Stanley E Althof, Linda Banner
What do mental health clinicians mean when they say they are working with a difficult case? Are they suggesting that the symptom is especially severe, or the duration of the problem is lifelong, or that the patient is resistant to treatment? Before embarking on this chapter, it may be worthwhile to consider what experienced clinicians mean when they use the word “difficult”. Levine1 suggests there are four situations that define the difficult therapy patient: (1) the woman insists that her problem is entirely medical and is not open to any other interpretation; (2) the sexual problem is embedded in the interpersonal context and the partner is unwilling to participate, or support, the treatment; (3) the sexual symptom is comorbid with severe personality problems and/or addiction; and (4) the women’s sexual problem is complicated by her menopausal status. Segraves and Segraves2 define “difficult” in terms of mysterious, as when neither the therapist nor patient can reasonably explain the symptom in terms of any predisposing, precipitating, maintaining, or contextual factors. Finally, perhaps “difficult” refers to a case that is multidetermined with biologic, relational, cultural, religious, and psychologic overlays which all contribute to the onset and maintenance of the symptom.
Whatever one’s definition of “difficult” might be, therapists have had their share of such difficult patients. Some are frustrating, others challenging, some even impossible. Hopefully, no matter how difficult the case may be, we all learn something from working with these patients. With this in mind, we present a series of difficult cases of women with psychologically based hypoactive sexual desire and female sexual arousal disorders.3 A wide array of integrative techniques will be presented, including traditional psychodynamic/individual therapy, cognitive- behavioral interventions, behavioral prescriptions, hypnosis, and biblio-/videotherapy. We hope these case vignettes pique interest and stimulate readers to consider what they might have done in these situations.
While the nomenclature suggests that hypoactive sexual desire disorder and female sexual arousal disorder are discrete and separate disorders, women are seen typically in clinical practice with combined dysfunctions. Because the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR),4 and the World Health Organization’s International Classification of Diseases (ICD-10)5 nosology was not in keeping with what was seen clinically, a consensus panel of experts met to revise the definitions of women’s sexual dysfunction.6 The panel recognized the saliency of contextual factors and differentiated between the subjective and physiologic aspects of female sexual arousal disorder. The panel recommended that female sexual arousal disorder be divided into three distinct subcategories: (1) physiologic sexual arousal disorder; (2) subjective sexual arousal disorder; (3) mixed physiologic and subjective arousal.
We use the following metaphor with patients to sort through the multiple etiologic considerations for hypoactive sexual desire disorder and female sexual arousal disorder. For some, hypoactive sexual desire disorder is like not being able to find the ignition to start the engine of a car (i.e., sexual response cycle). This could be due to a low battery (i.e., hormones), low fuel (i.e., tired and other psychologic distractions), or starter problems (i.e., knowing it will not be satisfactory - no orgasm or pain - so why start the process?). Female sexual arousal disorder is like not being able to get the fuel to the engine and allow it to warm up and ignite.
It is always challenging to present clinical case material. For purposes of confidentiality and to protect the patients’ right to privacy, the material has been disguised and altered. The essential clinical problem and interventions, however, remain unaltered and described through the eyes of the therapist.
Case 1 - Sam and Sara
This was one of the most interesting and challenging cases because so much was going on to disrupt the couple’s relationship, let alone the wife’s libido. Sam, a 45-year-old businessman, had started and built up a successful construction company without support from anyone other than Sara, his 44-year-old wife of 27 years. They had been high-school sweethearts, had married when Sara left high school, and had quickly begun a family. Their older son had not gone to college because he struggled with substance abuse, while the younger attended college and was working with Sam.
Sara sought treatment for her low libido. Her childhood history revealed that she had been molested by several of her mother’s boyfriends from about 9 to 12 years of age. Her mother neither believed nor protected her when she was told about the incidents. Consequently, Sara learned to use sex to get attention in high school and learned that it was not something special to be enjoyed. Sex was something she did to “get and keep a guy”.
