Quick summary of Talli Rosenbaum’s richly informative pre-con called “Beyond the Physical, an integrated Psychosocial Model for addressing Sexual Issues in pelvic physical therapy practice. Summarized by Elizabeth Lewis, PT, OCS, WCS.

Talli R is an ASSECT trained sex, individual and couple’s therapist, who got interested in the area while working as a pelvic floor PT.

I tried to pull a few pearls:

1.      We work under something called the biopsychosocial model of treating sexual pain, which compartmentalizes different aspects of the problem to different specialties: we PTs and MDs work on the physical aspects and leave the sexual dysfunction aspect to the sex therapists.  This is a problem, because we PT’s are more likely than the sex therapist to witness the anxiety in real time.  PFM hyperactivity isn’t simply an isolated dysfunction, but a physical manifestation of the patient’s emotional state.

2.      Many clients can have triggering of anxiety, fear avoidance, etc., because the exam most closely mirrors the sexual setting.  We have limited training in how to handle this.

3.      Talli described her Mindfulness protocol (which can be used with dilators, making it also a behavioral technique).  I have included a summary of what she said about that, for a hand out.

4.      She also spoke about Behavioral Therapy, including:

·         Desensitization and gradual exposure, starting from stick figure pictures and graduating to the patient viewing her genitals with a mirror and her fingers. 

·         Anxiety reduction if unable to examine (I will summarize her protocol for this).

·         Body awareness and movement

·         Breathing and relaxation exercises

·         Gradual dilators (for female sexual pain)

·         Pelvic floor awareness and exercise

5.      She talked about what she called an existential conflict, of the cognitive and emotional split: Cognitive is thinking and judging “I have to fix this problem or my husband will leave me”, the emotional aspect is the fear and anxiety which they try to ignore, hoping it will go away, the sensory part is a flight or fight reaction, including muscles contracting and the Behavior aspect is a withdrawal response and dissociation.

6.      In this case, the clients are trying not to feel, using their cognition and motivation to try to get through it, (i.e. sex or an exam) but they need to learn to be aware of their anxiety and of what level it is.  Then, if they start to get nervous, they can do breathing and mindfulness exercises to try to bring them back.

7.      We therapists can help by communicating things such as “you say you’re ready but you look anxious to me.  What’s going on in your body-what are you feeling right now?”  You could say “I don’t examine on the first day” and then see their relaxation.  Then ask:  “what just happened, what you are feeling now?”  (This can help them to feel safe, not pressured, normalized and also in touch with their body/sensations and how they can begin to relax more.)

8.      Sexual abuse: many women don’t report it due to feelings of shame, lack of perception of safety or repression of painful memories.  It’s important to inquire about abuse and to know how to cope with post traumatic exacerbations, dissociative reactions or flashbacks.  Talli uses mindfulness for this.

9.      Mindfulness is a life approach of being in the present moment and not trying to change what’s going on.  It’s recognized in the treatment of chronic pain and anxiety, as well as sexual dysfunction.  It addresses perceptions, attitudes, feelings and thoughts.  It allows clients to recognize how cognitive judgment of their feelings and symptoms negatively affects their symptoms.  It allows them to focus on and accept feelings and perceptions.  It teaches that rumination and “chewing over” negative thoughts won’t solve their problem.  Rather, it’s Non judging, patience, letting go, Beginner’s mind, trust, non-striving and acceptance.  It is comprised of paying attention, being in the moment, having no goals other than staying present and: no “results”.

10.  Talli’s Mindfulness protocol:  

·         Step one: Lie on your bed, covered with a sheet, rate anxiety level from low to high, (0-5).  If it’s high, do whatever you need to do to drop it to 0-1.  This may include lying in a more protective posture on your side, or relaxation deep breathing.  This exercise is repeated until you are able to lie on your back with your knees flexed and together, at anxiety level 0-1.

·         Step two: Lying on the bed, fully dressed (with pants) and covered with a sheet, bend knees and separate legs.  If you feel anxious with your knees apart, do what you need to do to relieve your anxiety, by bringing your knees together or deep breathing.  This exercise is repeated until you are able to rate your anxiety level with legs apart at 0-1.

·         Step three:  As above but remove sheet.  Returning the sheet is now one of the anxiety lowering options available to you.

·         Step four:  As above but wearing shorts instead of long pants.  First with, then without the sheet.

·         Step five: As above but with underwear only, first with and then without the sheet.

·         Step six: As above without underwear, first with and then without the sheet.

11.   After this intervention, then homework or with PT: genital self-examination, mirror work, self-touch, dilators and then manual therapy can be initiated.  This is especially helpful for women from traditional cultures who experience a jarring and difficult effect with the transition from modest dress/manner to complete exposure.

12.  Advantage of this is that it allows the client to reach the genital exam when she is far more prepared for it and can be both physically and emotionally present and less likely to dissociate during the exam.

It also teaches her to value her anxiety and be with her pain mindfully