Annon 2015
Annon 2015
Annon 2015
Jack S. Annon
To cite this article: Jack S. Annon (1976) The PLISSIT Model: A Proposed Conceptual Scheme
for the Behavioral Treatment of Sexual Problems, Journal of Sex Education and Therapy, 2:1, 1-15
Article views: 17
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JOURNAL OF SEX EDUCATION AND THERAPY
problems has been known to be costly and assessment only to have their clients all go
time consuming, and, in the past, the through the exact same therapy program.
prognosis for change was not very encour- In such standardized programs it is difficult
aging. With the advent of a learning ori- to see what purpose the initial intensive
ented, or behavioral approach to treat- assessment serves.
ment, more successful therapeutic results It should also be made clear that the
have been obtained in resolving such prob- current stress by many behavior therapists
lems that have long been known to be on a broad spectrum approach to therapy
resistant to other forms of therapy. Al- has no virtue unless there is some theoreti-
though this model has produced some cally based plan for the ordering and
promising results, its application to sexual selection of appropriate treatment tech-
disorders has been relatively recent, and niques from among the various therapeutic
there is a clear need for a broad spectrum interventions now available. Without such a
approach which allows the clinician a wide plan, broad spectrum treatment is just as
range of therapeutic procedures for imple- much a shotgun approach as is using the
menting his treatment strategy. On the same one or two procedures for all prob-
other hand, use of a particular procedure lems. As a step in this direction, and due to
just because it is available is obviously not the prevalence of sexual problems and the
therapeutically justified. Careful assess- difficulties associated with their resolution,
ment of relevant factors in the client's life, it was considered of practical as well as
history, and environment should dictate theoretical value to design and carry out a
which treatment procedure to use for study to investigate methods of assessment
which aspect of the client's problem in a and treatment in this area.
given social setting.
In other words, initial assessment should Research Background
have a direct relationship to the treatment Such research was carried out (Annon,
procedures used. Contrast this approach 1971) with the goal of developing, testing,
with that of many sex therapy clinics who and refining a conceptual scheme for the
Dr. Annon is Senior Consultant with the Sexual Counseling Service, Department of Obstetrics and
Gynecology, School of Medicine; and on the Affiliate Graduate Faculty, Department of Psychology,
both at the University of Hawaii in Honolulu.
*Paper presented at the Annual Meeting of the Society for the Scientific Study of Sex, Las Vegas,
November, 1974.
Spring-Summer, 1976 1
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ordering of sexual problems and their those settings where the client could not be
treatment from within a learning theory seen on an ongoing, possibly long term
framework. The major conclusion of the basis, (b) effective use of the system was
research was that an initial analysis of a restricted to those who had a thorough
client's sexual problem from within the knowledge of learning theory together with
A-R-D framework advanced by Staats relevant training and experience in be-
{1968, 1970) followed by a behavioral havioral methods of treatment, and (c)
diagnosis of relevant behavioral repertoires, even those with suitable training and ex-
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offered the most promising learning based perience who worked in settings where
approach for the ordering of sexual con- they had sufficient time available reported
cerns and the development of appropriate that the use of the scheme was often
therapeutic strategies. unnecessary for treating some of the more
This conclusion was based on a number common problems such as those concerned
of considerations. The use of the scheme with arousal, ejaculation, erection, or
offered a plan for simultaneously consider- orgasm.
ing the full range of circumstances that In sum, the conceptual scheme was
might be related to the client's problem. appropriate for those problems requiring
Such an approach also allowed for the intensive therapy, but not for those which
ordering of priorities for intervention and could profit from a brief therapy approach.
provided guidance for the timing of mul- What was needed was a more flexible and
tiple interventions. Finally, the use of such comprehensive scheme that could be
a conceptual scheme was not tied to any adapted to many settings and to whatever
particular behavioral technique or proce- client time was available. To be most
dure, but fostered the development of effective such a plan should also be able to
efficient procedures based upon theoretical be used by a wide variety of people in the
analysis. helping professions and allow for a range of
treatment choices geared to the level of
Clinical Background competence of the individual clinician.