When she and Sam started dating in high school, she did not want to have sex on the first or second date because she wanted it to be “special with him”. However, he had been accustomed to demanding and receiving sex, so he threatened to end the relationship after a couple of weeks unless “she put out”. Ultimately, she complied. Sara was 14 at the time of her first sexual experience and she admitted that she never enjoyed it or experienced an orgasm. Due to Sara’s sexual abuse history, she learned not to trust primary caregivers and to use sex in an unhealthy way. In their early years of marriage, Sam had numerous affairs and prodded Sara to join him in “swinging” parties. With great reluctance, she complied for a period of years.
Two years before beginning treatment, she had an affair with a family friend and considered divorce. However, she did not want to end up like her mother, with many men, so she chose to disclose the information to her husband, precipitating their beginning couples therapy.
Multiple predisposing, precipitating, maintaining, and contextual events helped explain Sara’s hypoactive sexual desire disorder, including her history of sexual abuse and feeling that “women were not safe or valuable sexually”; feeling a lack of trust and respect from her husband’s many affairs; and guilt from her affair and comparing her husband to the other man sexually. Sara also had perimenopausal symptoms of mood swings, depression, and low libido. She had a hypercritical mother and absent father, and her older son’s substance abuse problem was a significant distraction. Sara was the primary office person for her husband’s business.
Sara’s initial visits were individual, with attempts to quell her anxieties through guided relaxation tapes. Then, Sam and Sara began couples therapy. Sam was able to be consistently empathic to and supportive of Sara, and this helped her build trust and respect. She was reminded that the relationship she and Sam were creating was unlike anything either of them had experienced previously.
They were asked to make a list of positives about their partner and themselves and share it in the therapy room. They described their ideal relationship and steps to enable them to achieve mutual relationship satisfaction. They were instructed to take turns planning a relaxing and romantic evening for each other without the endpoint of erections, intercourse, or orgasm. The endpoints were relaxation, romance, sensuality, and pleasure. In addition they were to make a past, present, and future affection list and plan a surprise from these lists for each other. They watched educational videos and talked about sex openly with the emphasis on intimacy instead of performance. Sara reported that she had always experienced performance anxiety, so that was part of the reason for having her do the relaxation tapes. Additionally, Sara began a regimen of hormone therapy to help stabilize her moods.
The couple began to focus on fun and making time to get away from the household stressors. They also developed a mutually agreed upon plan for dealing with the oldest son’s substance abuse. By working holistically and understanding the presenting problem from broad perspective, they were able to make the necessary changes to promote interpersonal growth and increased intimacy. Sara admitted she now actually felt closer to Sam than ever before - both emotionally and physically.
Case 2 - John and Jane
What made this next case difficult was that both partners were resistant to changing and “giving in” to the other partner. John, a 55-year-old computer consultant, and his wife of 32 years, Jane, a 55-year-old marketing manager, presented for treatment of low sexual desire. This couple had two children in their twenties attending college. A medical evaluation to assess hormonal status indicated that Jane was perimenopausal, with no significant alterations in hormone levels. During Jane’s sex history taken separately from John,2 she reported being aware of “using sex as her power within the marriage”. She was the oldest of three children and as a child felt like she was “closer to her father than her mother”. Jane was always the “responsible and good girl” and had been with a couple of partners during the “swinging ’70s” but had been monogamous since marriage. When stressed, she became private and enjoyed being alone.
John had normal sexual function and a very high libido. He was the youngest of three children and had two older sisters. He was also quite responsible and yet learned to quiet his anxiety with “connecting”. They were the classic isolator/fuser combination.
Each partner tended to keep score of what the other did. Jane used sex as her power within the relationship. She felt she had to use this power because it was “what her husband wanted and she had control over it”. When the children were growing up, she could stay busy being “supermom” and avoided sex by the excuse, “the children might hear us”. However, when the children left home for college, John began requesting more sex. His desire for physical intimacy was about once or twice a week, after it had fallen to once a month during child-rearing years.
