The fact that psychological therapy can help women with vulval pain is not to suggest that vulval pain is ‘all in the mind’: quite the opposite, as the mind is integral to the experience of pain and the brain-body connection is vital to an understanding of pain. Psychological factors tend to play a role in maintaining or exacerbating long-term pain, for example:
- Worrying about the pain can lead to bodily tension and greater pain;
- The experience of pain can lead people to avoid formerly pleasurable activities for fear of exacerbating it (e.g. sexual ‘shutting down’) – this tends to bring our mood down, increasing a negative view of ourselves;
- Feeling that we cannot control the pain can lead to a sense of helplessness and hopelessness – this lack of perceived control is likely to increase stress;
- Our thoughts and emotions affect the intensity with which pain is experienced.
Stress influences how pain is processed in the brain. Essentially, the pain circuitry in the brain is influenced by our emotions and thoughts. By acting on the way we process emotions and thoughts, psychological therapies aim to change that brain circuitry in order to improve coping and reduce the intensity of the pain. Furthermore, therapy can help women who are experiencing distress as a result of sexual and relationship difficulties in relation to vulval pain.
Various psychological therapies have demonstrated benefit for women with vulval pain: in being able to manage and cope with the pain, as well as reducing its severity, and in having satisfying sex lives. The most common approach is cognitive behavoiural therapy (CBT). CBT involves learning and practice of specific pain-relevant coping and self-management skills, including adapting some of the unhelpful thoughts and beliefs we might have about ourselves in relation to pain, sex and relationships. It helps people explore different ways of behaving that are more pleasurable. CBT is often augmented by related therapies of acceptance and commitment therapy and mindfulness – these work by encouraging an attitude of acceptance and working ‘with’ rather than ‘against’ the pain.
This service tends to be provided within hospital-based Clinical Health Pasychology departments, where psychologists work closely with other professionals. As part of their role, clinical psychologists will also usually provide sex therapy.
Dr John Newbury-Helps, Specialist Clinical Psychologist (Genital and Pelvic Pain), Jefferiss Wing, Imperial College Healthcare NHS Trust, London.