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Seven studies have assessed pelvic muscle activity with a surface electromyography (EMG), vaginal probe or needle EMG, and pelvic muscle palpation by trained physical therapists (Binik, 2010). There is some indication of differences in resting muscle tone and in response to contraction–relaxation instructions among women with vaginismus or dyspareunia and control participants without pain. However, at this point, no consistent differences have been established. It has been suggested that increased pelvic muscle tension and/or contractions are a "general" protective mechanism in response to potential threat for all women (van der Velde, Laan, & Everaerd, 2001); women with vaginismus show this specific defense reflex in response to potential vaginal penetration (Shafik & El-Sibai, 2002).

**Sexual and Psychological Factors**

Vaginismus is classified as a sexual dysfunction; however, little information is available on sexual function and response in sufferers. Whereas some women report few sexual problems if vaginal penetration is not anticipated or attempted, others find their sexual function significantly compromised (e.g., van Lankveld et al., 2010). Women with vaginismus appear to respond differently to erotic stimuli, reporting more thoughts about negative consequences of intercourse, and demonstrate increased negative affective appraisal of vaginal penetration. For example, elevated fears of injury and losing control, as well as negative self- and genital image, worries about genital incompatibility, and disgust have been reported (e.g., Borg, de Jong, & Weijmar Schultz, 2010; Reissing, 2012; Klaassen & ter Kuile, 2009). Despite the negative affect and cognitions to sexual stimuli, thermographically measured sexual arousal while watching erotic films depicting vaginal penetration or other sexual activities remains intact in women suffering from vaginismus (Cherner & Reissing, 2013).

**Fear-Avoidance Model of Vaginismus**

The fear-avoidance model of vaginismus (FAM-V; see Figure 8.1) is based on the fear-avoidance model for chronic pain (Vlaeyen & Linton, 2000). This model provides an explanation of why vaginal penetration problems develop in some women who experience anxiety and/or pain with attempts at vaginal penetration (Reissing, 2009; ter Kuile, Both, & van Lankveld, 2010).

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**FIGURE 8.1** **.** Fear-avoidance model of vaginismus (FAM-V).

The basic tenet of the model is that catastrophic thinking about vaginal penetration and/or a catastrophic interpretation of a negative experience with penetration will give rise to vaginal penetration-related fears. To cope with fear, a woman may avoid all activities related to vaginal penetration or she may be hypervigilant to stimuli that are related to her specific fearful thoughts (e.g., pain, genital incompatibility). The latter can result in an exaggerated attention to physical sensations and increased anxiety that facilitates the experience of pain during attempted vaginal penetration. These attempts are met with defensive pelvic muscle contractions. Increased muscle tone, along with lack of sexual arousal and lubrication, result in further pain. The inability to "achieve"

penetration in turn contributes to negative experiences and confirms negative expectations, thereby further exacerbating and perpetuating the vicious cycle of vaginismus. Vaginismus, as conceptualized by the FAM-V model, may be akin to a specific phobia. As with the treatment of phobias, exposure to the feared object or situation is essential in overcoming the phobia. The goals for treatment in lifelong vaginismus are to reduce catastrophization, to promote a decrease in avoidance, and to increase positive experiences with vaginal penetration. This direct confrontation and disconfirmation of penetration-related fears results in breaking the cycle of vagnismus.

**ASSESSMENT**

The current lack of universally agreed-upon and empirically supported diagnostic criteria complicates the assessment of vaginismus. In our clinical practice, the components that constitute the FAM-V guide us in a comprehensive assessment of all aspects related to the patients vaginal penetration problem.

**Ruling Out Organic and Psychological Comorbidity**

We recommend a consultation with a gynecologist to rule out hymeneal and vaginal pathology that could interfere with vaginal penetration and to educate the woman about 171

her anatomy. Whenever possible, it is preferable that the examination be carried out by a health care professional familiar with genital pain and penetration problems. A visual inspection of the external genitalia is typically sufficient in revealing pathology. Patient preparation is central to an educational pelvic examination (EPE) to avoid further distress. To facilitate the EPE, the patient is informed of what to expect, reassured that no vaginal insertion will be attempted, invited to be an active participant (e.g., holding a mirror to observe the exam), and reminded that she can terminate the exam whenever she wishes. Instructions on coping with fear and anxiety can be very helpful (e.g., breathing techniques). In our experiences, almost all women can tolerate an examination with good preparation. For many, a successful gynecological examination is reassuring, eliminates fears about physical pathology, and represents an important first step in overcoming their problems.

Psychological concerns may need to be addressed prior to treatment. Although there is no evidence that women with vaginismus demonstrate worse psychological adjustment, problems such as untreated trauma, affective disorders, significant couple conflict, or a partners sexual problem can interfere with treatment. A brief, structured interview and the use of self-report questionnaires (e.g., Outcome Questionnaire [OQ-45], Lambert et al., 1996; Dyadic Adjustment Scale, Busby, Christensen, Crane & Larson, 1995; or the Achenbach System of Empirically Based Assessment (ASEBA) family of scales, www.aseba.org) can be very useful in determining when a referral for psychological counseling should precede treatment for vaginismus.

Evas physical examination was limited to a visual inspection of her external genitalia, and no pathology was noted. She was quite anxious in anticipation of the examination but put at ease by the process of the EPE. No mental health concerns were noted during her interview, and she reported no sexual abuse.

**Severity of Vaginal Penetration Problems and Treatment Motivation**

Eva, like most other woman with lifelong vaginismus, had also never been able to insert a finger or tampon or to have a pelvic exam with finger or speculum insertion.

She and her husband were very anxious that "physical causes" were making vaginal penetration impossible and colluded in avoiding attempts. This was their first attempt at formal treatment, and both were very hopeful of overcoming the problem in order to be able to conceive children.

Treatment motivation is particularly important in overcoming vaginismus because fear and avoidance need to be countered with significant commitment to therapy.

Discussion of previous failed attempts and partner collusion can shed further light on avoidance behaviors that can compromise therapy. In addition, it appears that for some women, the desire to conceive a child is the foremost treatment goal, and additional goals regarding overall sexual function may not be considered relevant. It may be useful for some women to be provided with information on self-insemination and guidance in 172

selecting a midwife or obstetrician with an understanding of vaginismus.

**Catastrophizing Cognitions and Penetration-Related Fears**

The FAM-V suggests that catastrophizing cognitions typically result in specific, penetration-related fears. The most common penetration-related fears are that penetration is impossible because of a small vagina or pathology and/or will be exceedingly painful. Eva initially indicated that she desired nothing more than being able to experience intercourse, but her inability to insert a tampon led her to believe that her vagina could not possibly accommodate a penis. Her belief of genital incompatibility may have led her to fear that intercourse would be impossible or very painful. The Vaginal Penetration Cognition Questionnaire (VPCQ; Klaassen & ter Kuile, 2009) can be used to assess vaginal penetration cognitions.

**Avoidance/Hypervigilance**

In the FAM-V the driving force is the avoidance of vaginal penetration, which eliminates the possibility of confrontation and disconfirmation of catastrophic cognitions. While the woman is avoiding intercourse, she is temporarily stepping out of the FAM-V, which serves to negatively reinforce the cycle; that is, if she is not attempting vaginal penetration, she experiences no symptoms. The occasional attempt is accompanied by significant fear and hypervigilance for dreaded emotions or experiences (e.g., loss of control, pain). Invariably the attempt ends in failure and disappointment.

Importantly, the negative experience of a failed attempt further perpetuates and exacerbates the vicious cycle of the FAM-V.

Evas husband colluded with her in avoiding intercourse. He had observed her difficulties and shared her fears about physiological pathology. He cared for his wife and wanted to avoid the negative emotional fallout. They had been married for 3

years but could barely remember attempts at intercourse. However, Eva and Rob did not avoid sexual intimacy but explicitly agreed that vaginal penetration would not be attempted.

**Marked Tensing or Tightening of the Pelvic Floor Muscles**

Pelvic reactivity is an important component in the FAM-V because of its potential of maintaining and exacerbating the vicious cycle by making attempts at penetration painful and impossible. At this point, it is not clear whether women with vaginismus are able to provide reliable information on the presence or severity of their pelvic floor muscle tone and/or reactivity. Gynecologists may observe reactive pelvic muscles, and observations from the partner can be helpful. Questions about micturition and/or 173

defecation problems can also be revealing and indicative of more chronic and severe tonicity. Some women may benefit from a formal assessment by a physical therapist with experience in pelvic floor problems. In the absence of resources for assessment by allied health care professionals, therapists can help clients increase proprioception and accuracy of self-assessment by practicing contract–release exercises using a mirror.

Eva displayed an elevated degree of pelvic reactivity during the EPE but reported no micturition or defecation problems.

