Mindfulness in Sexual and Relationship Therapy

Lori Brotto, Meg Barker, Lori A Brotto, Meg Barker, Lori A Brotto, Meg Barker

• Publisher: Routledge
• Year: 2015
• eBook ISBN: 9781317746805
• Edition: 1
• Topic: Psychology
• Subtopic: Human Sexuality in Psychology
• Index: Psychology

Mindfulness represents the most significant shift in the world of counselling and psychotherapy within the last decade. Mindful approaches have been hailed as the 'third wave' of cognitive behavioural-therapy and mindfulness has been recommended – and found to be effective at treating – a wide variety of mental health issues. There has been a proliferation of popular self-help books based on mindfulness approaches, and much debate between western mindfulness practitioners and Buddhist scholars about the ways in which mindful theory and practice is being adapted for western audiences. To date, however, there has been relatively little research or writing considering the potentials of mindfulness for the arena of sexual and relationship therapy.

This book aims to address this by bringing together many of the key practitioners and researchers who are working in this area. The book presents a range of perspectives on what mindful theory and practice has to offer to our understandings of, and work with, sex and relationships.

This book was originally published as a special issue of Sexual and Relationship Therapy.

Orienting to the Present Moment

Where are you now as you are reading this Editorial? Can you read these words and notice the positioning and posture of your body? Can you observe individual sensations in a particular part of your body at this moment? Take a moment now to close your eyes and guide your attention to the sensations within your body. When you return to this page, can you be aware of mental sensations that arise (many people refer to these as thoughts). Perhaps there are thoughts about the contents of the upcoming articles in this special issue. Maybe there is anticipation about a desire to learn something new. Or maybe there are mental events related to a variety of issues completely unrelated to this Editorial or this special issue. Can you notice those mental events like you might notice streams of water in a river? From a distance. Can you remain firmly planted on the bank while you observe the flow of water that is your thoughts? This is a difficult practice. This is an essential practice. This is mindfulness. And sexologists have caught on that mindfulness is central to the experience of sexuality.

Although different practitioners define mindfulness somewhat differently, my own affinity is for the operational definition that resulted from a consensus meeting of mindfulness teachers, practitioners, and experts (Bishop et al., 2004). Here they define mindfulness as a two-component process that involves (1) the self-regulation of attention “so that it is maintained on immediate experience” (p. 232), and (2) orienting to the present experience with “curiosity, openness, and acceptance” (p. 232).

The idea for this special issue on Mindfulness and Sexuality arose in June 2011 at an Editorial Board meeting for Sexual and Relationship Therapy. Meg Barker and I shared our own personal and professional interests in mindfulness meditation, and each remarked on the lack of literature specifically on mindfulness as it applied to sexuality. Yet, both of us had garnered considerable experience using mindfulness meditation with clients seeking sexual health or sexological care, and each of us had a strong conviction about its utility. We were each familiar with some academics and clinicians in the sexological and sex therapy spheres who were similarly convinced. Thus began the process of encouraging those individuals to capture their experiences applying mindfulness to sexuality with words. What resulted was an astounding response to our call for papers for this special issue. Unfortunately, due to an aggressive timeline, there were a handful of excellent papers on the application of mindfulness to sex that did not make it in time for this special issue. We are thus excited to see the ripple effect that this special issue will have on the larger field of sexology as additional publications arise in this and other journals.

This special issue boasts an impressive 13 articles on topics related to the application of mindfulness meditation to sexual health, sexual dysfunction, relationships, and love. You will delight in the combination of empirical and review papers, and in authors’ descriptions of how mindfulness has applied to and transformed their own lives. Mindfulness teachers maintain that one cannot “teach” mindfulness without having their own regular practice. As you read this special issue, take notice of the writers’ own commitment to the practice of mindfulness in their lives.

As you read this special issue, we invite you to pay attention to your own body sensations and mental events. Notice your interaction with the words on the page. Observe thoughts that may arise moment by moment. Do so with curiosity, openness, and acceptance. Enjoy.

