VEST In A Multicultural Community



The Canadian Journal of Psychiatry, Vol. 48, No. 11 (December 2003) (Brief version)

Ontario Psychiatric Association, 81st Annual Meeting, Toronto, Canada, *Best Paper Award, January 17, 2002
American Psychiatric Association, 154th Annual Meeting, Philadelphia, Pennsylvania, USA, May 21, 2002
A version of this paper was presented at the XVth World Congress of Sexology, Paris, France, June 26, 2001


The modern practice of sex therapy originally dating from the Masters and Johnson, Hartman and Fithian, Jack Annon, and Helen Singer Kaplan era has revolutionized our approach to the sexually dysfunctional patient or couple. Visually Enhanced Psycho-Sexual Therapy (VEST) aims to further enhance this work, and promote patient recovery.

The use of films and videos as an educational tool have a well-established history.1,2,3,4,5,6 Accumulating research is providing promising data on efficacy. An offshoot, virtual reality technology (VRT), is also finding significant applications in the treatment of a variety of disabling symptoms, such as fear of heights. However, Bloom’s 1997 review of research, sounds a note of caution with respect to psychiatric therapeutic applications of VRT.7

In the field of sexology, recent work by a number of investigators has focused primarily on the erectile or libidinal response to audio-visual sexual stimulation.8,9,10

Delizonna’s very interesting recent study in Boston has significant implication for clinicians treating real patients. Essentially, they demonstrated that achievement of mechanically induced erection or penile tumescence “was not accompanied by a subjective state of physical or mental sexual arousal.”11

The incipient era of pharmacological options for treatment of erectile dysfunction may indicate, at least, a new view or evaluation of the therapeutic journey. This prospect is furthered by the renewed focus on the kindling of desire, a necessary condition for the success of sexual pharmacotherapy, and a major therapeutic challenge for clinicians.

Visual stimuli integral to the role of imagination in the sexual arousal process are well known. The Internet is one that has become a significant, if anemic, delivery channel for millions. Nevertheless, the audio-visual medium has a powerful potential beyond arousal. Properly used as a teaching and therapy tool, audio-visual media can form a crucial part of modern sex therapy, counselling and education.

Thirty Years’ Experience with VEST

This private psychiatric/sexological solo practice, established in Toronto, Canada, in 1975, has been treating the full range of sexual dysfunctions within a rapidly growing urban population approaching 5 million. Its perhaps unique multicultural character has been described in detail.12


Total visible minority population 1,712,535
• Black 310,500
• South Asian 473,805
• Chinese 409,530
• Korean 42,615
• Japanese 17,415
• Southeast Asian 53,565
• Filipino 133,680
• Arab/West Asian 95,820
• Latin American 75,910
• Visible minority, not included elsewhere 66,455
• Multiple visible minority 33,240

To gain perspective on the multicultural nature of this work, consider a selection of patients seen recently:

– a couple from Bangladesh, desperate to have children, unable to have intercourse due to the wife’s vaginismus
– a man from India with erectile dysfunction, engaged to marry a woman back home, afraid to go through with the wedding for fear of sexual failure
– a woman from Somalia whose husband still lives there, fearful of her annual visit with him because of painful intercourse. She was genitally circumcized and infibulated at 8 years of age
– a couple from Iran married 12 years with 2 children, where the wife has lost sexual desire, despite a loving relationship
– a woman from Hong Kong with orgasmic release problems
– a couple from Yugoslavia with a very unhappy wife due to her husband’s fast ejaculation
– a young man from Canada unable to ejaculate at all, except through masturbation
– a woman from Bulgaria who feels driven to have sex from one to several times a day with a variety of partners; none orgasmically satisfying
– a couple from Canada, married 21 years with a very unhappy wife because her husband wants sex several times a day

What unites all these patients is their deep distress or even depression about their sexual relationship, and thus their life in general. When gently probed, some even reveal suicidal ideation, or loss of a zest for living.

Treating delicate sexual dysfunctions in such a diverse patient population is an ongoing challenge. In the presence of not infrequent language difficulties eliciting an accurate sexual history requires extra patience, tact and empathy. Many of these patients have never spoken of these concerns with anyone, and often lack the words to meaningfully describe them. Besides language, religious, and cultural barriers need also to be recognized. The vulnerability triggered by dealing with these touchy issues, usually for the first time in their lives, after significant suffering, poses a significant, time-intensive challenge for the therapist and patient(s). Only if embarrassment and shame ease or dissolve, and hope gets kindled for a successful outcome, can a positive therapeutic alliance emerge.


