Behavioral Therapy

The aim of group or individual behavioral therapy is to break the stimulus -response pattern and regain optimal control over the situation. For the group therapy protocol, the reader is referred to centers where group therapy is given. The protocol described below is for individual behavioral therapy.

Treatment comprises self-exploration, relaxation of the pelvic floor muscles, and systematic desensitization. This can be achieved in a step-by-step exercise program that consists of self-exploration, muscle relaxation exercises, and gradually learning to accept penetration in situations where it is the woman's own expressed wish to do so. Each step requires a great deal of practice; the next step cannot be taken until the previous one has been successfully completed. Every new step can trigger resistance, which manifests itself as anxiety, tension, or pain. Intrapsychological and interpsychological aspects can come to light that require referral to a psychotherapist or relational therapist. It is important to warn the patient right from the start that further referral may be necessary, in order to alert her "not to feel dumped" in a later phase of treatment.

Step 1: Self-exploration

The patient is given the following assignment to do at home in her own peaceful and quiet environment: examine her genitals with a hand-mirror (exposure in vivo). A second step is for her to touch her genitals. It is expressly not the aim to experience sexual arousal, but to become accustomed to her genitals. Next she is given the assignment to manipulate her pelvic floor muscles at various intervals, by systematically contracting and relaxing them. In order for her to recognize the feeling, she can be told that the muscles are the same ones that prevent her from inadvertently breaking wind. In this way, assignments are combined with relaxation exercises.

Step 2: Systematic Desensitization

After the successful completion of step 1, the next assignment is for the patient to place her finger between her labia just in front of the vaginal opening and to see how that feels. At the same time, she can be advised to reduce the tension in her pelvic floor muscles by repeatedly contracting or relaxing them and giving reversed pressure. This reversed pressure creates room to continue pushing or contracting the muscles, which is followed by relaxation. At the moment of relaxation, she can push her finger inside, or a cotton bud, hegar rod, vaginal rod, or a vibrator. Disadvantages of cotton buds, hegar rods, vaginal rods, and vibrators are that they are alien to the body and they give an awfully mechanical and coitus-oriented impression. Thus, if the patient has a history of indecent assault, rape, or incest, old fears can be rekindled. Advantages are the variety of diameters that enable gradual habituation. All the advantages and disadvantages of whether or not to use artificial aids in the exercises should be discussed fully prior to any decision-making about this issue. Ultimately, it is the patient's decision. In addition, there is nothing against exercising in a variety of ways, or first with the fingers and if that is unsuccessful, with artificial aids or vice versa.

The patient can do the exercises on her own, in the presence of her partner or together with her partner. She is asked to make time to do the exercises at least two or three times per week. However, a prerequisite is that when she decides to try the exercises, she is feeling relaxed, at peace with herself and is certainly not thinking "I will just do them quickly to get them over with".

Once she has managed to accept penetration of her finger or an artificial aid, she can keep it in place for a period of time and experience what feelings arise on a conscious level and how the tissues feel. Careful movement of the pelvic floor muscles, fingers, or artificial aid will increase the sensations. Then it is the end of the exercise for the moment and the fingers or artificial aid are slowly withdrawn. Short exercise sessions prevent the patient from becoming obsessively preoccupied and also prevent tissue irritation. The use of a lubricant will facilitate the exercises and also prevent tissue damage. Quite apart from this, there is no change in the advice to continue love-making with the partner, albeit with a strict ban on coitus or attempts at coitus.

Step 3

Once the patient is successfully able to insert one finger or an artificial aid (i.e., without anxiety, tension, or pain), the next step is to insert two fingers (at the moment of insertion, one above the other, then moved next to each other) or an artificial aid with a slightly larger diameter. This procedure is repeated until the fingers or artificial aid can be inserted in a relaxed manner and, once inserted, can be moved without anxiety, tension, or pain. If artificial aids are being used and the patient has a male partner, then if she so desires, the procedure can be continued until she can successfully (i.e., in a relaxed manner) insert and move an artificial aid with a diameter that matches the partner's penis. If the patient has a female partner, then being able to insert a finger or dildo in a relaxed manner will suffice. Sometimes when a patient is using vaginal rods, she experiences the progression from one rod to another as being too big. In such cases it is useful to wrap the rod in more and more condoms during each exercise session, in order to make the transition more gradual. In addition, this makes the rod more user-friendly.

Step 4

During treatment, the partner can gradually become more involved in the exercises. All the steps are repeated, starting with the discussion about genital anatomy. In some cases, it is necessary to start with genital "look and feel exercises." Each new step is always discussed thoroughly and tailored to incorporate attention to the thoughts and feelings that arise. Between steps, this usually requires a number of individual and/or relationship-oriented interventions. Sometimes the exercises prove to be a bridge too far and it is necessary to refer the patient to a psychotherapist, relational therapist, or physiotherapist (electrofeedback).

Step 5

It is the patient herself who indicates when she feels the time is right to experiment with her partner. She can choose a moment within or outside the context of love-making, or choose a moment in extension of an exercise session with fingers or artificial aids. In order to prevent the male partner from insisting on penetration while the patient is not yet ready, it can be worthwhile only to tell her that the coitus ban has been lifted. When the patient is ready, she takes the leading role (i.e., determines the timing and position) and he makes himself totally subservient. The penis is inserted in exactly the same manner as that employed in the penetration exercises. Both partners should be warned that in the initial stages, love-making will seem rather technical or mechanical, but that gradually the technicalities will sink into the background.

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