The most prevalent female sexual dysfunction by women is arousal and orgasm. Many women have encountered orgasmic disorder their whole life. It is known as Female Orgasmic Disorder (Ohl, 2007). Female Orgasmic Disorder is one of the female sexual disorders, affecting 22-28 percent of female women (Zakhari, 2009). It is defined as a persistent or recurrent delay or an absence of orgasm during normal sexual activity marked by distress over the lifespan (Ohl, 2007). This paper will demonstrate Counseling Plan a woman who was referred by her gynecologist for counseling because she has never experienced an orgasm. It will include assessment of the dynamics of the couple’s relationship as well as issues regarding their sexual functioning, possible sexual dysfunction within the framework of the sexual response cycle, sexual normality as well as a evidence-based counseling interventions grounded through research and treatment plan with ethical considerations.
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Table of Contents
Abstract 2
Case Study: Michelle and Tom 5
Assessment of Sexual Issues 6 Biological Assessment of Sexuality 6 Cultural Assessment of Sexuality 6 Religious Assessment of Sexuality 7 Psychological Assessment of Sexuality 8
Assessment of Dynamics of the Relationship 8 Family and Couples 8
Diagnostic and Multi-Axial Impressions 9 Diagnostic 9 Multi-Axial 10
Integration of Disorder 11 Sexual Response Cycle Framework 11 Sexual Normality and Sexual Response Cycle 12 Sexual Disorder and Sexual Response Cycle 13 Psychosexual Development over the Lifespan 14 Psychosocial Contributions 15
Treatment Goals 15 Individual Goals 15 Couples’ Goals 16
Counseling Interventions 17 Initial Assessment 17 Counseling Techniques 17
Treatment Plan 18 Biological 19 Cultural 19 Multicultural 20 Religion 21 Psychological 22 Treatment Outcomes 22
Ethical and Legal Considerations 23 Ethical 23 Legal 24
Conclusion 25
References 26
Case Study-Michelle and Tom Michelle is a 42 year old Latina who came to your office referred by her gynecologist, because she has no orgasm. She reports that she is not very sure she has ever experienced an orgasm. She has been married to Tom for 9 years and reported having no experience with masturbation. She was raised in a very traditional and religious community, where sex was not talked about. Tom is a kind man of Arabic descent. Both Michelle and Tom grew up in Boston, MA. Michelle grew up in Catholic Church, and Tom was raised Baptist. They have two children together, a 7-year-old girl, and a 5-year-old boy. Michelle tells you that Tom feels she should come to therapy alone, since this is her problem. They have a good relationship overall, but sometimes they have arguments because of finances. Michelle does not trust Tom’s financial decisions since he has accumulated some debt over the years. Even though Michelle works as a teacher, the couple has a traditional marriage in regards to their spousal roles: she is the one who primarily takes care of the children and of their house. Michelle reports that their sexual encounters last around 20 minutes. She says that Tom is romantic and sensual, but that secretly she would like him to be more sexually assertive towards her. However, she is afraid of expressing her preferences to him. She experiences no pain with intercourse, but at times she feels she is not aroused enough when Tom begins intercourse and experiences dryness and some discomfort afterwards. She is in good health and is not currently taking any medication. She reports that they are affectionate towards each other in the bedroom and out. She is in your office because she would like to start having orgasms. She tells you that all her friends say she is missing out! Assessment of Sexual Issues Michelle is a woman who was referred for counseling because she reports she has never experienced orgasm. Details of her case are included in this counseling plan along with her complete case study.
Biological Assessment of Sexuality Michelle is 42 years old with two biological children, a girl and a boy. She is in good health and is not on any medication. The essence of a woman’s sexuality is basically defined through her relationships with others, both in the present and past. It also has an impact on her family, friends, and partners, and it is consistent with relational theory (Striepe, & Coons, 2002). According to traditional gender role socialization, patriarchal standards requires that males accept the dominant and aggressive behaviors and role in the public arena, while females accepts the adaptive and nurturing behaviors and role in the private arena of the family (Levant et al., 2003). Social and cultural factors play a much greater role in sexuality with women than men and women are the individuals that create the sociocultural contexts. Physical factor plays a part in the environment, which is most influential and the social and cultural issues are secondary when it comes to sexuality for men (Baumeister, 2000).