**Additional Consideration in the Assessment for Exposure Therapy:**

**Vasovagal Syncope**

Although most women with vaginismus respond with increased autonomic arousal upon exposure to the feared penetration stimulus, 5–10% have a unique pattern of responding. This consists of a diphasic response in which heart rate and blood pressure increase briefly and then suddenly drop. This is accompanied by feelings of dizziness and can result in fainting. The term "vasovagal syncope" has been used to describe this phenomenon, and it has been reported in patients with blood, injection, and injury phobias (Barlow, 2002). In our clinical experience, patients who respond to attempted penetration with a diphasic response typically have a history of fainting upon exposure to other feared cues. Briefly verifying such experiences is useful in the development of the treatment plan.

Eva recalled experiencing fainting spells when exposed to blood and injections, and she was very afraid that she could faint during the gynecological examination.

**APPROACHES TO TREATMENT**

**Medical Treatment**

Different forms of medical treatments have been used to address vaginismus. These include surgical interventions to remove the hymen or to enlarge the introitus, injections of botulinum toxin, application of topical anesthetic creams, and the use of anxiolytic medication. However, no evidence of the effectiveness of these treatments is available from controlled studies (e.g., van Lankveld, et al, 2010).

**Pelvic Floor Physical Therapy**

Referrals for physical therapy (PT) appear to be increasingly common, but specific treatment techniques and therapy course and outcome are currently uncertain because 174

women with vaginismus are typically excluded from outcome studies evaluating PT for sexual pain disorders. A retrospective study demonstrated positive treatment outcome with interventions similar to those used in treatment of vulvodynia but with significantly longer treatment duration (Reissing, Armstrong, & Allen, 2013).

Prospective, controlled studies including women with lifelong vaginismus specifically are urgently needed to elucidate whether PT is a promising therapy option.

**Psychological Treatment**

Anxiety-reduction techniques, along with gradual exposure to vaginal penetration, are frequently applied in the treatment of vaginismus and form the core element of treatment, which typically includes a range of other interventions, such as cognitive restructuring, education, and sex therapy (Melnick, Hawton, & McGuire, 2012).

The first randomized controlled trial (RCT) investigated 117 women with lifelong vaginismus assigned to cognitive-behavioral therapy (CBT) either in group or bibliotherapy format or to a wait-list control group (van Lankveld et al., 2006). After receiving either treatment format for 3 months, 18% of the treated participants had successfully attempted intercourse, compared with none in the wait-list group. CBT did not produce changes in subjective reports of sexual functioning of participants or their partners. Successful treatment outcome was partly mediated by a reduction of "fear of coitus" and of avoidance behavior. Consequently, it was hypothesized that the effectiveness of treatment could be enhanced by focusing more explicitly and systematically on exposure to the stimuli that are feared.

To test this hypothesis, a prolonged, therapist-aided exposure treatment was developed (ter Kuile et al., 2009). Exposure at the hospital was self-controlled, (patient performed vaginal penetration exercises), facilitated by a female therapist, consisted of a maximum of three 2-hour sessions per week, and followed up with exercises at home.

Of the 10 participants, 9 reported intercourse following treatment, and, for 5, intercourse was possible within the first week of treatment. Exposure was successful in decreasing fear and negative penetration beliefs and treatment gains were maintained at 1-year follow-up. Recently, these results were replicated in a multicenter, wait-list RCT

including 70 women with lifelong vaginismus (ter Kuile, Melles, de Groot, Tuijman-Raasveld, & van Lankveld, 2013). Following treatment, 89% of the participants could experience intercourse and reported decreases in negative penetration beliefs and sexual distress. For most (90%), intercourse was possible within the first 2 weeks of treatment after an average of 2.5 hours of exposure at the hospital. The ability to experience intercourse did not result in complete sexual rehabilitation for 50% of participants. All couples who were able to experience intercourse at 3 months follow-up were offered three sessions of sex therapy aimed at increasing overall sexual function and pleasure.

More than 40% chose additional sex therapy. At the 1-year follow-up, the large reduction in symptoms related to vaginismus, negative penetration beliefs, and sexual distress obtained after exposure treatment remained. However, other aspects of sexual function (e.g., desire, orgasm) did not improve, and there were no indications that the 175

extra sessions of sex therapy affected treatment outcome in the long term.

**Current State of Knowledge**

The treatment success of recent exposure-type treatments is significantly greater than that of therapies that combine multiple treatment techniques. Although it is potentially promising, not enough information is available to evaluate the effectiveness of physical therapy. We posit that treatment success can be significantly increased by directly focusing on confronting vaginal penetration-related fear via in vivo exposure.

**In Vivo Exposure Therapy for Lifelong Vaginismus**

We have previously suggested a conceptualization of lifelong vaginismus as a penetration phobia. Specific phobias are one of the best understood psychological disorders, with considerable treatment success using in vivo exposure to feared objects and situations (e.g., Barlow, 2002). Therapist-aided exposure results in fewer avoidance behaviors and greater reduction of fear compared with treatment with less therapist involvement. A critical component of exposure is that the duration of the session has to be long enough (2–3 hours) to disconfirm a priori catastrophic expectations and to consolidate such learning. It is generally accepted that massed, in vivo exposure (i.e., over several consecutive days) is more effective for fear reduction than spaced exposure (i.e., one weekly session). Exposure in a variety of locations and situations to a variety of stimuli can reduce the rate of relapse. Furthermore, there are indications that including the partner can improve outcome (e.g., Barlow, 2002). In vivo exposure for vaginismus can be therapist assisted or carried out in the home setting. Therapist-aided exposure has a number of advantages over home-based exposure only. The initial exposure session takes place in a professional setting with a knowledgeable therapist, increasing the womans feelings of reassurance. The role of the therapist is to guide the woman (and her partner) through the difficulty of approaching the penetration-related fears, to manage the associated intense fear, and to encourage nonavoidance. The therapist can actively assist the couple in learning how to best practice exposure at home and support the couple in overcoming difficulties as they occur. Exposure treatment carried out at home is a possible alternative, but the role of the therapist is crucial in focusing the couple on confronting avoidance, managing anticipatory anxiety, and practicing massed exposure. Our recommendations concerning exposure therapy for vaginismus are as follows:

1\. Exposure is carried out in vivo, and the duration of the practice is long enough to disconfirm a priori catastrophic expectations.

2\. Exposure is practiced with varied stimuli (fingers, own or partners; dilators; tampon; penis).

3\. Exposure is practiced in varied situations (e.g., different positions, locations, with 176

and without partner, with and without sexual arousal).

4\. If possible, the partner is always included in treatment. The partners role is to assist the woman in reducing avoidance and to encourage her during exposure exercises.

5\. During the therapist-aided exposure session, insertion is carried out by the woman.

6\. The role of the therapist is to coach the woman and her partner to manage fear and avoidance and to prepare for home exercises.

**Multidisciplinary Treatment of Lifelong Vaginismus**

The treatment of vaginismus is best carried out in a multidisciplinary context, with all members of the treatment team sharing the conceptualization of vaginismus and the treatment plan. It is essential to rule out organic pathology; however, we believe the value of the gynecologist on a multidisciplinary team goes well beyond this task. The educational pelvic examination can be a first step in overcoming vaginismus by presenting an opportunity for education on vulvovaginal structures, reproductive health, and physiological capacity for intercourse. The educational role can also be assumed by a pelvic-floor-expert physical therapist who can also assist the patient to increase proprioception of her pelvic floor muscles. Clinical psychologists who are trained in the basic principles of exposure are best equipped to accompany the couple during exposure treatment. A number of professional caveats face psychologists working with therapist-aided, in vivo exposure in vaginismus (e.g., seminudity, client practicing vaginal penetration in the presence of the therapist), and we recommend that therapist-aided exposure be carried out in a medical setting.

**CASE DISCUSSION**

After a clinical intake interview and external gynecological examination, it was recommended that Eva and Rob start with therapist-aided exposure treatment. Massed exposure is emotionally intense, and homework assignments are time-consuming.

Therefore, we generally recommend that couples take time off from work in the week following the first exposure session. In our clinical experience, practice of relaxation exercises prior to in vivo exposure did not contribute to treatment process and outcome; therefore, specific relaxation exercises prior to exposure were not included in the treatment protocol. During the therapist-aided session, however, relaxation and/or breathing instruction can be suggested by the therapist (for the treatment manual, see ter Kuile et al., 2007).

Prior to the first exposure session, Eva and Rob attended an information session discussing the following topics: (1) the rationale of exposure treatment for vaginismus (using the FAM-V); (2) what to expect during exposure therapy; (3) the nature and 177

frequency of homework exercises; (4) Robs participation at the hospital and his active involvement in the exercises at home; and (5) the development of a hierarchy of fear-and tension-eliciting vaginal penetration stimuli to use during exposure (tampon, finger[s], penis with and without movement). Eva expected that the most fearful step would be penetration, regardless of who would insert a dilator or finger and whether or not there was movement. The goal of the exposure sessions at the hospital was self-insertion of a dilator or fingers that was slightly larger than the circumference of the erect penis of her partner.