Both were committed to the marriage and had previously been to three other marriage counselors. This was their first experience with a sex therapist. In addition to hormonal assessment, Jane was evaluated for depression and anxiety. The psychiatrist prescribed a variety of psychotropic medications to treat her depression.
The treatment regimen for this couple included traditional cognitive-behavioral sex therapy, relationship counseling, communication and negotiation skills, and recorded hypnosis for Jane. Traditional cognitive-behavioral sex therapy included focusing on the “goods” about themselves and their partner; defining their relationship and sex therapy goals; identifying the “hot buttons” from their families of origin that would create barriers to intimacy; and taking turns with a special romantic, relaxation, and pleasure-focused evening where the endpoint was not intercourse. They were instructed to take turns with blindfolds and hand restraints during the sensate focus massage sessions to focus on increasing sensual awareness. Hence, the sexual responsiveness in the areas of visual and tactile hand responses was minimized, while that of the olfactory, skin, taste, and hearing were increased. This process has a double benefit of increasing intimacy and trust within the relationship and increasing anticipatory arousal.
When this couple watched an educational video series, they enjoyed being able to observe it in the comfort of their home, so that they could stop and start it as they desired. Many couples report stopping the video and trying some of the exercises presented and then continuing the video on another day. Again, the goal is not the endpoint of intercourse and orgasm, but rather of romance, relaxation, and pleasure (i.e., connection, communication, and intimacy).
In the case of John and Jane, real progress in their treatment plan was made once Jane felt heard by John due to their enhanced communication and negotiation skills. John was able to pull back on his sexual demands and empathize with Jane’s depression. It is a fine line between “identified patient” and whole and healthy partner when doing couples counseling and cognitive-behavioral sex therapy. The therapist must be ever mindful of not getting into the middle of the couple’s power struggle, and triangulating with the couple. Another difficult topic to address and be aware of is the potential for secondary gain for maintaining the problem. Jane knew that withholding sex was her only power in the relationship, so her motivation to “fix” the problem was much lower than John’s. This potential of secondary gain is what made this a difficult case to treat. It was further complicated by the long-term symptoms of depression, and her peri-menopausal symptoms of decreased libido and vaginal dryness.8
The good news was that once the integrative treatment began, and the couple worked collaboratively, progress was made in decreasing the sexual power struggle. Unfortunately, this couple faced many other stressors and distractions during the treatment process. Each spouse lost a parent and each lost their job at one time or another during our treatment process. Because of their commitment to therapy and their marriage, they persevered until their relationship moved to a place that allowed for the trust and safety that fostered relaxed physical intimacy together. The treatment process ended 2 years ago, although they still come back from time to time for tuneups and to refresh their intimacy skills.
Case 3 - James and Joan
This couple had been married 15 years but had never had intercourse or consummated their marriage. Joan was defensive in therapy and presented for treatment of pelvic pain and low sexual desire because of threats of divorce from James. Her motivation to fix the problem was more extrinsic than intrinsic. The case demonstrates the comorbidities associated with, and the complexity of, female sexual dysfunction. That they could remain married and friendly for that length of time without intercourse is remarkable, and underscores their commitment to the relationship. However, the chronicity of their asexual relationship suggested that this behavior was entrenched and would be difficult to change. James was a 43-year-old computer engineer, and Joan was a 44-year-old interior designer. She had been to other physicians and psychotherapists without success for treatment of low sexual desire and pelvic pain disorder. She had tried hormones and exercise, but was resistant to other medications.
The author2 focused on helping her find her voice in the relationship and at work. As she developed feelings of safety and trust within her marriage, she also increased her self-confidence about her sexuality, and this allowed for more frequent physical intimacy.
In addition to the psychotherapy that included guided relaxation and recorded hypnosis to help quiet her anxieties around work and sexuality, Joan also worked with a physical therapist to treat her pelvic pain. She was advised to watch a video on physical intimacy in the context of emotional connection. It seemed that by using this collaborative and broad treatment protocol, this couple were able to overcome patterns of sexual inhibition that had plagued them for their entire married life. At the completion of treatment, the wife admitted looking forward to daily physical connection with her husband, whether it included intercourse or not. As her self-confidence and relationship satisfaction increased, the pelvic pain dissipated, as did the hypoactive sexual desire disorder.