New Patients 10/01/97 – 06/30/04

• Female 62
• Male 279

cf. Total no. of patient visits 2000-2003: 4,375 (1,359 M, 320 F, 1,348 couples)

Female Male
Sexual Dysfunction Not Otherwise Specified (302.70) 4 2 9 15
Hypoactive Sexual Desire Disorder (302.71) – Male 70 0 23 93
Hypoactive Sexual Desire Disorder (302.71) – Female 118 18 0 136
Male Erectile Disorder (302.72) 118 0 165 283
Female Sexual Arousal Disorder (302.72) 8 8 0 16
Female Orgasmic Disorder (302.73) 68 35 0 103
Male Orgasmic Disorder (302.74) 45 0 37 82
Premature Ejaculation (302.75) 62 0 94 156
Dyspareunia (302.76) 6 1 0 7
Sexual Aversion Disorder (302.79) 4 1 0 5
Sexual Disorder Not Otherwise Specified (302.90) 8 3 12 23
Vaginismus (306.51) 18 5 0 23
Other 24 4 16 44

Mode of Treatment

While the psychiatric orientation is eclectic, the sexological treatment approach may best be described as Visually Enhanced Brief Directive Psycho-Sexual Therapy (VEST).

After a thorough consultation interview, including in-depth sexual, personal, medical, and psychiatric history, a diagnostic formulation is made and treatment options are reviewed. If a couple exists, both partners are usually seen together in the initial consultation/assessment. This important step promotes later cooperation in any subsequent therapeutic process, and active participation by both partners, not just the ‘identified patient’. Experience has also shown that the partners’ joint participation in treatment is a memorable and powerful bonding (or re-bonding) episode in their life journey as a couple. This initial “couple” interview is even more essential and thus required for the increasing number of desire-disordered patients seeking treatment.

In the usual 8 to 10 sessions of this treatment program, the general ‘cure’ rate, as indicated by presenting symptom reversal, is about 80-85%, including the desire-disorder problems. While each therapy session is unique and carefully tailored to the initial, and often variable, clinical picture, some common elements prevail. For example, a couple’s intensive treatment session can last three hours, sometimes more, though the interval between sessions varies according to therapeutic progress, the average being 2 to 4 weeks.

The approach begins by presenting the neuroanatomical and psychophysiological facts of sexual functioning. This factual base enables patients to grasp, and concretely visualize, the universal biological structure and function of the human autonomic nervous system, its parasympathetic and sympathetic components, and their specific and critical role in arousal and orgasmic release.

Core Treatment Elements

The medicalization of an aspect of the presenting complaint can, and does, at least offer some relief to many patients. Furthermore, the awareness that the problem is functional, not structural, but involves body and mind, makes patients not only receptive to, but often welcoming of, the psycho-sexual treatment approach. Such receptivity occurs even without the aid of pharmacological agents, although their potential availability on an “as-needed or “as-wanted” basis may offer comfort to some.

The Overwhelming Importance of Dealing with Time and the Role of the Senses

In our approach, we teach all patients Two Basic Principles relating to how they deal with the flow of time:

1. Being Present Centred (P.C.) – implies developing the ability to choose not to think of the future, or the past, but to be caught up in the moment
2. Being Process Absorbed (P.A.) – implies the opposite of being goal directed, possibly for some, even, goal obsessed

These Two Basic Principles are key to helping patients acquire the mindset of sex as adult play and as a form of communication, that can, at times, become profound or even spiritual.

A Note of Caution

Giving patients ad hoc assignments—whether reading books or some sensate focus exercises—is unlikely to produce consistent positive therapeutic progress without a proper context. The missing crucial element seems to be a carefully constructed therapeutic matrix that provides a meaningful framework for the requisite assignments. Thus the subsequent introduction of therapy “at home” exercises will have a clearer cause-and-effect purpose, thus reinforcing the patient(s)’ therapeutic compliance and motivation – a major challenge and not infrequent stumbling block.

The Crucial Role of Visual Aids

The saying that “a picture is worth a thousand words” is certainly validated in the VEST Program. For example, in the first therapy session after introducing the Two Basic Principles, a short film by the author, Taking Time to Feel, Part 3, is presented. This 10-minute video, with only a musical sound track, of a real couple, married 14 years with 2 young children, is watched in silence, as the patient(s) sits alone in the semi-dark viewing room. If a couple, they are asked not to speak with each other but to monitor their feelings, as evoked by the images.