**The Therapist-Aided Exposure Session**

A brief conversation at the beginning of the exposure session indicated that, as expected, both partners were very nervous. It had been established in the assessment that Eva was at risk for experiencing feelings of dizziness and that she was afraid of fainting.

Therefore, she was instructed to drink two glasses of water before the session to prevent loss of blood pressure. In response to dizziness, she was instructed to briefly stop the exercises and tense the muscles of her body to raise blood pressure. "Applied tension"

has been demonstrated as an effective intervention in patients with blood phobia (e.g., Barlow, 2002). Care is also taken to arrange the gynecological examination chair or table in a fashion that does not interfere with the exercises and so that, should the woman faint, a fall can be prevented.

The therapist and Rob stood beside the chair, and all were able to see the vaginal penetration exercises by means of a handheld mirror. Eva began by touching her vulva with her fingers and spreading her labia minora. As expected, she felt increasingly dizzy when touching (and seeing) her vulva and vaginal entrance. The therapist instructed Eva to use applied tension and moved the chair to a more horizontal position. Within a couple of minutes she was able to compensate for the decrease in blood pressure and continue the exercises. She was very relieved that she mastered this step. She subsequently proceeded with the gradual insertion of one finger using lubricant. Eva was inclined to withdraw her hand immediately whenever she had unpleasant feelings or sensations. Rather than avoiding these feelings, she was encouraged to hold her finger still and to describe sensations and feelings she was experiencing. Unpleasant sensations disappeared within a few seconds. The experience of increasing anxiety, being able to tolerate the feelings, and the subsequent decrease in anxiety was described as

"surprising" and increased Evas confidence that she would be able to handle more exposure exercises.

She was encouraged to move her finger gently, which she experienced without much anxiety. As she did not experience any feelings of dizziness at this phase of the exposure exercises, the chair was moved back to the original position, allowing for practice in different positions. Quite soon she was able to insert two fingers. Eva was surprised by her progress in disconfirming her penetration-related fears that vaginal penetration was impossible and painful. She experienced some pain when she moved her fingers, but the pain subsided when she focused on a gentle down-bearing pressure in her pelvic area.

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Next, she practiced the same steps in squatting, sitting, and standing positions, first with her finger and then with different-sized dilators. She experienced a precipitous rise in anxiety and intense desire to terminate the session when inserting the largest dilator.

She was encouraged to focus on the sensations she felt, to describe her discomfort, and to stay still and practice relaxation with diaphragmatic breathing. Negative sensations subsided gradually, and she felt significant joy and pride at her success in sustaining and reducing heightened anxiety. After 1.5 hours of practice, she was able to insert a vaginal probe of 12 cm circumference and three of her fingers; the ultimate goal of 12 cm was achieved and exceeded. To conclude, she practiced with a lubricated tampon, which she was able to insert without problems.

During the postexposure conversation, Eva stated that she was extremely relieved and very satisfied with the results she had achieved. The experience of vaginal penetration with very little pain and using a dilator that was slightly larger than her husbands penis directly disconfirmed her fears. She described the experience of unpleasant feelings and sensations disappearing gradually if she did not stop the exercise but talked about her experience while trying to relax her body as the most important step for her ("This is a huge discovery for me!"). Rob felt reassured that vaginal penetration was possible without pain and felt empowered to assist Eva actively in home exercises. They went home with instructions to repeat the exercises the same day using plenty of lubricant. Progressive steps for Rob during homework exercises included: (1) inserting his fingers (one, two, or three); (2) touching the entrance to Evas vagina with his erect penis without penetration; (3) inserting his erect penis without thrusting; and (4) inserting his penis with thrusting.

**Following the Therapist-Aided Exposure In Vivo Session**

Eva and Rob had an appointment at the outpatient clinic 2 days later, during which they related that practicing at home had gone well. Rob could easily insert two fingers, but his third was more difficult. His penis could be inserted halfway, but it felt awkward because they struggled to find a comfortable position. The therapist and the couple concluded that no further exposure sessions at the hospital were necessary while daily home exercises continued. During the third appointment, the couple reported that intercourse was possible and painless. Evas menstruation had started, and when she tried to insert a tampon, she nearly fainted and experienced heightened anxiety. Rob stayed calm, reminded Eva of the applied tension exercise to manage her dizziness, and suggested that Eva insert the tampon while lying on her back. She followed these steps for a couple of days, and every day tampon insertion became easier. Managing and overcoming this challenge was an important step for Eva and Rob and increased their confidence that they had the necessary tools to handle any future challenges.

During the 6- and 12-week consultations, Eva and Rob reported that sexual intercourse was still possible but not pleasant. The arousal created during foreplay decreased as soon as penetration was attempted. Three additional sessions were planned focusing on maintenance of sexual arousal during penetration. Eva chose to practice 179

alone initially by allowing arousal to build with clitoral stimulation and then inserting a finger or a small vibrator. During the third consultation, she recounted that she was able to move the vibrator intravaginally and was able to facilitate orgasm. The couple encountered more difficulty when practicing together. Eva appeared to be hypervigilant to unexpected movement from her husband, which prompted a decrease in arousal.

They believed, however, that they could progress further without additional sessions.

During a final appointment a year following treatment, the couple was satisfied with their sex life, stating that sexual intercourse was arousing and pleasant for both if they used the woman-superior position. Other positions still elicited a decline in sexual arousal. Nevertheless, the couple stated that they were very satisfied with the results achieved, and treatment was concluded.

**Evaluation**

In line with research findings, the couple was able to experience a first intercourse within the first week of exposure therapy. Overall, 10 sessions were necessary to achieve the desired treatment outcome of pain-free, pleasurable intercourse; only one of these sessions involved a therapist-aided exposure session at the hospital.

What can be said about possible mediating influences on the effects of treatment?

According to the FAM-V model, the penetration-related fears are maintained in women with vaginismus because avoidance prevents disconfirmation of the catastrophic beliefs.

By directly reducing avoidance and increasing successful penetration behaviors, fears are disconfirmed; catastrophization is reduced and eventually eliminated. In the case of Eva and Rob, beliefs about vaginal pathology, genital incompatibility and expectation of pain were progressively disconfirmed by "normal" findings with the gynecological examination and the ability to insert dilators or fingers with little and later no pain during exposure exercises. Reduction of catastrophizing resulted in a reduction of fear, and avoidance behaviors as a coping strategy were no longer necessary. In vivo exposure results in intense anxiety and negative emotions; nonetheless, the rewards to the patient(s) in terms of pride, sense of achievement, and empowerment are highly beneficial. Eva and Rob described experiences in the exposure session as "a discovery"

and "changing their views on vaginal penetration." Subsequent massed exposure at home consolidated and expanded on the successful experiences of the therapist-assisted exposure session. Rob was quite effective in helping Eva through a critical moment when a new penetration experience (tampon) briefly reversed treatment gains, which further empowered the couple to manage possible future challenges.

**CONCLUSIONS**

In this chapter we focused on women with lifelong vaginismus who have never been able to experience complete vaginal intercourse and who demonstrate marked fear and 180

avoidance of vaginal penetration. Recent treatment outcome reports are in line with research suggesting that lifelong vaginismus may be more akin to a penetration phobia.

We can assume with a good degree of confidence at this point that focusing treatment on fear and avoidance behaviors will result in a significant decrease of negative penetration beliefs and fears, in turn resulting in successful intercourse for nearly all women with lifelong vaginismus. However, the experience of intercourse does not automatically imply that penetration is also pleasurable. Future research has to investigate which additional treatment interventions may be helpful to improve overall sexual function and pleasure. Finally, it is currently unclear to what degree women with acquired vaginismus or dyspareunia could benefit from exposure therapy and how or whether the treatment protocol would need to be adjusted.

In general, a significant paucity of research for lifelong vaginismus has to be noted.

Only recently have researchers attended to possible differences between women who develop an inability to experience intercourse, typically in response to dyspareunia, and those women who have never been able to experience intercourse. The combination of vaginismus and dyspareunia into GPPPD for DSM-5 (American Psychiatric

Association, 2013) is empirically based and in line with the available research on the overlap and/or continuity on various symptom dimensions between the two penetration-related problems. However, in view of the relative neglect of lifelong vaginismus in the empirical literature thus far, it can be argued that not enough information is available to conclude that both problems are indeed the same disorder. A combination of vaginismus and dyspareunia, at this point, carries the risk of extinguishing the recently nascent empirical research interest in lifelong vaginismus which may—or may not—demonstrate lifelong vaginismus as a distinct clinical affliction requiring differential treatment recommendations.