Lori A. Brotto, Ph.D.

Reference

Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Segal, Z. V., Abbey, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology Science and Practice, 11, 230–241.

Impact of an integrated mindfulness and cognitive behavioural treatment for provoked vestibulodynia (IMPROVED): a qualitative study

Lori A. Brotto^a, Rosemary Basson^b, Marie Carlson^c and Cici Zhu^d

^aDepartment of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada; ^bDepartment of Psychiatry, University of British Columbia, Vancouver, Canada; ^cGF Strong Rehabilitation Centre, Vancouver, Canada; ^dDepartment of Medicine, Queen’s University, Kingston, Ontario, Canada

Provoked Vestibulodynia (PVD) is a chronic pain condition involving sharp pain to the vulvar vestibule. Because of compelling outcomes using mindfulness-based approaches in the treatment of chronic pain, we developed and tested a four-session mindfulness and cognitive behavioural therapy tailored to women with PVD (called “IMPROVED”). Here we report on the experiences of 14 women (mean age 39.6 years) following IMPROVED using qualitative analysis. Six major themes emerged that captured women’s narrative stories: (1) feelings of normality and community in the group setting, (2) positive psychological outcomes following IMPROVED, (3) impact of relationship – including the beneficial effect of having a supportive partner and the negative impact of having an uncooperative partner, (4) an appreciation for treatment, including gratitude towards group facilitators, (5) barriers impeding ongoing practice of acquired skills following the completion of IMPROVED and (6) self-efficacy, which included a feeling that pain management was much more under women’s own control than they previously believed. Although the precise mechanisms of action are unknown and quantitative analysis of outcomes is still pending, these data are the first to report on the benefits of a mindfulness-based approach for improving quality of life and reducing genital pain among women with PVD.

1. Introduction

Provoked Vestibulodynia (PVD) is a major cause of vulvar pain, otherwise known as vulvodynia, which affects up to 16% of women (Bergeron, Binik, Khalife, & Pagidas, 1997; Friedrich, 1987; Harlow & Stewart, 2003). Provoked Vestibulodynia encompasses sensations of burning, stinging, irritation and rawness in the vulvar vestibule – the area delineated by Hart’s Line on the labia minora and containing the urethral opening and the introitus. The pain is provoked by touch (tampon insertion, sexual penetration, gynecologic examination). Genital pain that occurs spontaneously (i.e., not provoked by touch), is known as generalized or dysesthetic vulvodynia. Affecting women of all ages (Bergeron, Binik, Khalife, Pagidas, & Glazer, 2001; Friedrich, 1987; Landry & Bergeron, 2009), PVD is the most common cause of dyspareunia, or pain during sexual intercourse, in pre-menopausal women. Primary or “life-long” PVD is present since the first attempts at tampon insertion or intercourse, whereas secondary or “acquired” PVD begins after a period (often many years) of painless intercourse (or other penetration such as fingers, dildo insertion or other means of confirming absence of pain). Because intercourse hurts or may be impossible, PVD has a markedly negative effect on women’s emotional well-being and their sexually intimate relationships (Connor, Robinson, & Wieling, 2008). The diagnosis of PVD is clinical and based on history of the illness and a physical exam. Though the vestibule appears normal, except for variable erythema similar to what is seen in women without PVD, a cotton swab touch to the vestibule reproduces the pain sensations (Bergeron, Bergeron, Binik, Khalife, Pagidas, & Glazer, 2001).

Although much remains unknown regarding pathophysiology, there is increasing evidence that, similar to other chronic pain syndromes, PVD is associated with dysregulation of central pain circuitry (central sensitization) such that the “volume control” on pain is heightened (Bohm-Starke, 2010; van Lankveld et al., 2010). Central sensitization is defined as an amplification of neural signalling within the central nervous system that elicits pain hypersensitivity. Moreover, a number of other medical and chronic pain conditions are frequently co-morbid with PVD, including interstitial cystitis, irritable bowel syndrome, fibromyalgia and muscle tension syndromes (Peters, Girdler, Carrico, Ibrahim, & Diokno, 2008).

