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:
- An intake assessment session resulting in the formulation of a
diagnosis of FSIAD due to situational anxiety
- 6 therapy sessions (psychological education with its content, CBT,
decision making and couple’s therapy).
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.