Use of the conceptual scheme in clinical Ideally, the approach also needed to pro-
practice provided additional evidence that vide a framework for screening out and
the approach was highly effective in devel- treating those problems that would be
oping and ordering relevant interventions responsive to brief therapy approaches and
resulting in positive outcomes, particularly those that would require intensive therapy.
with those sexual problems of long term After further experience in devising and
duration (e.g., pedophilic, transsexual, fe- testing a number of different plans in
tishistic, etc.). However, as others at- diverse settings with a variety of sexual
tempted to use the approach in different problems, a conceptual scheme that looked
settings with different problems, it grad- promising was finally developed . This ten-
ually became apparent that the scheme was tative scheme was then shared and taught
not always appropriate, and there seemed to others, and , after further refinement,
to be three main reasons for this situation: the final model emerged. Since that time
(a) use of the system was not suited to this model has been passed on to others via
2 Spring-Summer, 1976
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lectures, courses, consultations, workshops, variety of clinical settings. Let each line in
and training programs. It appears that Figure 1 represent the different presenting
many in the helping professions have found sexual concerns that a particular clinician
it to be useful, as it is currently being encounters over time. Depending upon his
employed by: health aides, clergymen, setting, profession, and specialty, these
nurses, paraprofessionals in a range of problems may represent what he meets in
disciplines, physicians from diverse special- one day , one month, one year, or even one
ties, practical nurses, psychiatrists, psychol- professional lifetime. For reasons pre-
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Spring-Summer, 1976 3
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ing their knowledge, training, and skill at the thought that there may be something
each level. The remainder of this paper will "wrong" or "bad" with what they are
be devoted to brief practical suggestions on doing. Frequently, clients just want an
how to apply the four levels of treatment. interested professional to act as a sounding
board for checking out their concerns. In
other cases, the clinician can let them
The First Level of Treatment: know that they are not alone or unusual in
Permission their concerns and that many people share
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Sometimes, all that people want to them. Reassurance that they are normal
know is that they are normal, that they are and permission to continue doing exactly
okay, that they are not "perverted," "de- what they have been doing is sufficient in
viated," or "abnormal," and that there is some cases to resolve what might eventu-
nothing wrong with them. Mostly, they ally become a very major problem. Thus,
would like to fmd this out from someone permission giving can also be seen as a
with a professional background or from preventive measure as well as a treatment
someone who is in a position of authority technique. Permission giving will certainly
to know. Many times these people are not not solve all sexual problems, or even many
bothered by the specific behavior that they such problems, but it will resolve some as
are engaging in, but they are bothered by Figure 2 suggests. Furthermore, it has the
Brief
Therapy
Intensive
Therapy
4 Spring-Summer, 1976
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advantage in that, provided that there is sion glVlng is also sufficient to stop the
some measure of privacy, it can be used in recurring sexual dream that was associated
almost any setting at any time, whether it with anxiety, just as it can alleviate the
may be at a cocktail party, a business persistent thought or fantasy.
luncheon, or a private practice office. It
also takes minimal preparation on the part Feelings. It is not uncommon for people
of the clinician. Finally, it may be used to to respond with anxiety when they experi-
cover a number of areas of concern, such as ence sexual arousal to what they consider
thoughts, fantasies, dreams, and feelings, as inappropriate stimulation. Many of these
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Spring-Summer, 1976 5
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but now they begin to worry whether they most appropriate and helpful when it is
are "normal," "oversexed," or "under- used in direct relation to the client's goals.
sexed." A response by the clinician that in Keeping this in mind will make it easier for
essence gives them permission to continue the clinician to decide what form of
with their own preferred frequency may be permission giving will be most beneficial
all that is necessary to relieve their anxiety. for a particular client concern.
There are other numerous examples, such The use of the permission giving ap-
as the man who really likes the "woman on proach has a number of advantages. It is
top" position, but remembers reading adaptable to almost any setting and takes
somewhere that this was indicative of relatively little time or preparation on the
latent homosexual tendencies; or the part of the clinician. It can resolve a wide
young couple who "secretly" enjoy mutual range of sexual concerns, and it may also
oral-genital contact, but they have read or prevent new ones from evolving. In addi-
heard somewhere that this is considered tion, it may also be applied in conjunction
"perverted" or "abnormal" or the symp- with all other levels of approach in the
tom of "homosexual tendencies." The list P-LI-SS-IT model. However, there are also
could go on indefinitely, but by now the limitations to its application. As stated
major point should be clear: many of these earlier, this approach will certainly not
types of sexual concerns may be resolved solve all sexual problems, or even many
by a permission giving approach. problems, but it may resolve some con-
It should be further pointed out that cerns for some people.
many sexual concerns can also be handled Limitations. On the surface, it may
by giving the client permission not to appear that the basic assumption under-
engage in certain sexual behaviors unless he lying the permission giving approach is that
or she chooses to. For example, the young the clinician may sanction whatever sexual
woman who is receiving pressure from her thought, fantasy, or behavior that a con·
partner to experience "multiple orgasms" senting adult wishes to privately engage in,
or who has read or heard that it is every or engage in with other mutually consent-
woman's right to "expect and demand ing adults. In a very general sense this may
them," yet she is very satisfied with the be correct, however, there are some def-
one orgasm that she experiences with her inite limitations to such an assumption.
