In Joyce's case, effective treatment first required relating her history of sexual abuse to her husband, Bill, so that we could begin to interpret her aversion to him in the context of her adolescent experience. This revelation evoked some sensitivity to Joyce's response from Bill and temporarily tempered his insistence on intercourse. We used this period to assess more fully their sexual history, to describe her sexual disorder to them both, and to develop a treatment plan. The theory and methods that characterize systematic desensitization were reviewed and the couple agreed to the treatment plan.
The literature on treatment of sexual aversion emphasizes the usefulness of cognitive behavioral treatment approaches (9,12) and there is support for the practical and relatively brief use of systematic desensitization (13). In this case, treatment consisted first of the creation of a hierarchy of aversion- and anxiety-provoking images, ranging from masturbation, which evoked the least anxiety, to intercourse, which evoked the greatest anxiety. In addition, Joyce was taught diaphragmatic deep breathing and an autogenic relaxation technique. The least anxiety-provoking stimuli were addressed first, with Joyce imagining each situation and reporting being able to remain relaxed and anxiety-free before each stimulus was subsequently approached in vivo. Importantly, sexual situations were designed to remain fully in her control; Bill had agreed to allow Joyce to determine the rate at which each of the items on the hierarchy was engaged. Fifteen sessions conducted over a period of 5 months were needed to help Joyce and Bill resume the healthier sexual life that had characterized their early history.
The persistence of avoidance behavior was first articulated by Freud (14); Mowrer (15) subsequently described this phenomenon as the neurotic paradox. The common observation that avoidance is remarkably difficult to extinguish has been explained by the theory of conservation of anxiety. The theory suggests that individuals learn rapid avoidance over time, which prevents the elicitation of fear. It is further suggested that if fear is not elicited it will not extinguish.
The theory of conservation of anxiety explains why sexual aversion rarely abates on its own and can be so treatment resistant. Crenshaw (1) posits that the sexual aversion syndrome is progressive and rarely reverses spontaneously. Patients like Joyce are treatable in so far as they are willing to purposefully expose themselves to the anxiety accompanying sexual behavior. We have found (11) that this exposure process can be facilitated by the following:
1. the clinician's conceptualizion of the patient's sexual aversion in clear behavioral terms, emphasizing how aversion is acquired and maintained;
2. the patient's ability to verbalize an understanding of the ways in which aversion is acquired and maintained. This understanding should allow her to generate specific examples of the process of exposure;
3. the patient maintaining records of anxiety and aversion symptoms during the treatment process and the clinician referring to those records frequently during sessions. We have found that patients are likely to adhere to record-keeping instructions to the degree that clinicians make those records integral to the process of psychotherapy;
4. emphasis on maintenance and generalization as the therapy draws to a close to address relapse issues.
Psychodynamic psychotherapy, with its emphasis on deeper conflicts, defense mechanisms, and transference, is considered to be the treatment of choice for those patients who report psychic pain as a component of their sexual aversion or who conceptualize their problems as symptomatic of early childhood issues (16). Patients who desire insight and express psychological curiosity about themselves are particularly likely to benefit from insight-oriented treatment.
There is evidence that sexual aversion may be predicted by a history of childhood sexual abuse. Noll et al. (17), utilizing a prospective design, demonstrated a relationship between childhood sexual behavior problems and subsequent sexual aversion, and found evidence that abuse by the biological father particularly predicted later sexual aversion. In clinical practice, patients with such a history may well benefit from desensitization approaches in conjunction with more traditional, uncovering psychotherapy.
The literature on psychodynamic approaches to sexual aversion emphasizes the integration of behavioral strategies and insight-oriented approaches (2). In clinical practice, this combined approach typically takes one of two forms. First, psychodynamic therapists recognize the utility of behavioral strategies and integrate them into their treatment regimens. Second, interestingly, it is often the case that patients who embark on a behavioral treatment will find that the process of behavior change itself begins to stimulate internal exploration. "Behavior change leads to insight" is at least as commonly observed in practice as the more familiar notion that "insight leads to behavior change." These patients are likely to pursue psychodynamic psychotherapy after completion of a course of cognitive behavioral psychotherapy.
In the case example above, the aversion response was gradually desensitized and she was able to resume and maintain a healthy sexual relationship with her husband. This psychotherapeutic process stimulated her desire to better understand her history of abuse and the psychological trauma that followed. As the behavioral treatment of her sexual aversion neared its completion, the therapeutic strategy moved to the development of insight into the effects of her childhood and adolescent trauma.
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