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**PART II**

**SEX THERAPY FOR OTHER SEXUAL DISORDERS**

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**CHAPTER 9**

The Paraphilias

An Experiential Approach to "Dangerous" Desires

Peggy J. Kleinplatz

**P** araphilias are typically treated today via cognitive-behavioral and/or pharmacological therapy aimed at controlling or reducing the frequency and intensity of atypical sexual behaviors and their corresponding sexual urges. Indeed, controlling (if not eliminating) unusual sexual interests is often the wish of the client or couple, as deviant interests often wreak havoc on their lives and in the extreme can result in legal difficulties and incarceration. Kleinplatz reviews the gaps in our knowledge of the paraphilias and cautions against filling in these gaps with moral judgments. Indeed, she raises the question as to whether these diverse sexual interests have much in common other than their presumed low prevalence. Whereas forensic psychology addresses criminal and coercive paraphilias, sex therapy could, but has not, adequately addressed treatment of non-coercive paraphilias. In this chapter, Kleinplatz argues that Experiential Psychotherapy, which focuses on effecting substantive personality change rather than overt behavior, may be an effective strategy for treating the paraphilias.

**Peggy J. Kleinplatz, PhD,** is Professor of Medicine and Clinical Professor of Psychology at the University of Ottawa. She is a clinical psychologist, Certified in Sex Therapy, Sex Education and as a Diplomate in and Supervisor of Sex Therapy. She is currently Chair of Ethics and former Chair of Certifications for the American Association of Sexuality Educators, Counselors and Therapists. Dr. Kleinplatz has edited three books, most recently New Directions in Sex Therapy: Innovations and Alternatives (Routledge, 2012), winner of the AASECT 2013 Book Award. Her clinical work focuses on eroticism and transformation. Her current research focuses on optimal sexuality, with a particular interest in sexual health in the elderly, disabled, and marginalized populations.

In this chapter, I present a survey of the literature on the paraphilias, offer a clinical illustration, and discuss the outcome of a clinical case against the backdrop of the predominant paradigms. The difficulty is that much of the literature in this area is geared toward readers working with forensic populations rather than for sex therapists.

In addition, the methods, goals, and outcomes are focused on reducing recidivism rather than on the kinds of personal development valued by psychotherapists. Please bear with me as I move across different domains, suggesting the application of an established clinical model, that is, Experiential Psychotherapy, for an innovative use by sex therapists in working with atypical sexual desires.

In attempting to provide an overview of the paraphilias, a major obstacle is that the literature in the area is divided across professional (and other) lines. It appears in three different domains: First, the large forensic literature on sex offenders is focused on controlling the paraphiliacs behavior, distinguishing or determining commonalities among deviant behavioral patterns; on reducing recidivism or at least predicting 184

recidivism rates accurately; and on protecting the public from the sex offender (Laws & ODonohue, 2008). Second, the scarce sex therapy literature discusses the etiology and meaning of unusual sexual desires, classification of sexual variations, the possibility of comorbid disorders, whether or not the paraphilias are subject to change, and, almost parenthetically, the relative absence of patients and their lack of motivation for treatment (Darcangelo, 2008; Hucker, 2008: Krueger, 2009b; Lussier & Piché, 2008; Morin & Levenson 2008). A third and growing domain is in the literature among those who are aroused by consensual albeit unconventional sexual activities. This literature is mostly oriented toward education and support of sexual minority community members and advocacy in the face of uncomprehending, judgmental and downright hostile mental health professionals and an adversarial legal system. Within this literature, the entire enterprise of trying to diagnose, classify, and control sexual behavior among consenting adults is seen as morally rather than scientifically based and is thus ethically dubious. None of these vantage points is especially friendly toward the major concerns of the other domains, which makes an integrated perspective on the paraphilias rather challenging.

This chapter calls for a review of the empirically based treatment literature. That would require accurate information on the prevalence of the paraphilias, how to classify and conceptualize them, how to assess them, what the goals of treatment ought to be, what the treatments consist of, and how to assess effective outcome of treatments for the paraphilias. It might also be nice to know what causes the paraphilias. Unfortunately, there is little information in some of these areas and even less consensus on the rest.

**WHAT ARE THE PARAPHILIAS?**

By definition, paraphilias are unusual sexual interests. The DSM-IV-TR (American Psychiatric Association, 2000) listed the paraphilias as follows: voyeurism, exhibitionism, frotteurism, pedophilia, fetishism, sexual sadism, sexual masochism, and transvestic fetishism. A ninth category, paraphilia not otherwise specified (NOS), is a grab-bag category for an unlimited assortment of other sexual proclivities, most of which will probably never appear in the clinical or research literature. The paraphilias tend to be divided in terms of coercive or illegal (i.e, voyeurism, exhibitionism, frotteurism, pedophilia) versus the non-coercive paraphilias (i.e., fetishism, consensual sexual sadism and masochism, transvestism).

The professional literature on the paraphilias is limited by uncertainty as to what they are, how many there are, and what their frequency might be. The category comprises sexual proclivities listed together only by virtue of being relatively uncommon. It is clear that some are unusual (e.g., pedophilia, frotteurism) and others are downright rare (e.g., apotemnophilia), but we do not even have accurate data on just how atypical they are. A recent German population sample found that 62.4% of men reported sexual arousal to at least one of the DSM-IV-TR paraphilias, indicating that the presence of paraphilic desires may be far more common than previously believed (Ahlers, 2011). Frequency 185

estimates are also compromised by the fact that most people who have unusual sexual interests do not have only one sexual proclivity, unusual or otherwise (Langevin, Lang,

& Curnoe, 1998). Of course, prevalence estimates are also limited by the reluctance of individuals who have been pathologized, criminalized, and otherwise marginalized to report their conduct to the authorities. The only consistent element across the literature is the notion that the large majority of paraphiliacs are male.

Outside the forensic or clinical literature, one can learn about the astonishingly broad variety of unusual sexual interests in the community via the Internet (e.g., by visiting Fetlife.com, a social networking site for the "kink" world). As of February, 2012 Fetlife listed 1,243,518 members, who shared 5,604,935 pictures and 47,191 videos, participated in 1,734,663 discussions in 37,801 groups, were going to 5,070 upcoming events, and reading 597,138 blog posts. Or as it states on the opening page of the Fetlife website,

"Welcome to kinky heaven!"

**CONCEPTUALIZATION AND CLASSIFICATION**

Newring, Wheeler, and Draper (2008, p. 301) have observed, "Before we can treat it, we need to know what it is, or whether it is worth a diagnostic label." A review of the literature indicates precisely how arbitrary classification of the paraphilias has been over the last 50 years or so. Sexual deviations have been listed and removed from the DSM


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across successive editions (Moser & Kleinplatz, 2005). The social rather than empirical basis for classification of "deviant" sexuality was most notoriously exemplified by the early inclusion of homosexuality and subsequent removal in 1973. The current list has shifted repeatedly. The question of whether or not the paraphilias necessarily constitute a disorder at all remains controversial.

As for theoretical conceptions of the paraphilias, our understanding is even more limited. The forensic practitioner is not especially concerned with how to conceive of the origins and meaning of sexual variations. The average sex therapist may have been trained in psychodynamic, behavioral, and biological theories of psychopathology but generally is unlikely to be seeing patients who present for treatment of atypical sexuality.

The literature is filled with references to the paraphilias overall, making statements that are not particularly useful to either set of practitioners. As described by Darcangelo (2008, p. 115), "Many studies draw conclusions about paraphilias in general, rather than differentiating among the various types of paraphilias. Given the considerable overlap among paraphilias, this is not too surprising." On the other end are clinicians or researchers who have a specific interest in a particular paraphilia, for example, fetishism or frotteurism. However, that literature tends to be sparse, and there is no way of knowing to what extent our understanding of the frotteur can be extrapolated and applied to understanding of the fetishist. If researchers agree that it is difficult to even estimate the prevalence rates for the various paraphilias (e.g., Lussier & Piché, 2008), the consensus in the literature is that it is more complex to imagine a cohesive conceptualization of the paraphilias. Much of the literature on sexual deviance is 186

focused on pedophilia, rape, and exhibitionism (Laws & ODonohue, 2008). All three of these associated behaviors are illegal, although rape is not currently listed as a paraphilia in DSM-5 (American Psychiatric Association, 2013). The other paraphilias are

"orphans" with little funding for research into their prevalence, conceptualization, or treatment. In other words, the focus is on criminality rather than psychopathology, which are hardly synonymous. Thus our knowledge of the paraphilias is limited by the bifurcation by which professionals are assigned to deal with which "disorder," making it impossible to discern whether we are even talking about one kind of phenomenon or a variety of discrete phenomena.

