I would suggest dealing with sex in the same way you deal with other issues: talk about it directly and specifically. See how early history may be contributing; how their relationship dynamics such as power struggles or just plain chemistry may be contributing, in addition to taking in real-life practical constraints such as job stress, children, medical issues etc. So it's wonderfully complicated and you play with that in order to get change and that’s all fascinating to me.
DB: Your enthusiasm and passion for working with couples is evident. I'm glad you also use the word “complicated” to describe couples work.   I have another very successful psychotherapy colleague who has written several books on therapy but doesn’t do couples therapy, saying “They are too complicated.” And you're now saying couples are “wonderfully complicated”!
LB: I have a road map in my head when I'm working with a couple and it’s a lot like writing a book. I know where I’m headed and I’m trying to figure out best how to work with them to get there. I believe that an intimate relationship is really the place where people can be healed most effectively--where emotional wounds are healed. So you are involved in a process where each partner is able to heal the other.
DB: Does that mean you've seen instances where you see an individual as part of a couple who might've been somewhat or completely resistant to individual therapy, but within the couples therapy format, that person was healed and got what they needed? Perhaps they could not have gone to or been successful in individual therapy.
LB: Absolutely! And sometimes with couples I also like to see them individually for a session here or there if there are individual issues that are contributing and both partners are very reactive to each other, and they take the other’s feelings too personally. So the couple dynamic comes into play when the reactivity keeps us from going deeper in the couples work. An individual session with that person may bring some clarity so they may be less reactive to their partner’s words.
 
If I were to speak with graduate students, I would suggest that they not start out with couples. As we’ve discussed, it is very complicated. One of my first internships was working at a Synanon-type program at Oak Knoll Naval Base in Oakland. I was working with drug users who were pretty hardcore. I had standard intern responsibilities and was the only female on the ward. I was also leading a couples group for the men and their wives or girlfriends. I was so lost that the guys kept having to explain to me what was going on! I was so over my head. I loved working with the guys and actually signed up for a second go around--the learning was amazing.  However, I would recommend you learn psychotherapy with individuals first and get comfortable with that before attempting work with couples.
 
When I do individual work, I’m always thinking about what is going on with my client’s partner, presuming innocence about them and not just seeing things from my client’s point of view. Also if you're not comfortable talking about sex, you are really limited in the kind of help that you can give couples because so many couples with relationship problems have sexual problems. I've had people come to see me who say, “I went and saw a couples therapist but when I talked about sexual stuff he said, ‘I don't do that’" and they were referred to me.
You're very limited in the kind of intimacy work you can do if you are not comfortable dealing with sex.
You're very limited in the kind of intimacy work you can do if you are not comfortable dealing with sex. The more depth and breath in your skills, the more you can be of assistance to the people you work with.
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Sexual Issues in Therapy

DB: Can you give any advice to graduate students and therapists who may feel they have not had enough sexual experience themselves, or somehow feel that their sexual life is not up to some standard, or are just uncomfortable and may have a taboo sense of talking about sex. Any recommendations?
LB: I would say to people to read the books that are out there to get the basic information. Read Bernie Zilbergeld’s book The New Male Sexuality - still the best male sexuality book that's out there. Read For Yourself and For Each Other. Read a book on menopause, like The Pause. Read The Sexual Healing Journey by Wendy Maltz on sexual abuse and about sex and aging so you know about the changes people experience in their sexuality. 
 