Subsequent and prompt debriefing by the therapist forms an important component of their introductory learning experience, and helps to dispel lingering discomfort, if any, and thus illuminates the coming therapeutic process. Furthermore, the visual approach efficiently re-enforces cognitive and emotional re-structuring in a powerful and affective manner, which would be hard to achieve by talk therapy alone. Patients start to “feel in their bones,” so to speak, what the Two Basic Principles really mean, and how their lives could be enriched by their application. At times, Taking Time To Feel triggers tears as they recall memories of an earlier, contented time of life, and poignantly become aware of what they are missing now.

After careful assessment of the patient(s)’ physical and emotional state in subsequent sessions and a review of therapeutic progress since the previous appointment, a very careful and deliberate selection is made of the appropriate visual material to utilize. This selection process can be the most challenging part of the VEST therapeutic protocol, as the potential to do harm exists either in selecting the wrong program or choosing an otherwise proven and effective program but at an inappropriate time.

This practice makes potential use of over 100 audio-visual aids. The clinical judgement required for the selection of the most effective and suitable one at the appropriate time for a particular single patient or couple is a core, crucial clinical skill honed by experience.

Some Essential Points in the Practise of Visually Enhanced Sex Therapy (VEST)

– Most importantly, the therapist must be intimately familiar and comfortable with the material chosen for presentation and confident of its potential to enhance, not impede, the therapeutic flow and rhythm with a particular patient or couple.
– Underlying the choice of each program, the clinician is implying endorsement of the material used, thereby making a judgement and ethical statement. This implied endorsement may powerfully re-enforce the therapeutic bond but may also threaten or weaken it—even break it asunder, at times dramatically.
– Access to a comfortable space with the assurance of viewing privacy, often preceded by an active relaxation exercise, enables patients to be emotionally available and fully focused on the often emotionally challenging material presented.
– Personal introduction of the program by the therapist appears helpful to its acceptance by the patient, illuminating the context and rationale for its selection and use at this particular time in the therapeutic process.
– Personal debriefing of the program, following private viewing, is also helpful. This debriefing clarifies the experience for the patient and promotes its integration into an evolving different, better, healthier mindset, and potentially changed behavior. Obviously, the value of the debriefing process negates the notion that patients can be simply handed a certain video program to view at home with instructions to process its impact on their own.
– The audio-visual components form an integral part of the total therapeutic approach, keeping careful pace with the patient(s)’ progress. Thus, the various assignments—such as specific readings or sensory, communicative, or relaxation exercises at home between sessions—need seamless integration. Their impact needs re-enforcement as much as possible, by the therapeutic working through with the trusted clinician within the cumulative evolving therapeutic context.


Some 30 years’ of using audio-visual aids in this subspecialty Psychosexual Therapy Practice has strengthened the perception that VEST forms a most powerful component among our therapeutic resources. Indeed, these audio-visual aids may be viewed as quasi “medication,” as it were, with the power that implies for doing good or doing harm. As always, the first rule of medicine, “primum non nocere” applies.

Since ethical clinicians have the privilege of catalyzing healthy growth in our patients, especially in this profoundly private core area of their lives, this opportunity needs to be honoured and carefully nurtured. Hopefully, our patients’ gratitude at the conclusion of their liberating, life changing journey with us, will further our own growth as sensitive, caring healers, and provide us with nourishing professional satisfaction.

Ethical Application of Visually Enhanced Sex Therapy

From many years of experience using these quasi “medications” in practice, a number of helpful impressions have emerged, and been presented elsewhere.13, 14

Since the ethical practice of sex therapy is a commitment of all qualified professionals worldwide and the most likely assured path to clinical success and patient satisfaction, we all should heed and respect the Code of Ethics of the World Association for Sexology (WAS). The WAS Code of Ethics now includes the following:


As sex educators, counsellors and therapists, the videos/multimedia we use must be congruent with our basic values. Otherwise, we send a mixed message harmful to our patients, and unworthy of our professional obligations. Ethical practice requires that we use ethical materials in our work.


1. Strive to use videos and multimedia that affirm our basic values and depict human sexuality as a bonding force between authentic, loving adults.
2. Carefully, personally, review all videos/multimedia to be used in practice and seek out and heed reviews by peers.
3. Refrain from using videos/multimedia that perpetuate a “sex as performance” model, including the depiction of sexual acts by known or aspiring porn-industry participants. If such use, occasionally, with careful professional judgment, occurs, such actors will be clearly so identified.
4. Not participate either as principal, or in any other capacity, in exploitative ventures, commercial or otherwise, that are not in accord with these guidelines, and the Code of Ethics of The World Association for Sexology. In particular, ethical practitioners will not offer endorsement in any manner, on screen, or off, to any venture that in its practices demonstrates that it does not share the ethical standards adhered to by our profession, and our Association.


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