Initial Assessment
The client was referred by a physician for psychologist review, and so she walks in for a scheduled appointment. An initial intake assessment (history taking) was done.
A 35 year old female banker, who is married with one child, was referred by a physician as a result of a loss of interest in sexual activity/ libido. This is because the physician had done a thorough physical examination and perceived a psychological cause for client’s sexual dysfunction. Client complains of being worried and disturbed because she cannot fulfill her sexual duties in her matrimonial home. She reports that, about a week to her wedding, she surprisingly found out that her husband had 2 children. She had gone to visit her soon-to-be in-laws in their house when she met the children. Her would-be sister-in-law introduced them to her as her fiancé’s children. This information she claimed was heartbreaking but since her wedding was only a week away, she decided not to call it off but go ahead with the marriage. She, however, confronted her husband, who confirmed the news and apologized. Her trust for the man waned, but she stuck on with him, she added. Secondly, a year after her marriage, she found out that her husband had contracted HIV/AIDS when he travelled for work outside the country for a period of six months. Her husband could not tell her upon his return home, instead, he gave excuses whenever she made any move towards intimacy. After resisting her over a period, he agreed to get intimate provided they use protection (condom). This confounded her. Her husband eventually broke the news to her several months later when he invited her to his doctor’s office. She has since lost interest in intimacy with her husband.
As exists in African cultures, she is being pressured by her extended family and her husband’s extended family to have more children. Although her in-laws do not know about her husband’s HIV status, her mother knows about it. Her mother also puts on the pressure for her to divorce her husband so she can remarry and have more children. She is under emotional blackmail from her husband, as he keeps threatening her with committing suicide should she divorce him. Out of distress, the woman finally breaks the news of her husband’s HIV status to her in-laws. Per the culture of the client’s husband, a wife is supposed to be married by her husband’s brother (successor) when she is widowed. For this reason, the in-laws suggested that the client continues with the marriage but then, her husband’s younger brother would have to get her to conceive another child. However, she refused this arrangement because, according to her, it goes against her moral values. Client has no significant past or medical history or psychiatric history. A mental status examination was done. The client was well groomed and cooperative. She made good eye contact, normal psychomotor activity with no tremors. She spoke fluently but with a quavering voice as though wanting to cry. She admitted to having a depressed mood, and this was congruent with her low affect, looking unhappy and worried. Her thought content was logical and coherent; and with a good memory, she was well oriented in time, place and person. She also had good insight into her situation with fair judgment of her presenting complaint.
Using the DSM V criteria, it was formulated that client has an anxiety disorder (specific phobia which is situational). This is because, client has deep fear or anxiety of being infected with HIV/AIDS (phobic stimulus) and also because of her husband’s threats of committing suicide should she divorce him. Moreover, her fear worsens every time she and her husband would have to share a bed and especially during bedtime. The client actively avoids any physical contact with her husband, not even a handshake; and tends to be busy with house chores. Although many people may not intentionally risk their lives to contract HIV, the level of fear or anxiety exhibited by the client was out of proportion. In a typical Ghanaian setting, people living with HIV/AIDS are stigmatized and discriminated against. It is perceived that they acquired the virus through promiscuous lifestyles. This client did not want to go through such an ordeal, even if she contracts it from her own husband. Likewise, she was also not ready to reveal her husband’s medical status to any other person, and to her that meant she had no valid reason for a divorce. Nonetheless, she is under conflicting pressure from her mother and in-laws, but needs another child. These issues have been client’s cause of distress for the past year, affecting her efficiency at her workplace.
Management of the client followed this outline:
Client was seen on weekly basis at the out-patients’ department (OPD) for six sessions. During those sessions, she received help through her state of confusion and education as to why she has lost interest in intimacy. In the first session, she was given insight (psychoeducation) into what was happening with her. Her loss of libido was as a result of fear of contracting the virus if she goes intimate with her husband. She did not have in-depth knowledge of HIV/AIDS and its transmission and so she held some misconceptions. Even though she was ready to engage her husband in active conversations and live a normal life with him, the misconceptions she had prevented her from doing so; and that yielded to severe anxiety, to the extent of avoiding any physical contact. Client was taken through anxiety reduction or desensitization process and taught breathing exercises and biofeedback. She was encouraged to practice it regularly.
Cognitive behavioural therapy (CBT) has been used to treat sexual desire disorders by focusing on dysfunctional thoughts, unrealistic expectations, partner behaviour that decreases desire in intercourse, and insufficient physical stimulation. In this case, cognitive restructuring technique was used to help the client reframe the irrational beliefs (misconceptions) that prevented her from having any physical contact (such as hugging) with her husband. Client was tasked to deeply reflect on all that had been discussed, and pen down what she makes of the discussion. This would help her come up with a decision that may be deemed appropriate in her current situation.
Couple’s therapy (communication therapy) was held for the couple in order to help them understand that one partner (wife) has lost interest in sexual intimacy as a result of fear of being infected with the virus. They were, therefore, encouraged to reestablish open communication in their marriage so that they can freely express themselves to each other. However, husband was made to understand his wife’s current situation and her reason for aversion.
Outcome: during the early stages of the therapy sessions, client had much difficulty coming to terms with reality, but her husband continually persuaded her for intimacy. However, after the second session, client exhibited better coping strategies because she had decided to stay married, for religious and moral reasons. She also understood her husband’s distress and communicated her decisions to her mother, in-laws and her supervisor at work. Months later, she reported for psychological review but this time with a new decision to embark on separation (and not divorce). Generally, she looked better and her anxiety had reduced significantly. Client was discharged with the option to report whenever she found the need to, since she had resolved the matter at hand.