If it is difficult to disentangle sexual deviance, illegal behavior, and psychopathology, any attempt to understand atypical sexuality is further hampered by the lack of theoretical integrity or even appropriate empirical measures for sexual normalcy (Kleinplatz & Moser, 2005; Moser & Kleinplatz, 2005). As the situation is described in Laws and ODonohues review, "There are no well-corroborated accounts of the psychopathology involved in the paraphilias. In addition, too little is known about

normal sexuality and sexual development. Thus, again, there are gaps in what constructs ought to be measured" (2008, p. 6).

In addition to disciplinary divisions, public opinion plays a role in classification and conceptualization of the paraphilias. Depending on which particular paraphilia is under discussion, the lay public reactions vary from "Throw those perverts in prison and throw away the key" to "Lets castrate them all" to "Why does anybody care what a bunch of consenting adults do in the privacy of their own homes?" Both professionals and the public react quite differently to those who sexually abuse children—whether or not they actually are pedophiles—as compared with cross-dressers at home, whether or not they are diagnosable as transvestic fetishists. In addition, community groups have taken stands on the consequences of being diagnosed as pathological in terms of social stigma. Parents who have lost custody disputes or individuals who have lost their jobs or civil rights due to DSM diagnoses object strongly to the diagnosis of paraphilia, particularly given that most paraphilias cause no distress or dysfunction. Most conspicuously, BDSM activists object to receiving any kind of diagnosis for behavior that is judged as pathological based on social prejudice as opposed to empirical evidence (Kleinplatz & Moser, 2004; Moser & Kleinplatz, 2005; Nichols, 2006; Reiersøl & Skeid, 2006). Krueger (2009a) reports that in over 400,000,000 visits to primary care physicians in the United States, not one case was diagnosed of Sexual Sadism or Sexual Masochism.

Such evidence, the controversy about DSM classification, and the lack of compelling empirical evidence for pathologizing atypical sexuality per se have had an impact on classification and conceptualization of the paraphilias.

**DSM-5**

DSM-5 redefines the concept of paraphilia as "any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting adult human partners" (Blanchard, 2009a). This 187

definition advances a conceptualization for the paraphilias that was missing in the DSM-IV. Blanchard notes that its main advantage is replacing a definition by concatenation (i.e., listing) with a definition by exclusion. For better or for worse, it makes it decidedly clear that our professional conception of sexuality is still focused on activities directed between the legs and that whatever deviates from that goal is construed as abnormal.

Although the main advantage of this new DSM-5 definition is the umbrella description of the paraphilias, the specifying of abnormal behaviors listed in the DSM-IV-TR paraphilia section remains. In addition, according to the DSM-5 website, two new paraphilia categories were proposed in 2009: "coercive paraphilic disorder" and

"pedohebephilia" to replace and expand the pedophilia category. See Quinsey (2009), Blanchard (2009b), and Blanchard, Lykins, Wherrett, Kuban, Cantor, et al. (2009) respectively, for a description of these proposals. Neither of these new categories was retained in DSM-5.

Most important, DSM-5 accepted Blanchards proposal (Blanchard, 2009a, 2009b) to differentiate between the designation of paraphilia as a proclivity versus as a disorder: Paraphilias are not ipso facto psychiatric disorders. We are proposing that the DSM-V make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder (Blanchard, 2009b).

**THE ORIGINS OF DESIRE(S)**

This still leaves some sexologists and lay people with the question "Why does that turn them on?" as opposed to the more fundamental question of why anything might turn anyone on. The traditional, etiological discourse has focused on the cause(s) of unusual sexual interests, whether explained in terms of psychodynamic, behavioral, or other theories of psychopathology that explore developmental factors in the origins of unusual sexual proclivities. In recent years, the evolutionary discourse has supplanted the etiological discourse. That is, the evolutionary discourse defines normal sexuality in terms of purpose (i.e., propagation of the species), with sexual psychopathology defined in terms of deviating from the presumably biologically driven correct purpose of sexual behavior (see Cantor, Chapter 10,  for a discussion of the biological basis of pedophilia).

Such literature tends to investigate physiological markers of atypical sexuality among sex offenders (e.g. left-handedness, brain injury, neuropsychological profiles, functional asymmetry [e.g., Blanchard, Cantor, & Robichaud, 2006]). Even within this body of research, there is no consistent evidence for a distinct biological basis for the paraphilias (Cantor, 2012). But the focus remains on the atypical, as though we need to explain (away) divergent sexuality with no need to even notice our corresponding lack of understanding of normative sexual inclinations.

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In the 1980s, Money contributed the theory of "lovemaps," a construct intended to describe the origins of all sexual desire (1986). Money hypothesized that early sexual interactions (e.g., childhood sex play acting as a rehearsal for adult sexual expression) create a mental template during a childs vulnerable periods, at approximately age 8.

These become imprinted and later manifest in adult sexual expression. Prevention, prohibition, or other interference can cause the developmental process to go awry, thus resulting in "vandalized lovemaps," that is, the paraphilias.

Freund (1990) conceptualized the paraphilias as "courtship disorders," while Blanchard describes them as erotic target location errors (Freund & Blanchard, 1993).

The former refers to the inability to engage in the appropriate behaviors leading to heterosexual intercourse, whereas the latter refers to an incorrect object choice, which should be an adult, heterosexual partner. Both presuppose a correct sequence and ultimate objective for sexual relations.

**ASSESSMENT**

It is commonly known that a significant proportion, and perhaps most, of patients referred for the assessment of paraphilia are referred as a result of committing a criminal sexual offense. Assessment of the paraphilias is complicated not only by the factors mentioned earlier but also by methodological and ethical considerations in evaluating sex offenders. Those who undergo assessment or treatment procedures in compliance with court orders or in an effort to reduce their sentences may not be motivated to be honest. The clinicians conducting the assessment for sentencing or for risk of recidivism upon release are acting in societys best interests but do not necessarily represent the best interests of the individual being evaluated. One way of circumventing self-report biases and aiming for objectivity has been the use of phallometric testing. However, there are serious reservations about the reliability, validity, and lack of standardization in phallometry (Darcangelo, Hollings, & Paladino, 2008, p. 122).

As for the individuals with various paraphilias who are unlikely to seek therapy in any case, there is even less literature on assessment of them. The general recommendations are for assessment via clinical interview with a detailed developmental and sexual history, as well as the history of the problem. In particular, clinicians are advised to determine whether the individual would even qualify for diagnosis at all, based on the existence of distress or lack thereof and social, occupational, or interpersonal impairment. There are mixed recommendations as to the value of psychometric measures. For example, Krueger and Kaplan (2008, p. 154) state,

"Generally speaking, individual clinicians should review available instruments and alternatives, and decide for themselves what would be most useful." That is, there is no set of "best practices" or preferred assessment tools available in the literature for such evaluations (cf. Hucker, 2008; Mann, Ainsworth, Al-Attar, & Davies, 2008; Newring et al., 2008). Laws and ODonohue (2008) recognize the need for effective assessment tools in their comprehensive review of the literature but report concerns about accuracy, 189

validity, and reliability in current assessment of the paraphilias. Clinicians are advised to be attentive to any signs of neurological deficits, to enquire as to history of head injuries and drug use, and to consider possible referral for neuropsychological assessment. These recommendations are more likely to appear in the literature on pedophilia and exhibitionism than in the literature on cross-dressing or masochism.

It is unfortunate that the literature on assessment of the non-coercive paraphilias is so vague and sparse, given that individuals or couples in which one or both have unusual—and sometimes discrepant—sexual interests do occasionally appear in our offices. For example, patients often present with difficulties with arousal or desire in a particular relationship that upon enquiry are related to different conceptions of sexuality; these differences are often distinguished by divergent sexual fantasies, some of which may be atypical. Experienced sex therapists recognize that sexual fantasies often cause shame and guilt and are shrouded in secrecy, even when the fantasy content is normophilic, not to mention when it is unusual. It is helpful to treat the desire discrepancy rather than focusing on the atypical nature of the sexual desires, particularly when the individuals do not conceive of the nature of the sexual desires as requiring treatment (Kleinplatz & Moser, 2004; Nichols, 2006).

Perhaps one reason for the dearth of literature on the paraphilias in psychotherapy practice is the discomfort among clinicians in dealing with atypical sexuality per se, as well as the potential for assessment and treatment to result in legal entanglements (e.g., court testimony). Although the clinicians reluctance is understandable, for those who are willing to expand practice in this area, it is recommended that they consult with skilled forensic sexologists to learn how to navigate through legal complexities.