Cultural Assessment of Sexuality
Michelle is a Latina. She stated she came from a very traditional community. Comas-Diaz (2010) denotes that gender roles of Latina women are expected to take care of their relatives and tend to the house. Although Michelle is a teacher, she shared that she cares for the children and their house. Tom is of Arabic descent. According to Awad (2010), there is little information on Arab/Middle Eastern Americans and their practice due to a lack of respect as a minority group by the United States officials. Therefore, very little is known about this cultural group. Even though some research indicate that discrimination and psychological are associated issues such as emotional distress. The author mentioned the role of acculturation and ethnic identity play in Arab Americans’ perception is limited. Additionally, the author asserts that Arab Americans are frequently spoken of monolithically or their religious connection is either unnoticed or assumed to be Muslim. Finally, the author also convey that most importantly, family is central to Arab Americans and high priority is given to family responsibilities and parents are extremely involved in their children’s lives for most of their lifetime; and they share cultural values for Arab Americans include the significant role of religion and the immigration experience (e.g. finding a job and raising American children).
Religious Assessment of Sexuality Michelle came from a religious community and her affiliation is Catholic. Knapp, Lemoncelli and VandeCreek (2010) indicate that religious beliefs are linked to good mental health and social functioning. Catholics believe that Mother Mary is a key figure and they believe in saints and angels. Members are granted forgiveness for their sins by confessing to their priest who acts as the agent of Christ (Catholic Online, 2011). Michelle will disclose the depth of her involvement in her faith if it is a precipitating factor for her treatment. Society has connected the Catholic religion with very prudent views on sex and it is factual that the Catholic Church sees sex for reproduction purposes; it also sees sex as the ultimate expression of love between partners and some people believe that the Catholic Church look down upon all sexual activity except for the purpose of reproduction (Epigee, 2011). Tom was raised a Baptist. Awad (2010) expresses the majority of Arab Americans are Christian which includes 77 percent of Arab American population. Whether Tom is active in his faith will be established. Historically, Baptists beliefs of gender and sexuality are consistent with Protestant views in general. However, in reference to human sexuality, normally, Baptists hold to traditional and conservative views and Baptists, as with other Christian religions, believe that intimate sexual relations are a present from the higher power to be enjoyed between a man and a woman in the context of marriage (Patheos, 2011). Tom’s religious background and belief will be evaluated.
Psychological Assessment of Sexuality Sex was never talked about growing up and Michelle has no experience with masturbation. She stated that she and Tom are affectionate in and out of the bedroom and that she wishes Tom were more sexually assertive. Michelle is afraid to tell her husband her sexual preferences. She indicated that her friends are the reason she sought counseling.
Assessment of Dynamics of the Relationship
Family and Couple Functioning
Michelle and Tom have a traditional marriage in regards to their traditional spousal roles. Therefore, as a couple, identity crisis as a couple maybe a barrier for Michelle to seek counseling because of the support system in the marriage because they are not supporting one another (Reid, Dalton, Laderoute, Doell, & Nguyen, 2007). Michelle was raised in a very traditional and religious family, where sex was not discussed. Because Michelle did not talk about sex in her childhood; she lacks knowledge in the area of sex. She grew up has a Catholic and her husband grew up has a Baptist. Since they have different religious backgrounds, their views on sexuality are different. Wylie et al. (2008) convey that religious factors play a role in sexual problems. They argue because of financial debt created by Tom and she does not trust him with the finances of the home. Michelle works as a teacher and is the only one who primarily takes care of the two children and the household. Additionally, Michelle is afraid to communicate to Tom about her sexual problems and will not support her in therapy about those problems. This couple is lacking identity problems as a couple. Reid, Dalton, Laderoute, Doell and Nguyen (2007) convey that identity crisis as a couple maybe a barrier for Michelle to seek counseling because of the support system in the marriage. Tom and Michelle different communication styles because Michelle is afraid to talk to Tom about her sexual problems and Tom has no problems communicating to Michelle about anything. Women with anorgasmic have difficulty discussing their sexual activity (McCabe, 2009). Michelle is Latina and in her early forties’ and Tom is Arabic. Cultural, ethnic, and age differences may or may not be influencing the couple’s marital relationship issues. It needs to be noted that being the primary care taker of two children and the household can place stress on marital as well as the sexual relationship because of emotional changes such as fatigue, and anxiety because of the financial situation.
