Experienced clinicians know that clients are at risk of terminating treatment when a significant change appears to be close at hand. Given this quirk of resistance, I thought I'd share an intervention that I've used several times to ward off marital disaster in treating one of the most challenging sexual disorders presented to couples/sex therapists: vaginismus. Sensing she'll be penetrated, a vaginistic woman experiences an involuntary spasm of the muscles surrounding the outer third of her vagina. The result: intercourse is painful if not impossible. It's pretty easy to see how this disorder can wreck havoc on a marriage—studies have shown that vaginismus is the leading cause of unconsummated marriages and is often a serious threat for divorce—but because some vaginistic women cannot tolerate a gynecological exam, a scary health risk is also posed.
What does a married couple with vaginismus look like to the couple's therapist? Usually an angry, threatening husband is vociferously complaining that his wife is withholding intercourse and that he's fed up and considering divorce if she can't ante up...and soon. The wife, feeling pressured, is usually anxious, frustrated, and somewhat confused by her unusual symptom. "What's going on?" One woman said to me. "This is so weird. I've got no control over my own body."
In my opinion, treating vaginismus merits a two-front approach which includes behavioral sex therapy techniques and relational intervention (I prefer a psychodynamic systemic approach). When appropriate, the behavioral intervention consists of prescribing dilators (from smallest to largest) that the wife is to use in the privacy of her own home to gradually desensitize herself to penetration (the fourth and usually largest dilator is roughly the size of a penis). While the husband may be called upon to help his wife insert the dilators (depending on his wife's comfort level), for the most part his job is to ease off the pressure for her to perform, be supportive, and try to understand his role in the marital dynamic (usually an enabling one) and the associated symptom.
Ascribing to a psychodynamic model of treatment I believe it's helpful for a couple to understand where their symptom came from, but I'll admit this is not always necessary for them to achieve a positive outcome. Nevertheless, I employ the psychodynamic systems approach to uncover any conflicts that might be behind or exacerbating the vaginismus. These underlying causes may include prior sexual abuse, chronic control struggles experienced in the family of origin, negative messages or beliefs about sex emanating from the family of origin, religious values that conflict with sexual pleasure, to name a few. I also pay close attention to the couple's interactional style in order to assess whether it, too, is a contributing factor.
Depending on the dynamics of the couple, the treatment process can run from fast and smooth to excruciatingly slow and tumultuous, but the therapist's gentle and patient guidance is almost always a key to successful outcome. If the wife is compliant, anti-anxiety medication may be a tremendous help in speeding the process up and making her more comfortable. Unfortunately, many of the women I've treated were reluctant to take medication. For some, taking medication meant being even more out-of-control.
The specific intervention I want to share with you I usually employ when the wife approaches the third dilator. At this time—in a conjoint session—I warn both partners that it would not be unusual for the "husband" to create a disturbance, sabotage the treatment, or to even end the marriage in order to avoid getting what he says he's been wanting for so-o-o-o long: intercourse. My hypothesis: Most of the men I've treated were conflicted about "getting what they want in life." While the underlying reasons for this conflict varied, the one constant was a difficulty with achieving goals or getting their needs met. Thus, in the context of vaginismus when presented with the actual prospect of having sex—they had trouble taking it.
So far, this intervention hasn't caused any significant setbacks in treatment. Probably because it's part of the couple's defensive structure not to believe me anyway. Another reason might be because the intervention openly challenges the husband to be a success—to stop complaining and demonstrate that he can be part of a positive outcome. The intervention puts the husband in a bind of sorts because he and I both know, on different levels of course, that he, too, has a problem which is close to being exposed. This intervention has worked so well for me that I've had one or two men stay in therapy to see how their conflict might even be thwarting them in their career progression. I know I'm not the first clinician to suggest the paradoxical "prediction of failure" as an intervention, but perhaps suggesting that it be used in the context of treating vaginismus might be of some value to someone out there.