Therapists who recognize their own squeamishness in dealing with atypical sexuality may wish to seek supervision to process countertransference issues. It is also advisable that clinicians educate themselves about alternate sexual expression and familiarize themselves with local community resources and support groups.

**TREATMENT**

During the 1970s and 1980s, the cognitive-behavioral approaches to treatment for the paraphilias predominated. They attempted to control and reduce the unacceptable behavior and corresponding urges. Over the past 30 years, the literature has reflected the growing prominence of pharmacological approaches in treating sexual difficulties in general and paraphilic sexual behavior in particular.

The paraphilias qualify for treatment only when they involve distress and dysfunction—and a patient. In the sex therapy literature, there is little discussion in recent years of how to treat the non-coercive paraphilias, presumably at least partially because individuals with unusual sexual proclivities do not present for treatment of them. When sexuality has become the clinical focus of interest, the goal is increasingly to reduce distress (and sometimes the resulting dysfunction) caused by stigma rather than to treat the paraphilia per se (Kleinplatz & Moser, 2004; Moser & Kleinplatz, 2002; 190

Nichols, 2006). Individuals can reduce feelings of being alienated and ashamed by joining support groups (e.g., for cross-dressers), educational and advocacy groups, or social groups for like-minded individuals (e.g., the BDSM "munch," a social opportunity to meet others interested in BDSM at a restaurant, outside a sexual environment). These may include opportunities for meeting prospective sexual partners. All manner of options exist in online groups.

Although there are numerous single-case reports, there is a dearth of randomized controlled trial (RCT) literature on treatment of the paraphilias outside the forensic literature. First, obviously, for ethical reasons, RCT designs are not advisable for paraphilias when there are concerns about public safety. Second, although individuals with unusual sexual interests may appear in our offices (e.g., BDSM), given that these desires are not intended to be the focus of treatment (Kleinplatz & Moser, 2004; Nichols, 2006), the literature on "treatment" outcome is necessarily limited.

Of the individuals with a paraphilia that causes concern to society, many will not wish treatment. According to Morin and Levenson (2008, p. 101), "Sex offenders do not often choose therapy; therapy is chosen for them. The most skilled therapist, using the most effective techniques, will not change an individual who is not motivated to change." Obviously, there are ethical considerations in "offering" treatment to those who do not wish treatment except when the incentive is to stay out of or be released from prison. Conversely, contrary to the panic (and wording) in many news stories, not all pedophiles will ever act on their desires, and many, if not most, cases of child sexual abuse are committed by adults whose primary erotic arousal is to adults. Pedophiles may seek therapy to deal with their attractions to minors without any legal requirement or implications.

The predominant sex offender treatment programs at present consist of pharmacological intervention—specifically, the anti-androgens in combination with the SSRIs, for example, medroxyprogesterone acetate or cyproterone acetate with fluoxetine. This is referred to in the popular press as "chemical castration." It is generally recommended that this be combined with cognitive-behavioral therapy (CBT; Briken & Kafka, 2007; Guay, 2009), often including social skills training and relapse prevention. Symptoms are controlled for only as long as the patient remains medicated.

There is no cure; rather, the hope is for rehabilitation. That is, the predominant treatments do not attempt to change the nature of the individuals desires but rather their intensity and frequency and his or her ability to act on them.

A few of the sex offender treatment programs reject the traditional relapse prevention model and are supplemented by community support available to the sex offender upon his or her release (Marshall, Marshall, Serran, & OBrien, 2011). The Circles of Support and Accountablity (COSA) program, pioneered in Ontario, makes extensive use of volunteer and professional supports and shows significant promise for reducing recidivism (Wilson, Cortoni, & McWhinnie, 2009).

There is much controversy as to whether the existing interventions are effective. The outcome data are described as dismal, discouraging, inconsistent, and contradictory (Corabian, Dennett, & Harstall, 2011; Hanson, Bourgon, Helmus, & Hodgson, 2009).

The same complications that contaminate the initial assessment reappear in the 191

outcome literature. Although some clinician/researchers are optimistic about the salutary effects of treatment on sex offenders (e.g., Fedoroff & Marshall, 2010; Marshall

& Marshall, 2010; Marshall et al., 2011), others are less impressed. Some believe that treatment of sex offenders could actually make matters worse (Rice, 2010; Seto et al., 2008). A series of review articles on the treatment of the paraphilias cites reports of patient noncompliance, high dropout rates, long-term treatment failures, and the need for treatment to continue indefinitely, if not for life (Gijs, 2008; Greenfield, 2006; Guay, 2009).

Given the need for long-term use of these medications in sex offenders, it is striking that few articles identify reduction in sexual desire, arousal, response, and functioning as

"unwanted" or "significant side effects." On the contrary, such outcomes are seen as indications of treatment effectiveness. The fact that sexual pleasure is hard to relinquish does not seem to be a consideration. By contrast, Guay (2009) reviews the many adverse physical and sexual effects of these drugs, pointing out the need for better tolerated medications.

**THE EXPERIENTIAL MODEL**

An alternative approach originates in Experiential Psychotherapy (Mahrer, 1996/2004, 2002, 2011). It was developed over a 40-year period using extensive psychotherapy-process research on the worlds largest psychotherapy tape library, representing master clinicians of every orientation. The objective in developing Experiential Psychotherapy was to establish methods intended to bring about substantive personality change rather than aiming for treatment of specific DSM disorders (Mahrer, 1996/2004a, 2004b).

Although this model has not commonly been applied in treatment of the paraphilias (with certain exceptions; e.g., Kleinplatz, 2006, 2012; Kleinplatz & Krippner, 2005; Mahrer, 2012), its potential effectiveness in dealing with sexual problems, given its goals, methods, and so forth, makes it especially useful for sex therapy in general and for unusual sexual behaviors in particular (Kleinplatz, 1998, 2004, 2007, 2010; Mahrer & Boulet, 2001). It is likely to be brief psychotherapy and, therefore, time- and cost-effective. This approach can also be used for individual, marital/couple, and group therapy.

Experiential Psychotherapy (Mahrer, 1996/2004a) is unique, brings about fundamental change relatively quickly, and may seem intimidating to those unfamiliar with this approach. It does not aim to treat symptoms, problems, or conditions (Mahrer, 1996/2004a) but instead uses the presenting problem as an opportunity for qualitative change. The goals are for the client to integrate whatever is deepest within, thereby becoming a "qualitatively new person," and for the client to be free of any painful feelings that were present at the outset (Mahrer, 1996/2004a, pp. 81–82). In other words, the goal of Experiential Psychotherapy is to allow the individual to fulfill—rather than contain—his or her sexual and other potentials. Although there is no attempt to target behaviors—sexual or otherwise, deviant or normophilic—when fundamental

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personality change is effected, the results are manifest in sexual and other desires, wishes, fantasies, and behavior, intimate relationships, and bodily phenomena.

Each session uses moments of strong feelings as an entry point into the clients inner world. The shifts that occur in working with peak moments of strong experiencing provide the vehicle to help bring about deep-seated change (Mahrer, 1996/2004a). It is from within that the potential for substantive changes is accessed. It is a particularly apt approach for working with powerful impulses, intrusive and menacing images, painful feelings, or bodily phenomena. Precisely the same material that clients typically try to ward off, manage, or control (unsuccessfully) provides the perfect fodder for Experiential sessions. Whether it is the rape victims flashbacks and nightmares, the intense anxiety of the man reporting erectile dysfunction, the pain of the woman with vaginismus, or the fantasies of the individual with paraphilic fantasies (Kleinplatz, 1998, 2004, 2007, 2012), the distressing symptoms are never to be eliminated without attention to their value, meaning, purpose, and clinical usefulness. Sexual problems, including unusual sexual proclivities and troubling behaviors, are ideal to work with in Experiential Psychotherapy because the initial feelings that accompany them are so strong and close to the surface and therefore easy to reach (Kleinplatz, 2006, 2010; Mahrer, 2012; Mahrer & Boulet, 2001). The therapist and client are to enter into and dilate them. High or low desire or the "wrong" desires, compelling and recurring fantasies and impulses, can each provide the intensity required to begin an Experiential session.

The first step of each session involves finding a moment of strong feeling and using it to find something within that is accessed in the opening scene. In dealing with someone who is referred for treatment of a paraphilia, the content and context for this strong feeling could be a recurring fantasy, a disturbing desire, a fear of being discovered; it could be anything. The important thing is for the therapist to be open to letting whatever feeling is front and center at the outset intensify so as to access the inner experiencing. When that emerges, something shifts: What seemed ominous suddenly becomes less foreboding and instead is to be welcomed. What had been warded off now changes in character and is to be appreciated. New ways of being become possible. In order to make them real and attainable, the therapist is to accompany the client to live in moments from the past, where this new way of being could have, should have, or perhaps actually did surface. By making them increasingly vivid and by having the client live fully in such moments, the likelihood of enduring change increases. In the concluding step, the client, who has now lived as this inner, deeper potential, contemplates and rehearses actually being this new way in the real world. The patient has "a taste of what it is like to be this whole new person, to think, act, feel and experience as this whole new person who is living and being in the world outside the office" (Mahrer, 1996/2004a, p. 337). If therapy has been successful, the person who entered therapy is rather different from the one who has completed the process. He becomes what he might have been all along.