Diagnostic and Multi Axial Impressions
Diagnostic
The Diagnostic and Statistical Manual (DSM) is a manual that allows for a therapist to review criteria for diagnoses and be able to determine which mental health disorder a client is experiencing from the presenting symptoms (APA, 2000). Michelle presenting problem is she has no orgasm, which indicates orgasmic disorder. According to McCabe (2009), orgasmic disorder is labeled in the Diagnostic Statistical Manual for Mental Disorders as one of the main sexual dysfunction for women, and is described as a complete absence or recurred difficulty in reaching an orgasm after plenty of sexual stimulation, it is also categorized as primary or secondary, meaning that a woman has had an orgasm, but is no longer able to do so or she has never had an orgasm; and women this disorder is also known as anorgsmia described has a type of inhibitor for pain that also contributes to women not being able to achieve an orgasm (McCabe, 2009).
Multi-Axial
The following is the multi-axial diagnoses: Axis I-V 61.10, Axis II-302.73 Female Orgasmic Disorder Due to Combined Factors, Axis III-None, Axis IV-Psychosocial: Primary Support Group and Economic Problems, and Axis V-GARF-21-40/ Emotional Climate. The reasons for these diagnoses are: (1) Michelle and Tom have a good relationship, but they sometimes argue and have distorted communications because she is afraid to inform him of her sexual preferences, (2) the Diagnostic Statistical Manual (American Psychiatric Association, 2000) describes female orgasmic disorder as a persistent or recurrent delay or no orgasm following normal sexual stimulation that trigger orgasm, her age, and sexual experience and caused marked distress or interpersonal difficulty. Due to combined factors was diagnosed because she has no orgasm; she has no recollection of ever having an orgasm; no experience of masturbation; minimum sexual stimulation; she is not aroused enough; experience dryness and discomfort after intercourse; and afraid to express her sexual preferences to him, (3) No medical condition was noted, she is in good health and is currently not taking any medication, (4) Tom do not help with children nor household chores; not supportive in her sexual problem because he do not want to go to therapy with Michelle and they are in financial debt due to Tom’s financial decision, and (5) relational functioning scale/emotional climate was chosen because of Michelle’s sexual functioning; for example, Michelle’s feelings about Tom not attending therapy; feelings of not being sexually satisfied; no experience of masturbation or orgasm. The code was chosen because family routine does not meet the needs of members; they are ignored. For instance, Tom will not attend therapy with Michelle and does not share in the caring of the children and household chores. Decision-making is ineffective such as Tom’s financial decision put them in financial debt for several years. Characteristics of individuals are ignored; for example, Tom is not taking Michelle’s feelings into consideration because he feels he should not go to therapy because the problems are not his. The unresolved conflict because Michelle is afraid to inform Tom about her sexual preferences. The sexual dysfunctions among adult members like Michelle not experiencing orgasm and masturbation. Therefore Michelle meets the criteria according to the DSM because Michelle has persistent and absence of orgasm following a normal intercourse, she is only 42 years old and is not at the age where she is not interested in sex, the adequacy of sexual stimulation she receives such as not sexually aroused during intercourse, and disturbance cause marked distress or interpersonal difficulty such as Michelle is afraid to communicate her sexual preference to Tom. Because Michelle handles all of affairs of the home and takes care of the two children, the counselor would take this into consideration to further her diagnoses within the psychological factor.
Integration of Disorder
Sexual Response Cycle Framework According to Striepe and Coons (2002), women and their partners are instructed to learn about their sexual response cycle to turn from unnecessary physical discomfort and unrealistic expectations. A frequent request is for vaginal lubricant from women. It may be made known that women is attempting to go from a phase of no or low desire to orgasm. This is similar to a man expecting to ejaculate without erection. Lubrication is not a dependable indicator of subjective sexual arousal because some women become lubricated during sexual attacks and other women report psychological arousal in the absence of lubrication due to estrogen deficiency (Striepe, & Coons 2002). There is not a strong connection between subjective arousal and physiological arousal in women (Striepe, & Coons 2002). The models of sexual response cycle according to Striepe and Coons (2002), female sexual response cycle from a woman’s viewpoint is that the sexual response cycle can be the point of connectivity or intimacy that begins the response. The beginning of the response is not necessarily physiological or sexual in nature (Striepe, & Coons 2002). For example, a woman can feel aroused when her spouse helps with household duties or assists with the children. The effects of this intimacy brings a feeling of sexual desire emotionally and a cognitive state of wanting to become sexual (Striepe, & Coons 2002). For instance, the woman may or may not feel a physical sign of arousal at this point. The ability to feed her sexual desire and escalate sexual interaction, she may or may not reach orgasm. It is important to articulate that some women report feeling sexually fulfilled without having an orgasm (Striepe, & Coons 2002).