Management of PVD is complex and multiple treatment modalities with varying efficacy are currently available (Landry, Bergeron, Dupuis, & Desrochers, 2008). Treatments include biomedical, psychological, physical and surgical options. Very few randomized controlled trials exist and evidence suggests a marked placebo response compared to oral desipramine and topical lidocaine (Foster et al., 2010). The efficacy for topical formulations of estrogen and lidocaine vary widely between 13 and 67% (van Lankveld et al., 2010). Cognitive-behaviour therapy (CBT) carries an efficacy rate of 35–85%, depending on the endpoint (Bergeron, Binik, Khalife, Pagidas, Glazer, Meana, et al., 2001), has very good long-term effects (Bergeron, Khalife, Glazer, & Binik, 2008) and is more efficacious than topical glucocorticoids at follow-up in terms of pain, sexual functioning, treatment satisfaction and reduced catastrophizing (Bergeron, Khalife, & Dupuis, 2008). Although surgery (i.e., vestibulectomy) appears superior to medications (Haefner et al., 2005; Landry et al., 2008), exclusion criteria for this procedure are numerous and, despite moderate pain relief, resumption of intercourse does not always occur (Tommola, Unkila-Kallio, & Paavonen, 2010). There is evidence that baseline levels of pain is a significant predictor of treatment response, even 2.5 years following treatment, and the more pain women experienced during a gynaecological exam at pre-treatment, the less they benefited from treatment (Bergeron et al., 2008). Clinically, there is evidence that most women with genital pain use at least three different treatments before seeing any pain relief (Sadownik, 2000).

Psychological approaches to pain management have a long history. In the past decade, cognitive-behavioural therapy has been tested in the treatment of chronic pain in a variety of trials (Eccleston, Williams, & Morley, 2009). The use of this approach for PVD is based on the knowledge that chronic genital pain significantly impacts a woman’s psychological, sexual and interpersonal health. Moreover, stress has been found to dysregulate sensitivity to pain (Chapman, Tuckett, & Song, 2008) and to increase one’s vulnerability to developing a pain syndrome (Slade et al., 2007). Cognitive-behaviour therapy is focused on challenging maladaptive pain-related cognitions, teaching behavioural skills in anxiety reduction and improving affect. Cognitive-behaviour therapy administered in 10 group sessions led to significantly improved psychological adjustment and sexual function and a high rate of treatment satisfaction at 6-months, though only a 30% reduction in pain intensity. Effects were maintained at a 2.5-year assessment (Bergeron et al., 2008). These improvements in pain intensity are mediated by changes in psychological and sexual functioning (ter Kuile & Weijenborg, 2006).

Mindfulness is considered the third wave of cognitive behavioural therapies and is increasingly used together with CBT skills for a variety of psychiatric conditions, especially chronic pain (McCracken, Carson, Eccleston, & Keefe, 2004; Teixeira, 2008; Thompson, & McCracken, 2011). A recent meta-analysis found that mindfulness-based therapies are a good alternative to CBT in the treatment of pain, particularly for those who do not respond to CBT (Veehof, Oskam, Schreurs, & Bohlmeijer, 2011). Mindfulness promotes a state of awareness in which thoughts are allowed to enter consciousness and then are let go without any emotional attachment. It has been described as “uncoupling” of the physical sensation from the emotional and cognitive experience of pain (Kabat-Zinn, 1982). Research suggests that meditation primarily reduces the negative appraisal of pain during its anticipation (Brown & Jones, 2010). Given the documented hypervigilance to pain shown by women with PVD (Granot & Lavee, 2005), mindfulness may be of particular benefit. As well, there is evidence that mindlessness might be a precursor to pain catastrophizing – also characteristic of women with PVD (Schütze, Rees, Preece, & Schutze, 2010; Sutton, Pukall, & Chamberlain, 2009). Moreover, acceptance, a significant component of mindfulness defined as the “willingness to continue to actively experience pain along with related thoughts and feelings” (Thompson & McCracken, 2011) may allow women to accept their emotional response to PVD in a compassionate manner.