In Experiential Psychotherapy, the therapist is aligned with the client and listens experientially. That is, the therapist is to be disengaged from his or her usual sense of self and allow the clients experiencing to flow through him or her. Given that the 193

therapist is living in the clients phenomenal world, countertransference issues are minimized or eliminated (Mahrer, 2001). Although there are no contraindications as to clients undergoing Experiential Psychotherapy, therapists who are uncomfortable in entering the clients inner experiencing are advised to refer clients elsewhere when they are beyond their comfort zone (Mahrer, 1996/2004a). Additional training in Experiential methods can be very helpful in growing ones capacity to deal with taboo material.

In using this approach with couples, the same general format is followed. However, the concluding step involves having the client consider and try on for size the possibility of actually living as this new person, the inner experiencing, beyond this session. In this variation, the client also has the opportunity to include the partner and to experiment with or play out this new way of being with him or her, right then and there near the end of the session. Partners are typically receptive to these initiatives and tend to be eager to participate in the others growth.

**CAN THE OUTCOMES IN EXPERIENTIAL PSYCHOTHERAPY BE**

**COMPARED TO THE TRADITIONAL OUTCOME DATA IN**

**TREATMENT OF THE PARAPHILIAS?**

The goal in treatment of the paraphilias is reduction in the frequency of the behavioral manifestation of the paraphilia (e.g., voyeurism, exhibitionism, pedophilia). There is little attention to the clients underlying feelings. The criteria for effective outcome in Experiential Psychotherapy involve profound changes, specifically actualization and integration, rather than treatment of sexual disorders or, indeed, any psychopathology (Mahrer, 1994/2006, 2002, 2011). Such a model does not lend itself to producing traditional outcome data because the intended objectives are unrelated to a particular form of psychopathology—let alone sexual disorders—to be remedied (Mahrer, 2010).

The two objectives, however, are quite substantial: Successful Experiential sessions do result in (1) eliminating the original source of pain in the initial painful scene and (2) allowing the individual to become whatever is deeper within. Although Experiential Psychotherapy was not designed to treat sexual problems, it brings about changes so fundamental to personality that it eventuates in better intrapsychic and interpersonal relations, increases embodiment, sexual functioning, and the capacity for intimacy (Kleinplatz, 1998, 1999, 2004, 2006, 2007, 2010; Kleinplatz & Krippner, 2005; Mahrer, 1996/2004a, 2011, 2012; Mahrer & Boulet, 2001).

Based on the clinical and psychotherapy-process research evidence, I began to use Experiential Psychotherapy with my clients in sex therapy 25 years ago. As indicated previously, psychotherapy outcome research is not usually applied to a paradigm aimed at substantive personality change rather than treatment of psychopathology (Mahrer, 2004b). There is no traditional psychotherapy outcome research available on Experiential Psychotherapy for the treatment of voyeurism or, indeed, any of the DSM

sexual diagnoses. Nonetheless, it has been very helpful for a broad array of sexual 194

problems (Kleinplatz, 1998, 2004, 2007, 2010; Mahrer & Boulet, 2001), including the paraphilias (see the case history literature on the paraphilias in Kleinplatz, 2006, 2012; Kleinplatz & Krippner, 2005; Mahrer, 2012), and is worthy of consideration and systematic evaluation in the broader world of sex therapy.

**CASE ILLUSTRATION AND DISCUSSION**

The following case illustration involved a client who was referred for the treatment of voyeurism and was seen in Experiential Psychotherapy. The case is presented with informed consent. Identifying details have been changed to protect confidentiality.

Jeff and Nancy Sinclair contacted me as a last resort. They had first attempted therapy shortly after Mr. Sinclair was caught by his wife with one hand on his penis and another on his binoculars, pointed toward a neighbors open window. He had secretly been watching women or couples as his primary source of sexual arousal and release since early adolescence. He was deeply ashamed, not only of his clandestine need to see naked women or couples without their consent for sexual excitement but also of being discovered. He had previously spent 4 years with two therapists. He reported that the prior therapy had led to greater feelings of self-understanding and acceptance but that treatment had not affected his preoccupation with watching. He had also tried a 12-step group for several months and found it "depressing . . . those people kept talking about their shame but nothing ever changed." He was afraid that he was beyond help. During times when their relationship was especially sexually exciting, his pull to look at the forbidden was controlled. "But then it flares up. It will happen . . . its an obsession . . . it tends to be at a higher level of arousal than any other activity that I participate in." He reported having difficulty reaching orgasm without fantasizing to or enacting the voyeuristic theme.

Mrs. Sinclair had long been dissatisfied with their sex life. She complained that he never initiated sex, would sometimes refuse her, saying he was too tired, and would be unable to get an erection. She remarked that he would often fall asleep while stimulating her sexually. "I take a long time to come, and I hate to nag him." She wanted him to be assessed for narcolepsy but was not optimistic that he would be diagnosed as suffering from a neurological disorder. Mr. Sinclair said he was satisfied with their sexual relationship. When Mrs. Sinclair discovered her husbands voyeurism, she was relieved that the problem was "strictly his." She also wanted to deal with her feelings of betrayal given that his habit had long been clandestine. "He doesnt like to confront me. He always said that it would be much easier to protect and lie to me than to deal with upsetting me." His goal was to "get control" over his "sexual urges," but he did not anticipate giving up his fantasy entirely, nor did he wish to do so. I said that I would offer them the opportunity, if they were so inclined, to change as individuals and as a couple such that the context in which his symptoms existed as a painful source of conflict no longer occurred. They agreed, skeptically. I pointed out that I did not think I would be helpful by trying to change a man who found his sexual behaviour pleasurable 195

but that it was not up to me to make that choice.

Therapy consisted of Experiential Psychotherapy with a shifting focus, more or less from session to session, on the husband and then the wife. Both husband and wife are present for each session. In any given session, we focus on either individual but not both. The other observes and may occasionally participate toward the end of the session.

It is our second session and he is describing his family background—how his parents lavished attention on his older sister and ignored him and how he has always felt like an outsider. The words are insightful, but his feelings are muted. It is when he mentions his inability to urinate in public restrooms, that his feeling level increases noticeably: "Ive always been too sensitive." He says it started when he was 5 years old and his father would grab at his penis and mock him with the family present. "To him, it was a game, but I felt violated. It was sick and dirty." (As I allow his words to wash over me, listening experientially, I am feeling ashamed and squirming.) I ask him to speak to his father.

He says, "Leave me alone. Have some respect for me." But his father is answering that he was just joking around and that his son is overreacting. His brother, Colin, is approaching, menacingly. He is scared and looks at his brother, saying, "Dont you fuckin touch me." He is feeling frustrated, misunderstood, and alone. They continue to tease him. He is becoming increasingly distant and alienated. "Im not being heard. . . .

Hes denying that Im feeling what Im feeling." I say these words to his father directly but Mr. Sinclair responds, "I could never talk to him. He made me call him Sir!" He then turns to his mother. "Look at her. Shes pathetic. She just sits there! Each time it happened, I would pray for her to rescue me but she never said a word, and neither did I." I encourage him to speak right to her. He begins, "How can you stay with him? Do your thing! Just leave him and take me with you. Ive always been on the outside looking in but maybe . . . together, just the two of us, it could be different." (There is now a sense of reaching out, of closeness, of wanting to be intimate.)

I repeat his words but with more feeling. He continues, "If I let down my guard, hed accuse me of being a faggot, but with you, I had hope . . . there was a chance." As he focuses in on his mother, what emerges in the midst of violation, shame, frustration, and alienation is a sense of closeness, of reaching out, of connecting with one another. There is a sad wistfulness, an "if only" quality. I ask if this hint of what might have been evokes similar moments of closeness, warmth, reaching out, that were brought to fruition—

full-blown, fulfilled moments of this kind. He responds with memories of his maternal grandfather and of the time they spent together. "I love you because you cared . . . now youre gone and I miss you . . . I wish youd been my father." (He is speaking with fondness and affection and is beginning to cry quietly.) "I want you to know that I remember the way we would laugh together." He is now sobbing intensely. "Im longing for missed opportunities; there were times and people Id been drawn towards, feeling a desire to be closer with them, and Id blown it."