Sexual Normality and Sexual Response Cycle Some people think that a healthy sex life is a vital part of a healthy lifestyle and well-being, but a sexual normality is an important element to a healthy way of living and sexual functioning is also crucial to sexual well-being (World Association for Sexual Health, 2008). In a sexual relationship, couples are expected to share an intimate bond between them from sexual satisfaction that is believed to be useful and normal (McCarthy, & Metz, 2008). Michelle believes that she is not experiencing a normal sex life because she is not being sexually satisfied because intercourse last 20 minutes, she is not being aroused enough during intercourse, does not have orgasms and her friends tell her she is missing out. Developing a fundamental understanding of what is believed normal is vital in determining at what stage a client may be encountering difficulties within the sexual response cycle (Ohl, 2007). There is no correct, single, or normal sexual response. Therefore, it would not be suitable to the sexual response model to establish sexual normality of a particular sexual situation. The sexual response cycle might be used to conceptualize sexual activity that are described as problematic by the individual; and experiencing an orgasm can be a conflict because the of the difference in the spouses’ sexuality (Sewell, 2005). Furthermore, women may experience high levels of sexual arousal, but experience no orgasm from the sexual stimulation. In this case, Michelle points out that she is not aroused enough, therefore; she is not receiving any orgasm.
Sexual Disorder and the Sexual Response Cycle Female Orgasmic Disorder is one of the female sexual disorders, affecting 22-28 percent of female women (Zakhari, 2009). It is defined as a persistent or recurrent delay or an absence of orgasm during normal sexual activity. This condition should cause distress for the client and have no other medical conditions or drug use; and women with this disorder has encountered this problem their entire life (Ohl, 2007). Women experience this female sexual disorder from the sexual response cycle, which is the third phase known as orgasm. It is described as having intense pleasure sensations lasting seconds to minutes in the cycle, the muscles contracts in the perineum estimated to begin at every eight seconds and decrease in frequency near the end of orgasm (Sewell, 2005). Orgasm brings about a release of physical and sexual tension such that the sensation turns into relaxation. If the experience was satisfying, both partners were content, but if the sexual experience was not satisfying (e.g. dysfunction), this state of weakness is considered because of negative feelings on the inside (Sewell, 2005).
Psychosexual Development over the Lifespan
Psychosexual development is defined as the combining of sexual phases of a person’s development with other psychological issues. The psychosexual development consists of learning about touching genital body parts, learning the difference between male and female, learning about sex through childhood play in preschool years. Elementary years, there is no sexual interest (Greenberg, Bruess, & Conklin, 2011). Since Michelle grew up in a traditional and religious background where sex was not talked about and it was not shown in the household. Therefore, she did not learn about sexual relationship and how to relate to her husband. Greenberg, Bruess, and Conklin (2011) expresses that affection shown by the parents sets the pattern for their children. The sexual response cycle of excitement, plateau, and orgasm has to do with the touching in certain parts of the body to produce arousal and stimulation. Therefore, Michelle is not being aroused enough, cannot achieve orgasm because she does not know how to stimulate pleasure within her body parts. Zakhari (2009) emphasize that in order to understand the current experience of a woman’s sexuality, counselors would ask questions that would aid the counselor with information concerning the client’s sexuality. Questions that the counselor would ask Michelle are how did she learn about sex if it was not discussed in the home? How did she learn about menstruation and what was it like for her when she started menstruating? What experiences have she had with masturbation and how did it make her feel? However, Michelle did not know how to resolve her sexual and personal issues, she took on the role as woman, wife, and mother; her role is to care for the husband, children, and home. She allowed her husband to ejaculate inside her even if she was not experienced or ready. Then, she crossed over into the male domain, got a job and earned money. In her new position in the male world, she is allowed to care for herself and is now ready to pursue her sexuality by consulting with her gynecologist and friends to indicated to her that she do not know what she is missing.