Despite strong speculation that mindfulness-based approaches may be especially useful for women with PVD, there are not yet any published data. Here we report on the qualitative experiences of women taking part in group treatment program that integrates mindfulness-principles along with cognitive behavioural therapy. We named this treatment IMPROVED (Integrated Mindfulness for Provoked Vestibulodynia). Although participants were part of a larger randomized trial with primary quantitative endpoints, the goal here was to capture women’s narratives of the impact of this intervention on their life and their genital pain.

2. Materials and methods

2.1. Participants

All women who took part in IMPROVED between November 2008 and June 2009 were eligible to participate in the current study. They were referred to the program by specialists and primary care physicians with a diagnosis of PVD and all were treated in a large metropolitan west coast city. Participation was voluntary and no remuneration was provided. As a result of 22 letters of invitation, 14 women consented to the study and completed the interview (63.6% response rate). We achieved saturation of themes with these 14 participants.

The mean age of the participants was 39.6 years (SD 13.6, range 21–68 years of age) and the mean relationship duration was 7.2 years (SD 8.71) for the nine women who were partnered. Of the 14 women, 9 were of European ancestry and the remaining women were East Asian. All women had received post-secondary education with two having graduate degrees. Six women had lifelong PVD and eight women had acquired PVD, they ranged in the number of years they had PVD from 2 to 26 years.

2.2. Procedure

The IMPROVED program consisted of four, two-hour sessions, spaced two weeks apart. It consisted of basic education on PVD and pain neurophysiology, CBT skills in identifying problematic thoughts and progressive muscle relaxation and mindfulness exercises including eating meditation, mindfulness of breath, body scan and mindfulness of thoughts. These mindfulness exercises were adapted from those that form part of the mindfulness-based cognitive therapy (MBCT) program for depression developed by Segal, Williams and Teasdale (2002). Although mindfulness skills formed the basis of IMPROVED, it was not a traditional MBCT program given that, in IMPROVED, facilitators discussed the possibility of challenging problematic thoughts as well as described instances in which thoughts might simply be accepted as they are. Thus, IMPROVED was not strictly an “acceptance-based” treatment program but, rather, facilitators discussed instances in which acceptance might be preferable and others in which challenging thoughts might be preferred. IMPROVED also included elements of sex therapy, including a discussion of non-penetrative pleasuring and a description of the circular sexual response cycle as it relates to PVD (Basson, in press). A comprehensive treatment manual that included facilitator and participant handouts was developed by the authors.¹

Interviews were conducted by telephone or in person in a confidential setting, 12–18 months following completion of the 4-session IMPROVED by a trained interviewer not involved in the treatment sessions. Participants were told that the purpose of the interview was to explore how different aspects of their lives – physically, sexually, emotionally and psychologically – have progressed since their participation in IMPROVED. A list of pre-established guideline questions was prepared for the interviews and relevant fo...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• 1. Orienting to the Present Moment
• 2. Impact of an integrated mindfulness and cognitive behavioural treatment for provoked vestibulodynia (IMPROVED): a qualitative study
• 3. An integrated mindfulness-based approach to the treatment of women with sexual pain and anxiety: promoting autonomy and mind/body connection
• 4. Mindfulness and sexuality
• 5. Mindfulness and Good Enough Sex
• 6. Sexual Wellness Enhancement and Enrichment Training (SWEET): A hypothetical group model for addressing sexual health and wellbeing
• 7. The place of mindfulness in a sensorimotor psychotherapy intervention to improve women’s sexual health
• 8. Mindfulness: a sexual medicine physician’s personal and professional journey
• 9. Mindfulness in love and love making: a way of life
• 10. Mindful mating: exploring the connection between mindfulness and relationship satisfaction
• 11. The perceived effects of practising meditation on women’s sexual and relational lives
• 13. This very body, the Buddha
• 14. What’s wrong with sex? A Buddhist perspective
• 15. Reflections: Towards a mindful sexual and relationship therapy
• Index