Case 4 - Robert and Lana
Initially, Robert and Lana seemed like a straightforward case of combined desire/arousal disorder. What made this case difficult was that it seemed the explanation for Lana’s problems had clear recent precipitants that could easily be turned around. This bright, insightful, couple in their early thirties were highly motivated to overcome their sexual dilemma. Additionally, the author felt good about this couple, liking them and enjoying the therapeutic work. There was only one catch; no matter what was done, her sexual symptoms never improved. Both grew as individuals but ultimately grew apart as a couple.
This case seemed simple because there were three clearly precipitating/contextual factors. First, the couple had purchased a “fixer-upper house” where anything that could go wrong did. After 2 years, they were still living between sheets of plastic to keep the drywall dust off their bed, the bathroom was barely useable, and progress on the home was agonizingly slow. Second, Lana’s mother had unexpectedly passed away. Third, Robert’s appetite for sex seemed insatiable.
Prior to their marriage of 2 years, the couple reported a frequent and satisfying sexual life. As the marriage approached, however, Lana noticed that she was losing interest in being sexual. She was no longer able to get aroused or easily achieve satisfying orgasms.
Lana’s physical examination by her gynecologist was unremarkable - she took no medications and had no illness, her periods were regular, and she was athletic and fit. The gynecologist referred her for psychologic intervention, believing that the new sexual symptoms were the result of the stressful precipitating and contextual factors.
Weekly meetings were agreed upon to focus on the precipitating/contextual issues. Focus was on their feelings concerning the unfinished house. Robert felt he was to blame for them “living in a dump”. He felt incompetent and overwhelmed by the complexity of the necessary repairs. Lana had grown weary of his “fumbling”. Early in treatment, they decided to give up on their dream of building a “love nest” and hired a contractor, who quickly finished the job. Lana was also aided in the grieving process over her mother’s death. As expected, Robert held ambivalent feelings toward her mother.
We also began to examine Robert’s sexual insatiability. Two factors seemed responsible; as Lana withdrew sexually, he became increasingly anxious and calmed himself by being sexual (of course this pushed Lana to withdraw further). Second, the hypersexuality served as a compensatory mechanism for his wounded masculinity. He felt incompetent and inadequate because he could not successfully complete the home repairs. He agreed to initiate sexual interactions with Lana for the moment. These changes took place over the course of several months, and the couple seemed to be doing better; yet, surprisingly, Lana’s symptoms persisted.
At this point, the author rethought the initial hypothesis, that the precipitating and contextual factors were responsible for Lana’s sexual dysfunction. A new history was taken with an emphasis on finding predisposing factors that could help explain the impasse. Two facts emerged: at age 18, Lana had become pregnant and chose to have an abortion; and she recalled being molested as an 8-year-old by a baby sitter. At this point in her life, she no longer felt conflicted about the abortion and did not think it was related to her symptoms. She did, however, wonder about the impact of sexual abuse. It was still a mystery why she could have had 2 years of good premarital sex and then become symptomatic just prior to marriage.
Because the therapeutic work was now more focused on Lana’s past life, she began to be seen individually. While treatment appeared to help Lana work through the complicated feelings of being sexually victimized, her sexual symptoms did not improve. While Lana was being seen individually, Robert disclosed that he had fallen in love with another woman and wanted to leave the marriage. He did, and the next 6 months was spent on helping Lana deal with his betrayal and abandonment. Obviously, the sexual symptoms took a back seat to helping maintain her mental health through the divorce process. Two years later, when she was feeling better, we agreed to end therapy. This case was difficult because no matter what the focus, predisposing, precipitating, or contextual factors, Lana’s sexual symptoms never got much better.
A year after therapy ended, around Christmas, Lana sent a letter, stating, “First of all I owe you another big thank you. Shortly after we ended therapy, I felt something I didn’t expect. It was a wonderful feeling directly related to the finality of treatment. I felt like you had given me permission to go on with my life. By ending therapy you indicated that I had grown up, that I could take care of myself and that you trusted me to do just that. What a wonderful feeling that was. And, so very different from my mother who never acknowledged me as an adult.”