And then explore experiential exercises within a graduate program or workshop, such as sex history giving and taking. It can really help to be in a course situation where students ask each other and inquire into the specifics of someone's sexual history and life. Or just practice taking sex histories with friends or lovers. The idea is to get more comfortable talking explicitly about sex.  Most of us need to get over feelings of shame that we are different or not normal or we may be otherwise anxious because we are comparing ourselves to some mythology about others. The more information we have, the more we realize that sexuality has a huge range. It’s not about right or wrong or better or worse, but what is right for the individual person and how their body functions and how they fit with their partner.
DB: In the beginning of the sex therapy revolution in the 1960s and 70s, the focus was on the sexual dysfunctions: erection problems, orgasm problems, ejaculation problems. Over time, desire problems seem to have become preeminent for couples. Is that what you're seeing in your work?
LB: Every now and then I'll get a rapid ejaculator or someone who's not having erections or orgasms. But the vast majority of the people I see are concerned with their lack of sexual desire. There are so many causes for a lack of desire: relationship and communication problems are the most common cause, then there is menopause, lack of chemistry, poor sexual communication, interfering medications, etc. etc.  Half the problem is figuring out the cause.  For example, psychotherapy won’t work if the problem is caused by low testosterone.
DB: So much of you and your work has been showcased in the media, that I have to ask what it was like for you to be on shows like Oprah?
LB: Well, she was lovely, but the most memorable show I did was the Phil Donohue Show.  Before the show he came and said, “ Look, you're the only guest for this hour but I'll be out there with you. You’re not alone.” It was great to have a whole hour on TV with nothing but questions from the audience that I could address. At one point, Donahue started going off on something and then he stopped, looked at me, and said “Can you help me out here?” So I jumped in.  I figured, you’re going to help me, I’m going to help you. It was such a lovely relationship working with him. The questions from the audience were so real. There was one eight-month pregnant woman who asked about sex during pregnancy, “What can you do?” And I got to talk about oral sex and manual stimulation and all sorts of things on national television. So it was a great educational opportunity.
DB: On regular network television! Was anything bleeped?
LB: No nothing was bleeped at all, and a friend who had seen it called me up later to say, “I can't believe on national television you were talking about hand-jobs and blow-jobs.” Not with that language, but that's what happened. On Oprah, other guests get in the discussion and it goes in different directions so you don't get into the depth of coverage and aren’t able to educate the same way that I was able to with the Donahue show.
DB: I'm thinking of the cultural changes. In 1959 on the Jack Paar Tonight Show, they bleeped the word “pregnant!” And years later you get on television and are able to talk about hand-jobs and blow-jobs! 
LB: I have done maybe 20 book tours over the years, and I still remember that at one live local morning show in Seattle, I think, the interviewer asked me, “How do you have oral sex?” I asked her “Do you want me to describe it right now on the air?”  And she said “Yes, I think that would be educational for our viewers.” So I said,“Okay” and I explained how to have oral sex. I gave a “how to.” So that was the most startling for me. At another show the female host of the program introduced me as being responsible for her own first orgasm.
DB: Wonderful!
LB: Yes, it was very sweet.
DB: Is there a current book project that you're working on?
LB: I may have waited too long to actually put a book together, but I'm working a lot in the area of sex after 60.  Also, David [Geisinger] and I have a second book on relationships that we need to write, but haven’t had the time to get to. 
DB: Speaking in generalities, perhaps, is there one overall sense you have of what helps couples feel better about their sexuality?
LB: Self-acceptance and connection. First, you need to feel connected to your partner, to feel safe with them and cared for by them and turned on to them.  Second, the more compassion you have for yourself and the more self-acceptance, the more comfortable you are with yourself the more comfortable you are likely to be with your partner and the better your sexual relationship is likely to be. It all fits together. 
DB: Do you routinely get detailed sex histories from each person you work with?
LB: I get my own kind of sex history from a person. I don't get a formulaic one, because I think a lot of it's just not relevant. I follow my intuition, but almost always ask about the person’s first sexual experience, relevant previous sexual relationships and look for any kind of molestation or negative sexual experience or trauma. Trauma of any kind can affect a sexual relationship. I also want to know about the initial sexual experiences with their current partner. Absent a history of abuse, if the sex with this person was never good, if there was never any chemistry, I find it very difficult, if not impossible, to create it down the line.
DB: For couples therapy, do you do this sex history individually?
LB: Yes, I find it easier for people to open up completely when I meet with them alone and I may learn about other significant sexual experiences or problems within the current sexual relationship that the person might not be open about in the presence of their partner.
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Buddhism and Other Influences