partner and does not really care whether While it is ultimately up to the individual
she is multi-orgasmic or not. Giving her client to choose whatever behavior that he
6 Spring-Summer, 1976
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wishes to engage in, "blanket" permission cian. The extent to which clinicians feel
giving by the clinician may not be appro- comfortable with and are willing to use the
priate if the client is not making an permission giving approach will generally
informed choice. It is the author's definite depend upon their breadth of sexual
belief that it is the clinician's responsibility knowledge, their theoretical orientation
to inform the unaware client of the pos- and their value system.
sible adverse consequences that may result The more knowledge that clinicians have
from engaging in certain thoughts, fanta- of sexual behavior in their culture and in
sies, or behaviors. For example, a number
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Spring-Summer, 1976 7
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sion. Clinicians should also be able to give sidered his penis too small in comparison
permission to themselves not to be experts. to other males. He had withdrawn from
They must not be afraid to say that they any social contact, was depressed over his
do not know the answer when they do not. situation, and contemplating trying to
No one person is an expert in this field. obtain surgery to correct his "deficient"
Theory, research, and practice in the sexual penis. He was provided with the usual
area are so far ranging that no one individ- information that can be given in such cases
ual or group of individuals can be expected (e.g., the foreshortening effect of viewing
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to know or keep abreast of even a sizeable his own penis as compared to looking
fraction of the area. Clinicians do what across at other males; no correlation be-
they can for their clients based on their tween flaccid and erect penis size except
own knowledge and experience. In some the tendency for the smaller flaccid penis
cases, the most important thing that clini- to become longer in the erect state than
cians have to offer is themselves. Someone the longer flaccid penis; that the average
who will listen, who can communicate length of the female vagina is usually three
interest, understanding, and respect, and to four inches and that there are very few
who will not label or judge the client. If nerve endings inside the vagina, etc.). A
permission giving is not sufficient to re- few minutes of such relevant information
solve the client's concern, and the clinician giving was sufficient to change his outlook,
is not in the appropriate setting, or does and within two months he was socially
not have sufficient time or relevant knowl- popular and involved in a close sexual
edge and skills, then this is the time to relationship with a young woman with
refer the client elsewhere. On the other whom he eventually became engaged. Of
hand, if clinicians do have the appropriate course, it is impossible to predict what
setting, knowledge, and skills, then they might have happened had he not been
can combine their permission giving with given such relevant information, but it
the second level of treatment. seems likely that his situation might have
progressively deteriorated. Thus, as with
The Second Level of Treatment: permission giving, providing limited infor-
Limited Information mation may also be seen as a preventative
In contrast to permission giving, which measure as well as a treatment technique.
is basically telling clients that it is all right Also, in the situation described, the client
to continue doing what they have been was given permission to have his concern
doing, limited information is seen as pro- and to accept his own body, but he was
viding clients with specific factual infor- not directly given permission to avoid or
mation directly relevant to their particular seek out sexual contact with women. By
sexual concern. It may result in their supplying relevant information, he was
continuing to do what they have been doing, provided with an opportunity to change his
or it may result in their doing something behavior if he chose to do so.
different. For example, a young man was It should be pointed out that limited
seen by the author whose major concern was information is usually given in conjunction
a feeling of inadequacy because he con- with permission giving. While each may be
8 Spring-Summer, 1976
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used as separate levels, there obviously may fields as anthropology and sociology con-
be considerable overlap between the two. sistently reveal that cultures which are free
Furthermore, both can also be used in and encourage women to be free in sexual
conjunction with the remaining two levels expression, produce sexually responsive
of treatment. However, because each de- women who are as uninhibited and respon-
scending level of treatment usually requires sive as males. Cultures which encourage
more time, knowledge, experience and skill and expect women to experience orgasm,
on the part of the clinician for most yield women who do experience orgasm,
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Spring-Summer, 1976 9
JOURNAL OF SEX EDUCATION AND THERAPY
half of them experienced manual and tion here is that it would not be thera-
foreplay, and more than 25 percent had peutically appropriate or helpful to clients
experienced oral-anal foreplay." On the to offer specific suggestions without first
other hand, with a young couple who obtaining information about them and
casually ask if it is possible to transfer their unique set of circumstances. If clini-
germs through oral-genital contact, one cians were to immediately launch into a
may respond, "Yes, it is possible. The number of suggestions after hearing the
mouth has a very high bacteria count." client's initial description of their problem
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Whatever style of approach, clinicians (not their "label" of the problem), they
now have two strategies for approaching may not only waste the client's time (e.g.,
sexual concerns. As with permission giving, offering suggestions that the client has
the degree to which they feel comfortable already tried), but they may further com-
with and are willing to use the second pound the problem. By suggesting inappro-
limited information giving level will also priate and possible useless treatment pro-
generally depend upon their breadth of cedures based on insufficient data they
sexual knowledge, their theoretical orienta- may overlook other more necessary and
tion, and their value system. The limita- appropriate treatment such as medical
evaluation and therapy.