Five years later Lana telephoned, saying she had remarried. She talked about her new life and that she no longer had sexual problems. Perhaps the explanation had more to do with the relationship with Robert than originally thought. Or, perhaps the material discussed concerning her childhood allowed her to feel more adult and sexually comfortable in the new relationship.
Case 5 - Dan and Dawn
This next case is presented because it highlights several therapeutic difficulties, including the unwillingness of one partner to participate in treatment, childhood issues of mistrust and lack of respect from each partner’s family of origin,7 and the couple’s resistance to allowing themselves to be helped by someone outside their relationship. This case was further complicated by their internal conflicts between professing openness and willingness to change, and their deep personal pain relating to their inherent mistrust in primary relationships from their unhealthy families of origin, which caused them to be very resistant to change and psychotherapy.
Dan and Dawn were both 35-year-old elementary school teachers who had been married for 10 years. Dawn presented with low libido after their second daughter had been born, 5 years previously. Both of them thought that, since they were teachers, they could learn skills to overcome this problem on their own. They had tried vacations without the children, weekend getaways without children, and date nights. None of these solutions had worked. Instead, a cycle evolved where intimacy was avoided, and each became angry and aggressive with the other. From Dawn’s perspective, Dan would take his sexual frustrations out on her, and she would get defensive and resentful, further widening the wedge between them.
During the first meeting with Dawn, she said that because it was her problem, Dan was not interested in coming for sex therapy. However, he would participate in the homework that was sent home with her. The author began by taking a sex and family history from Dawn and establishing what their sex life was like before children, when things changed, and what solutions they had previously attempted. The family history revealed that Dawn had a history of always trying to please her parents but never succeeding. It was not surprising that she chose a husband who was also critical of her, whether it concerned her body image, sexuality, professional skills, parenting skills, or the way she combed her hair. She learned to develop better boundaries, and not react to Dan’s critical nature that had caused her to feel defensive and angry.
Clearly, the defensiveness and anger within the relationship made it difficult for Dawn to allow herself to relax enough to become aroused, let alone want to initiate physical intimacy. Dan, like many men, wanted to do “makeup sex” after a confrontation; Dawn felt like it would be like “sleeping with the enemy” without resolving the source of the conflict. The couple became mired in the negative feedback loop of attack and defend, and did not make progress until Dawn began responding instead of reacting to Dan.
As Dawn’s self-confidence increased and she learned not to personalize or react to Dan’s critical nature, she was able to stay more balanced and, ultimately, loving and available to him. She was taught effective communication and negotiation skills so that the confrontations were minimal and there was more positive energy for the relationship. Dawn practiced with guided relaxation tapes to help quiet her anxiety so that she did not amplify Dan’s inherent anxiety. She taught Dan breathing and connecting exercises so that they could both respond without reacting together. Dawn listed her past, present, and future ways of showing and sharing affection with Dan, and he made a similar list with her when she got home. They took turns planning a surprise from this list for each other each week. When treatment was finished, Dawn reported that she not only enjoyed the more frequent lovemaking with her husband, but she was also able episodically to initiate it. And, the more satisfied she was with their physical intimacy, the less anxious and angry Dan was with her. The negative feedback loop was converted to a positive feedback loop for this couple by giving them better physical intimacy skills in the context of the whole relationship.
Case 6 - Norm and Nancy
Norm and Nancy, a 30-year-old Asian couple, sought treatment because of her lack of desire, difficulty with lubrication, and total anorgasmia. What made this case difficult was her multiple sexual dysfunctions, the fact that they had not consummated their marriage, and Norm’s family demanding grandchildren.
Theirs had been an arranged marriage. They had been married for 10 years and were desperate to have children. This added an additional layer of complexity to the case. This was their first foray into treatment because they had been focused on Nancy’s establishing a professional career and gaining comfort living in America.