DB:  What aspects of Buddhist psychology and philosophy have you found helpful and intriguing?
LB: I would say that Buddhist philosophy makes sense to me. It’s fairly new to me as I've only been working in a meditation group for 3 years, so I don’t claim to be terribly knowledgeable. Certainly, the Buddhist concept of suffering has been useful in my practice; that we all have to endure suffering but that we actually create suffering through our attachment to impermanent things.  Meditation is very useful with a lot of my clients, especially those who are very reactive. So I teach my clients how to meditate and how to be more in the moment.  Also the importance of compassion for oneself and others. And the necessity of presuming your partner innocent before getting upset at them. I’m not sure this last one is specifically Buddhist in origin, but it seems that way to me. 
DB: How do you approach suggesting meditation techniques?
LB: I just say, “Try this,” then I give them a short hypnotic induction, and have them focus on their breath, especially that peaceful and spacious moment after the exhale and before the next inhale.  I explain how it can help them and work with them on incorporating it into their daily lives. I also find EMDR useful, especially with sexually abused clients
DB: You've also been interested in and studied NLP (Neuro Linguistic Programming).
LB: NLP works very well for me.  NLP and EMDR are both techniques, where as Buddhism is a philosophy and psychology.  I keep a whole store of Silly Bandz, which are these little colored rubber bands which come in different colors and shapes. I have clients put one on their wrist and use it to remind them to practice whatever we have been working on to help them stay aware of.  
DB: They don't have to snap it like the old behavioral aversive technique?
LB: No, it is just an awareness enhancement.  For example, maybe you say “yes” to the requests of others automatically; and since you may not even realize it, it can be hard to break that pattern. The Silly Bandz can help someone in between our sessions to stay conscious of what we are working on.
DB: Is there an overall sense you have of what helps people change in couples therapy?
LB: I believe we can start to move when we have compassion for ourselves, our defenses go down, we can relax, be more ourselves, and be more present in our relationship. Of course, there are also physical issues to stay aware of.  For example, since we've gotten Viagra, Cialis and Levitra, there are a lot fewer erection problems that I see. Sometimes men may have low testosterone and other medical or physical issues. And then we have relationship issues.
DB: No drug for that yet? 
LB: Not yet one for women.  Let’s end with a New Yorker cartoon I’ve seen: A couple is lying in bed, next to each other with their arms crossed. And the woman says, “I wish they would develop a pill for conversation.”
DB: I’ll trade you:  I saw a cartoon with a husband and wife where she has her arm around him, looking at him and she says, “I would agree with you Leroy, but that would make us both wrong.” Lonnie, thank you so much for allowing us to get a sense of what it is like to be doing the kind of work that you have done and are doing. 
LB: The pleasure was all mine.

© 2011, David Bullard, PhD
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Lonnie  Barbach

For the past 35 years, Lonnie Barbach, PhD, has been one of the most prolific and influential contributors to our understanding of how to help women and men enjoy the discovery of their sexuality and intimacy. Her dozen books, translated into an equal number of languages, have sold over 4 million copies in the U.S. alone. She has appeared on hundreds of local radio and television programs as well as most nationally televised talk shows, including Oprah, Good Morning America, The Today Show, CBS Morning News, Phil Donohue and Charlie Rose. She has a private practice of individual psychotherapy and couples therapy in San Francisco and Mill Valley, CA. Her website is lonniebarbach.com.

David Bullard, Ph.D., David has had a private practice of individual psychotherapy and couples therapy in San Francisco since 1976. He is a clinical professor in departments of medicine and psychiatry and a member of the professional advisory group of Spiritual Care Services at the University of California, San Francisco, and is a consultant for the Symptom Management Service (outpatient palliative care) at UCSF’s Helen Diller Family Cancer Center. His latest professional publication is the chapter “Sexual Problems” (co-authored with the late Harvey Caplan, M.D., and with Christine Derzko, M.D.) in Behavioral Medicine: A Guide for Clinical Practice, 4th edition (2014; McGraw-Hill). He has previously published interviews for psychotherapy.net with Allan Schore, Ph.D.; Bessel van der Kolk, M.D.; Mark Epstein, M.D.; Ida Gorbis, Ph.D.; George Silberschatz, Ph.D.; and Lonnie Barbach, Ph.D.; and also has written about conversations with Tibetan Buddhist scholar Robert Thurman, Ph.D.
This was a excellent interview of Lonnie Barbach by David Bullard. I particularly enjoyed reading about the early years and development of the Human Sexuality Program, and how radical and ahead of her times Lonnie Barbach was at the time. I also appreciated how easily I earned 1 CEU because of how well designed this site is for navigating that process with ease. Bravo to Lonnie, David and psychotherapy.net!
Gilda Meyers, LMFT
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