tions imposed by these factors discussed in
the first level of treatment apply here The sexual problem history. What the
equally as well. clinician needs is a sexual problem history.
This is not to be confused with a sexual
history. If clinicians begin to take a sexual
As suggested in Figure 2, the additional
history, then they are heading into
use of this level of treatment may resolve
intensive therapy, not brief therapy. It is
some concerns that could not be handled
an assumption of the model proposed here
by the application of the first level of
that a comprehensive sexual history is not
treatment, permission, alone. If giving
relevant or necessary at this level. As
limited information is not sufficient to
suggested in Figure 2, the application of
resolve the client's sexual concern, clini-
the specific suggestion approach may re-
cians than have two options available to
solve a number of problems that f!.ltered
them at this point. They may refer the
through the first two levels of treatment;
client for treatment elsewhere, or, if they
but, needless to say, it is not expected that
have the appropriate setting, knowledge,
it will successfully deal with all such
skills, and experience, they may proceed to
the third level of treatment. problems. If the third level of approach is
not helpful to the client, then a complete
sexual history may be a necessary first step
The Third Level of Treatment: for intensive therapy.
Specific Suggestions
Guidelines for taking a sexual problem
Before clinicians can give specific sug- history that is deemed necessary for a brief
gestions to a client, they must first obtain therapy approach to treatment are outlined
certain specific information. The assump- below.
10 Spring-Summer, 1976
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Spring-Summer, 1976 11
JOURNAL OF SEX EDUCATION AND THERAPY
problems. Also, this level of treatment may specific suggestions directly relevant to
easily and advantageously be combined their particular sexual problem and de-
with the previous two levels. signed to help them achieve their stated
There are two common sayings that are goals. This level of treatment is particularly
often quite helpful in applying this particu- effective for dealing with those hetero-
lar level of approach. These sayings may be sexual problems that are concerned with
passed directly onto the clients depending arousal, erection, ejaculation, orgasm, or
1pon their particular situation. One that is painful intercourse. The specific sugges-
!Jarticularly beneficial for those clients tions given (e.g., redirection of attention;
,.vith concerns about a particular feature of graded sexual responses; sensate focus tech-
1eir body is: It is what you do with what niques; dating sessions, alternate sessions;
·u have, rather than what you have that interrupted stimulation; squeeze technique;
, unts. Use of this saying in conjunction vaginal muscle training, etc.) will, of
.th specific suggestions on "what they course, depend upon the information ob-
--.ay do with what they have" can be very tained in the sexual problem history. In
~ rfective in promoting attitude and be- general, it might be helpful to consider
havior change in a particular client's area of such suggestions as falling into three cate-
concern. gories: Suggestions to the male alone,
The second saying has even broader suggestions to the female alone, and sugges-
application. Many clients who come in tions to the couple. Quite often the clini-
with sexual concerns relating to failure in cian is seen by a client with a heterosexual
-uousal, erection, orgasm, or ejaculatory problem who has no immediate partner
.;ontrol tend to see each sexual contact available. In such cases there are a number
vith their partner as their "final test." If of suggestions that can be made using
he man again ejaculates too soon, or again self-stimulation procedures (Annon, 1973)
does not obtain an erection, he often feels that may be helpful to the client until a
as though he has lost his last chance. partner is available. Often, too, clinicians
Similar concerns are reported by women in may be faced with a situation where they
search of orgasms. Thoughts such as, "will are seen by a client who is in a relationship
it happen this time? It's got to happen this with a second person who has a problem,
time or I'll die!" are not conducive to but the second person is not able, or
success in experiencing such goals. Helping willing, to come in for consultation. As-
the client to learn to say, and to believe : suming that the second person is looking
rhere is always another day; or There .is for suggestions, it is important for clini-
Spring-Summer, 1976
JOURNAL OF SEX EDUCATION AND THERAPY
together. If at all possible, the client should suggestions. It is assumed that clinicians
be encouraged to have their partner come will not suggest any readings to clients
in with them. When the couple comes in until they are first well acquainted with
together and they are willing to cooperate their content and feel comfortable with
with the treatment suggestions, there is recommending them.