Psychosocial Contributions
Michelle and Tom both came from the same town and state. This gives them a commonality of background, way of life, and even the use of certain slang. Therefore, the quality of the relationship, communication and arguments with partners, and problematic children can lead to stress and anxiety can lead to discord among family members (Zakhari, 2009). Rosenfield (2010) stresses client’s beliefs can produce guilt, shame, and worry. This can make it difficult for clients who do not fully embrace their church’s teachings to fit in their religious community. Differences about religious practices and beliefs can supply to discord among family members. For Michelle, the discord between her and Tom may have an impact on her sexual disorder.
Treatment Goals According to Stinson (2009), treatment of sexual dysfunction has been established for many years and takes many different forms of treatment. Therefore, in the case of Michelle and Tom; the goals will focus on individual and couples’ for treatment.
Individual Goals The treatment goals for Michelle would be: (1) to assess a thorough detailed psychological and social history of Michelle to address the psychological issues that contributed to orgasmic Disorder. McCabe (2009) stress that it is vital to have an understanding of the emotional trauma that is associated with sexual disorder, (2) education; Michelle would be asked to schedule another with her gynecologist to learn about her sexual functioning and body in a safe and non-harming way. As some women are not familiar with their vulva, what it includes and how the body parts are named differently. Michelle would be educated on the workings of the body (Striepe, & Coons, 2002). Medical information and knowledge of the female sexual response cycle are important to help Michelle determine her wants and wishes as well as help Michelle to experience a trusting relationship with her doctor (Striepe, & Coons, 2002), and (3) directed masturbation is a sexual skill learning model and a behavioral, time-treatment (Striepe, & Coon, 2002). This would aid Michelle in learning about masturbation and how to utilize it in their sexual relationship.
Couples’ Goal The treatment goals for Michelle and Tom would be: (1) communication, Michelle and Tom will learn to share their feelings and sexual needs. Michelle can take the initiative and inform Tom about her sexual experiences. Tom can learn to listen and respect her wishes. He will realize that her preferences and experiences are different from his. They will learn from each other for satisfying experiences (Striepe, & Coons, 2002); (2) religion, Michelle and Tom will request to meet with their priest or pastor to discuss the religious beliefs and sexuality. It has been shown that couples’ who expand their knowledge about sexuality through religion by couples’ having a monthly discussion group in the church (Striepe, & Coons, 2002); and (3) education, learning directed masturbation, which consist of exercises with images and physical total body exploration and moves that would increase genital stimulation (Striepe, & Coons, 2002). This would aid Michelle and Tom about masturbation and ideas of how it can be activated to increase sexual stimulation.
Counseling Interventions
Initial Assessment
According to Jones (2002), questionnaires are used to evaluate clients with female sexual dysfunction. They are Female Sexual Functioning Index (FSFI) Brief Index for Sexual Functioning for Women (BISF-W), and The Derogatis Interview for Sexual Functioning (DISF), which will be useful for Michelle’s sexual dysfunctions. The FSFI is a measurement that test sexual function such as arousal and lubrication as well as orgasm. Since Michelle is experiencing dryness after intercourse, have no orgasm, and is not aroused enough during intercourse. The BISF-W is used for women who are healthy and assess their sexual experience. It performs test on desire, arousal, frequency of sexual activity, relationship satisfaction, and problems affecting sexual functioning. This questionnaire will aid the counselor in assisting Michelle because she is in good health, no orgasm, marital problems that are affecting her sexual functioning. The DISF is a measurement tool used to assess the quality of the female sexual functioning. It will test female response cycle, gender, and sexual orientation. This questionnaire will help the counselor understand Michelle’s problems in the area of sexual behavior as well as her experience with sex because she has no prior experience of sexual activity (Jones, 2002); they will be administered before treatment.
Counseling Techniques Zakhari (2009) writes that many clients feel embarrassed taking their sexual concerns to their physicians because they feel there is no treatment and the physicians feel uncomfortable discussing sexual topics with their clients. The counselor, with this in mind, will have an atmosphere that is warm and comfortable so Michelle will feel at ease when she comes into the office. Zakhari (2009) convey that counselors must establish an open and therapeutic relationship in which the client feels comfortable sharing problems on sexual activities. In the initial interview with Michelle, the counselor will build a trust between her and the counselor by attending to Michelle sexual problems that are causing her life stressors such as sexual dysfunction, marital problems, and emotional distress. Conversations with Michelle and Tom, as a couple will be gentle, no persistent probing, nudging, but a rather calm and relaxed atmosphere. McCabe (2009) asserts that life stressors such as life events, and daily hassles has a great impact on sexual disorders.