Another therapeutic hurdle involved cultural messages that directed her to keep personal problems within the family, especially sexual difficulties.
Treatment began with the usual family and sex history, with Norm doing most of the talking because Nancy’s English was not as good as she would have liked it to be. After the histories, they were instructed about general sexual function and mechanics. Then, their enormous performance anxiety was addressed by giving them homework consisting of having them take turns doing a “special evening” with the emphasis on relaxation, romance, and pleasure and avoiding the goals of erection, intercourse, and orgasm. Norm prepared a special dinner for Nancy, dried her back when she got out of the bath, and did the “clean breast inspection”. This is a playful activity that takes the performance anxiety away by having the man kiss the woman’s breasts to make sure they are clean when she gets out of the bath. Then, Norm proceeded to give her a sensual massage while Nancy offered feedback about what ways and places he touched gave her pleasure. This was a good ice-breaker for this couple because it allowed them to get to know each other’s bodies and their own ability to give and receive pleasure without the expectations that it lead to traditional sex.
They discussed what previous methods they employed to demonstrate affection, what they were doing presently, and what they would like in the future. Then, they planned a surprise for each other from this assignment. Nancy decided to buy some silk boxers for Norm and reported “getting aroused” while wrapping them in anticipation of his opening them and wearing them. It worked! When Norm put on the boxers she was excited and began rubbing her body against his on the living-room floor, and he proceeded to try to penetrate her. Unfortunately, he was not able to because her hymen was still intact.
They were referred to a gynecologist who specialized in infertility. She worked on helping to perforate her hymen, used dilators to prepare for penetration, and then verify that she was fully capable of becoming pregnant. Recorded relaxation tapes were prepared for Nancy to use prior to inserting the dilators. She would listen to the tapes, take a relaxing bath, practice with the dilators, and then begin placing her finger into her vagina. In small increments she progressed from inserting the dilators in the tub, to inserting them outside the tub with lubricant, to touching herself sensually and finally achieving orgasm.
Then, Nancy was instructed to masturbate in Norm’s presence. He was encouraged to help Nancy relax by setting the mood with candles, stroking and kissing her body, and talking about how much he enjoyed touching her. She was eventually able to guide his hand to where she liked to be genitally touched. Norm responded with an erection when she did that with him. Next, Norm rubbed his erect penis on her leg as she was fingering herself. He then was able to put his finger into her vagina as well. He noticed that her natural lubrication seemed to be flowing, and sensed they might be ready for penetration. Because they trusted in their therapist’s leadership, they were able to decrease performance anxiety and follow the treatment plan to achieve their ultimate goal of pregnancy. They sent a picture of their lovely new daughter some months later.
The goal in presenting these challenging cases was to share the treatment process and to demonstrate multiple sex therapy interventions used by the authors. There is no one right way to treat any of these cases and in different hands they might have received alternative treatment interventions. Psychotherapy remains part art and part science.
Psychotherapy seeks to restore women’s desire and arousal to the optimal level possible, given the limits of physical well-being and life circumstances. Treatment attempts to overcome the psychologic barriers that preclude mutual sexual satisfaction. It is not about frequency of intercourse, intensity of arousal, or counting orgasms. Success is defined in terms of greater sexual satisfaction, enhanced intimacy, passion, and relational pleasure.
1. Levine S. Personal communication, 2004.
2. Segraves T, Segraves K. Personal communication, 2004.
3. Leiblum S, Rosen R. Principles and Practice of Sex Therapy, 3rd edn. New York: Guilford Press, 2000.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn, text revised (DSM-IV-TR). Washington, DC: American Psychiatric Press, 2000.
5. World Health Organization. International Classification of Diseases, 10th Revision. Geneva: World Health Organization, 1989.
6. Basson R, Leiblum S, Brotto Letal. Definitions of women’s sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynaecol 2003; 24: 221-9.
7. Hendrix H. Getting the Love You Want. New York: HarperCollins, 1988.
8. Barbach L. The Pause. New York: Penguin Putnam, 1993.