always a higher probability that they will
As Figure 2 illustrates, this level of
achieve their goals than when one or the
approach concludes the presentation of the
other comes in alone. It is always risky in
brief therapy approach of the P-LI-SS-IT
working with one person on a problem that
model. As Figure 2 further implies, a
involves two people in such an intimate
number of sexual concerns may ~uccess
situation, and the clinician should def-
fully be treated by such an approach, but,
initely attempt to see both people involved
on the other hand, a number of problems
if at all possible.
that cannot be solved by this approach will
Limitations. Efficient use of this level of also filter through. This is the point at
treatment will largely depend upon the which clinicians may refer the client for
clinicians' breadth of knowledge in the appropriate treatment elsewhere, or if they
behavioral and sexual area, their skill and have the requisite time, knowledge, experi·
experience, and their awareness of relevant ence, and skills, they may apply the fourth
therapeutic suggestions. The limitations level of treatment.
discussed previously apply here equally as
well. It is not within the province of this The Fourth Level of Treatment:
paper to offer extensive specific sugges- Intensive Therapy
tions covering all possible sexual problems.
It is not within the scope of this paper
For the interested clinician a detailed
to describe, or even to attempt to outline,
description of the application of such
an intensive therapy approach to the treat-
suggestions to the more prevalent hetero-
ment of sexual problems. For clinicians
sexual problems encountered by males and
who have already received training within
females is available elsewhere (Annon,
their particular discipline for intensive
1974).
therapy, this is the appropriate time to
Readings. Specific client readings may initiate such treatment. For the clinician
also be suggested by clinicians for a num· who is interested in a behavioral approach
ber of reasons. They may use them as to the intensive treatment of sexual prob-
another means of providing permission or lems, refer to Annon, 1975.
Spring-Summer, 1976 13
JOURNAL OF SEX EDUCATION AND THERAPY
may offer a framework for providing train- Finally, it should be pointed out that in
ing that can be geared to the level of the model proposed here, intensive therapy
competence of the individual trainee. For does not mean an extended standardized
clinicians, it is hoped that the model may program of treatment. By their very nature
provide a framework within which they such standardized programs will not be of
can continue to develop and expand their help to some people, or they may not even
knowledge, experience and skills. be necessary. It is the author's belief that
Clinicians will naturally have to adapt many of the essential elements of some of
their use of the P-LI-SS-IT model to their the current standardized programs can be
particular setting, the amount of time that successfully utilized within a brief therapy
they have available to them, and to their approach. In the P-LI-SS-IT model, inten-
particular level of competence. It is also sive therapy is seen as highly individualized
important to emphasize that while the treatment that is necessary because stan-
brief therapy part of the model is not dardized treatment was not successful in
intended to resolve all sexual problems, it helping clients to reach their goals. In the
may handle many. It is the author's firm present framework, intensive therapy
opinion, based on an ever increasing means that a careful initial assessment of
amount of clinical and research evidence, the client's unique situation and experi-
that it is now unethical to involve clients in ences is necessary in order to devise a tailor
an expensive, long term treatment program made therapeutic program that is unique to
without first trying to resolve their prob- the particular individual and to their life
lem from within a brief therapy approach. circumstances. This is particularly import-
As the schematic presentation in Figure 2 ant, because what is available to the client
implies, a number of sexual concerns may beyond the fourth level of treatment?
successfully be treated by such an ap-
proach if the clinician is willing to apply it. REFERENCES
On the other hand, as the model also Annon, J. S. The extension of learning prin-
ciples to the analysis and treatment of sexual
indicates, a number of problems that can- problems. (Doctoral dissertation, University of
not be solved by this approach will filter Hawaii, 1971). Dissertation Abstracts Inter-
national, 1971, 32 (6-B), 3627. (University
through. There will be times when the Microfilms No. 72-290, 570).
specific suggestions that may work for Annon, J. S. The therapeutic use of masturba-
many others will not be effective for a tion in the treatment of sexual disorders. In R. D.
Rubin, J. P. Brady, & l. D. Henderson (Eds.),
particular client's problem, whether the Advances in behavior therapy, Vol. 4. New York:
clinician has suggested one or a dozen. Academic Press, 1973, pp. 199-215.
14 Spring-Summer, 1976
JOURNAL OF SEX EDUCATION AND THERAPY
orgasmic dysfunctional women. (Doctoral disser· sonality research, Vol. 5. New York: Academic
tation, University of Hawaii, 1974). Dissertation Press, 1970, pp. 111-168.
Spring-Summer, 1976 15