We begin searching aloud for similar moments when he had felt warm, affectionate, and fond toward another, on the verge of reaching out and perhaps even taking the steps, the initiative to connect. He remembered the gym teacher Mr. Carter, who had protected him from the teasing of his peers. "I think back and I feel so good, so alive. Id love to write him a letter, telling him how much he meant to me."

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From there, Mr. Sinclair began to focus more clearly on the present and future, on those in his current life for whom he feels a special fondness but rarely acts upon it. A whole slew of possibilities seemed to pop up, including reaching out to his older sister, Ellen, and a friend in Montreal, Richard, saying, "I miss you. We dont see eye to eye and thats OK. I still care about you and I miss your crazy sense of humor. I feel more like myself around you than I normally do. . . . Yeah, I guess its pretty important to choose the people you want to be around carefully."

The next session began with Mr. Sinclair saying that he had written a letter to Mr.

Carter. He had also presented his father with a letter, confronting him. The feelings of victimization and alienation had now been replaced with a desire to connect, notwithstanding some trepidation. He discovered that others were receptive to his tentatively making contact and that he wanted more. Most notably, Mr. and Mrs.

Sinclair seemed warmer, and her stance seemed to have softened, becoming more intrigued and less condemning.

During our fourth session, Mr. and Mrs. Sinclair enter my office in the middle of a disagreement. He seems intimidated. I ask him whats scaring him. He says he cannot stand opposing her; he can barely handle expressing his opinions to her at all. I am getting fleeting images of a little pipsqueak, an ineffectual boy standing up to a big, powerful adult and feeling scared silly. I describe it aloud: "I am trying to imagine the consequences of standing my ground. What will she do?" I ask. "Im afraid shell stop loving me," he answers.

"How can you say that?" she asks. "Im proud of you for confronting me!" I motion to her to hold off as his feelings are growing stronger. As I listen to him, he seems to shrink. I am seeing a little boy again, only now he is terribly alone, wanting desperately to be accepted. I describe this image to him, and he says, "Yeah! Thats me. Always alone. As a kid, I was short and skinny with two left feet. I was the last one picked for every team. Theyd tease me and Id go inside, alone. Theyd be out in the fields playing and Id go home, into the basement to read."

His wife interjects, "He told me all about it. He was really smart and hed get into all these books and make up this whole, rich fantasy world. Hed live in it. . . . " I interrupt her, explaining that I prefer to hear Mr. Sinclair talk about his childhood in his own words so that I can attend to what it felt like to actually be him as a little boy. "How old were you?" I ask. "Describe it, take me along so I can be there with you."

"I was 8 years old and I was so shy. Our house faced on to the fields and I would sit on the edge of the stairs, watching from a distance," he clarifies. "I remember once I was listening to their voices and it sounded like they were having so much fun. Just once, I wanted to belong. So I went over there to say Can I play with you? but they just laughed."

As we continue reliving this memory, my attention shifts from the initial feeling of being hurt, rejected, alone, and inadequate to that moment of leaving the porch and heading toward the other children. I ask him to return to that window of opportunity wherein he attempted to join his peers. What exactly is to be found there? As we delve into that moment, making it more and more vivid, what emerges is a sense of venturing forward, of reaching out and of offering himself, on the verge of connecting. We stop 197

here for a few minutes in freeze frame just to take it all in, to appreciate how special this feeling is. There is a warmth in our bodies, a lightness in our chests, a building excitement and quickening energy. This is distinctly, qualitatively different from the prior feeling of being a loser, destined to be alone forever, watching the fun from a distance. This new feeling is barely familiar to him. He can recall lots of moments of his usual feelings of alienation but few in which he is acting on this inner feeling. I ask him to see if he can recall moments in which the kernel, a hint, of this new feeling was present but in which he refrained from following through and acting on it.

"Yes," he says, "there are a lot of those! Like when the guys from work are going out for drinks at five oclock. When I first started working there, they used to invite me along, but I told them that I dont like to drink and drive. Id get all uptight and rigid—

awkward—and theyd look pretty uncomfortable, too. Eventually, they stopped asking me all together. What I really wanted to say was, Great! Id love to join you." (I am now

[virtually] in his office saying, "Me? You want me to go out for drinks with you? Id love to.")

We go through a series of such moments, occasions when he was on the verge of risking, of venturing forward, of reaching out and extending himself toward others but customarily withdrew. In each instance, we go back and try out this new potential way of being in place of his previous inclination to feel alone and inadequate. As he delves into each of these past moments, he experiences the potential for extending himself that had been untapped. With every attempt to reenter such scenes and to discover how it would have felt to actually be this new person in past moments, the new way of being seems to change a little, becoming more comfortable, fitting, and real; it seems to suit him. Each of these moments seems to draw us into the future, into the possibility of becoming this newly activated potential in his current life.

Mr. Sinclair considers the possibility of actually allowing himself to be this way in a variety of situations that currently exist: going out with the group at work after presentations for drinks; going to baseball games with the office support staff; attending the upcoming annual company picnic (for the first time); and so forth. Furthermore, given that these possibilities seem not only viable but attractive, Mr. Sinclair now creates a slew of entirely new situations in which he could arrange to venture forth and extend himself in his local community. He detests the Conservative government and feels tempted to join the opposition partys riding association (local party organization office)

. . . and his eyes twinkle as he looks over at his wife, who is giggling her assent. He has always been shy, but he suggests that he could offer to come to speak to elementary school students on career day.

I point out that he has come up with quite a list of options but we have been playing exuberantly; now, as the session is winding down, I ask if there is anything that he would seriously like to initiate right away, within the next 24 hours, to make these ideas into reality. He answers that he would like to invite the neighbors over for a barbecue. He is tired of making polite, small talk with them from a distance. Second, he has always wanted to play bridge with his sister and brother-in-law, but they would need a fourth.

He turns to his wife and asks if he could teach her how to play bridge. She agrees and seems somewhat dumbfounded that these ideas are actually springing from her 198

previously socially recalcitrant and withdrawn husband.

By now Mr. and Mrs. Sinclair have learned that Experiential Psychotherapy is most effective when one allows oneself to be immersed fully in past memories or future imagery. This means focusing for as long as it is ones "turn," uninterrupted by the spouse, who may have questions, reactions, and so forth, but who is to appreciate this work from the sidelines until invited to participate. It is the comfort that the couple have developed with that position that allows Mr. Sinclair to delve within while Mrs. Sinclair is quietly attentive during the following session.

At the beginning of the seventh session, Mr. Sinclair said that in order to move ahead, he wanted to deal with his past and, in particular, his unresolved feelings about his first love, Michelle. He closes his eyes as he describes his relationship with Michelle when they met at summer camp at age 16. He had spent the summer falling more and more deeply in love with her. During their last week they spent every possible moment together. "It was like Id died and gone to heaven. . . . I felt so close to her . . . we were making out for hours." He had been sure that they would finally engage in intercourse, but she refused. He had been frustrated and frozen at that point, not quite knowing what to do, but saying that he would wait for her. "I respected her." He spent the entire following year turning down opportunities to date other women while holding out for Michelle. But when he arrived at camp the next July, he found out that Michelle had become serious about another man. He would see her occasionally over the years, but they never discussed their feelings for one another. "There are still a lot of what-ifs. I would like to let go if it will help me connect with Nancy."

I instruct him to speak directly with Michelle. He begins, "Im angry. I hung on to my virginity for you." [I am looking at Michelle longingly with frustration and resentment.]

He continues, "That last night . . . Id never felt so close to anyone before. I wanted you so much I thought Id die. I couldnt wait. But you made me stop. You said, No, I want to wait till were married. . . .  That we had to get hold of ourselves. That if I loved you, Id wait. And I did. I cant believe we stayed dressed the whole time! I was such an idiot but Id have done anything you asked."

As I listen experientially I am attending to that moment just prior to Michelle calling a halt to the sexual contact and exploration. The feelings are of erotic closeness and passion, being sexually driven and intense, on the verge of sexual frenzy and overwhelmed. I name and describe these feelings for him, identifying the mounting sexual passion in my body (the body of a 16-year-old male), the power of my blood surging, the throbbing in the tip of my penis, the intense desire for this woman. He responds that he rarely feels that kind of excitement anymore, that he recognizes that throbbing sensation in his penis but that the explosive passion is a thing of the past. We linger in these feelings for a few moments, savoring them.

I ask Mr. Sinclair to return to that moment just before it was interrupted and to imagine what it would have been like had the feelings that were building at that moment been given free rein. He returns to that basement couch, taking her clothes off and then his own. This time there are no impediments to sexual expression, and he is flooded by sexual passion. He allows himself to experience how it would have felt to make love with Michelle, to let go with her and to explode together. As he revels in his own capacity for 199

overwhelming sexual passion, he begins to imagine calling her, arranging to meet, and describing his fantasy to her of how it might have been between them in glorious detail.