Treatment Plan The treatment for Michelle would include multi-modal therapies of individual, couples, group, as well as medical interventions (Comas-Diaz, 2010). The basic elements of the treatment plan for lack of orgasm include education, self-exploration, self-exploration, body awareness, and direct masturbation (Striepe, & Coons, 2004) and cognitive behavioral therapy (CBT). Striepe and Coons (2004) propose that participation in women’s sexual health group. Michelle could learn about her own sexuality and discern between her own and her husband’s expectations and pleasures within the sexual relationship with other women. The group would be practice-oriented and founded on relational theory along with psycho-education on a variety of sexual issues (i.e. body image) (Striepe, & Coons, 2004). Michelle will be instructed on ways to listen to her body differently and begin to practice self-acceptance that will enable her to become aware of her body (Striepe, & Coons, 2004). Within the supportive environment of the group, Michelle can learn to say no and know whether at any given time, that she is willing to have sex with Tom (Striepe, & Coons, 2004). This will give Michelle some control so that there will be no penetration without lubrication that gives her discomfort. Striepe and Coons (2004) denotes that direct masturbation is the most effectual treatment for lifelong lack of orgasm in women, which allow couple-focused sensate exercises and how to face difficulties in their past and who have never had an orgasm. Research such as masturbation gives true nerve sensory response to women which helps them recognize what techniques sexually aroused them (Striepe, & Coons, 2004). Cognitive-Behavioral Therapy (CBT) helps women who suffer with female orgasmic disorder (inorgasmia) their entire life. This therapy will enhance directed masturbation, sensate focus, and the multimodal treatment to increase orgasm through cognitive behaviors (Stinson, 2009). This therapy will also assist couples in changing maladaptive thinking and unreasonable expectations, correcting misleading information about sexuality, and discover ways to improve couples distressing closeness and communication (Wylie et al., 2008).
Biological
The difference between men and women are identified through gender role. It argues that the concepts of masculine and feminine are not created through biology; and it also creates diverse jobs in the community (Levant et al., 2002).
Cultural
According to Comas-Diaz (2010), storytelling is an empowering and efficient tool in cross-cultural therapy. In line with cultural diverse, personal words spoken verbally draw out clients’ stories by asking questions such as what happen in your sexual background? The examining approach of distress is an effective tool used to bring out narratives from ethnic groups. While encouraging clients to share their views about their challenge and treatment, it is important to create a cultural sensitive environment that entails a flexible style of therapy that sets an atmosphere that is multiculturally appropriate. In Michelle and Tom’s case, the counselor will aid Michelle and Tom in presenting their sexual concerns by asking questions that coincide with their cultural beliefs.
Multicultural
Multicultural competence can be described as the ability to understand and beneficially communicate the uniqueness of each client in terms of the diverse cultures that influence each person’s point of view. The involvedness of culture is frequently missed because of this; multicultural research continues to increase stereotypes that are fashioned to prevent stereotyping. In order to prevent stereotyping thinking, counselors must evaluate cultural research and be attentively innovative when utilizing this method in counseling (Striepe, & Coons, 2002). Therefore, the counselor will have to become aware of how she communicates to Michelle and Tom because their cultural background is different. For example, when approaching Michelle about her sexual activity, the counselor must ask questions in a way they can relate according to their cultural background. For example, when dealing with younger adults, communication must be in a language that they can understand the topic at hand because Zakhari (2009) emphasize that language and age is very important when counseling cultural diverse clients. For example, young people may be at ease using slang while older adults may not understand the terminology on the subject being discussed.
Religion Many clients who seek aid for physical, emotional or personal issues between them are also in distress in their religion. Therefore, counselors must attend to the spiritual element that humans are experienced, to better understand the needs and experiences of clients and help them in their healing and growth (Nedumaruthumchalil, 2009). Since Michelle and Tom come from different religious backgrounds and no involvement in their religion maybe because religious beliefs influence ways of coping with hardship, the experience of suffering, and the meaning of the problem (Nedumaruthumchalil, 2009). It is important to discover whether Michelle’s Catholic beliefs or Tom’s Baptist beliefs or practices are contributing to her problems. Religious conflicts and beliefs regarding marital sex, masturbation, homosexuality, abortion, female submission, male dominance, sex and gender role expectations can add to Michelle’s presenting problem and might need to be incorporated into her treatment plan (Rosenfield, 2010), but Michelle or Tom must initiate it so the counselors’ religious beliefs will not influence Michelle and Tom and interfere with the therapeutic relationship between them and the counselor because Nedumaruthumchalil (2009) affirm by emphasizing that counselors were trained to remain objective and unbiased in order to protect their clients, and be careful to disclose their religious beliefs and morals, however; it is impossible to be unbiased or free of disclosing values if it is needed in the counseling process because Grabe, Shelly, Hyde, and Shibley (2006) advise counselors to incorporate religion conscious care for clients. Religion conscious care requires counselors to recognize when their client requires religion directive therapy and this therapy must provide care competently or appropriately or refer them to spiritual resources in the community.
Psychological Conner (2010) asserts that psychological differences between men and women are less noticeable. They can be difficult to depict. Yet these differences can deeply influence how men form and maintain relationships that can range from work and friendships to marriage and parenting. The author continued by conveying that women can be difficult when it comes to recognizing, understanding disappointment, frustration, tension and eventually it can damage a relationship, but men and women will accept or learn to live with the consequences or find some compromise or way of coping. In the case of Michelle and Tom, Michelle found arguing about finances, taking care of the children, household duties to avoid confronting the marital problems concerning Tom not helping with the household duties and the children because Tom may feel that it is the woman’s duty to take care of the children and the home. Therefore, counseling and therapy can help Michelle and Tom understand and appreciate one another and benefit from their differences. The counselor can also assist them in pointing out their differences as they arise, and lead them to a greater level of relationship (Conner, 2010). Once Michelle and Tom work out their differences, she will release some of the stress from working, caring for the children, and household chores, which will cause her to be happier in her marital relationship with Tom so when they become intimate, she may begin to have orgasm.
Treatment Outcomes
Masturbation has been demonstrated to produce the most intense orgasm as well as the most apparent method of creating one (Striepe, & Coons, 2002). If Michelle follows the goals and treatment for her and Tom, she will succeed in therapy, learn to have orgasms, and enjoy a new aspect and dimension in her sexual relationship with Tom.
Ethical and Legal Consideration
Ethical
Michelle is a multicultural client who is seeking counseling. She married to Tom who is also of diverse population. She will be receiving individual counseling as well as couples’ counseling. Therefore, the counselors will follow the ethical guidelines for counseling diverse clients based on multicultural competence, moral principles, code of conduct, cultural sensitivity, and couples counseling According to Stuart (2004), counselors must be aware of and respect cultural, individual, and role differences…must practice only within the boundaries of their experience…and must make a realistic effort to obtain the experience required by using pertinent research, training, consultation, or study. Counselors must have respect for client autonomy and respect for the client’s culture of origin that counselors should avoid impeding their religious beliefs or practices (Stuart, 2004). Standard 3.01 of the APA Ethical Principles and Code of Conduct, command that counselors do not engage in unfair discrimination based on…religion and General Principle E states that counselors are aware of and respect…differences, containing religion (APA, 2002 as cited in Stuart, 2004). Conversely, counselors are trained to challenge beliefs and practices that seem to limit their client’s well-being, autonomy, or functioning in society as written in the principle of beneficence (Stuart, 2004). General Principle A of the American Psychological Association Code of Ethics (2002) denotes that counselors must make every effort to benefit those with whom they work (Stuart, 2004). According to Principle E of the APA Code of Ethics counselors must be aware of and respect cultural, individual, and role differences, that is based on religion, and consider issues when working with Michelle in a group (APA, 2002 as cited in Saunders, Miller, & Bright, 2010). According to A.2.c of the APA Code of Ethics (2005), counselors must communicate information in ways that is suitable for clients’ culture. Counselors must use clear and concise language when discussing problems related to informed consent. When clients have a hard time understanding the language spoken, it is the responsibility of the counselors to provide the necessary services (i.e. qualified interpreter) to ensure that the clients can comprehend what is being discussed by providing informed consent forms where possible. Since the treatment plan will provide couples counseling. There are ethical guidelines to follow while counseling Michelle and Tom as a couple such as counselors must clearly define who are the main client and converse expectations and restraints about confidentiality. They must seek agreement in writing between all parties involved that is capable of giving consent concerning their right to confidentiality and any other pertinent information that is confidential (APA, 2005).
Legal Considerations The principle consideration in the American Psychological Association Code of Ethics provides for the client’s legal rights of confidentiality and discrimination. Counselors must respect the pride and worth of all people and the rights of individual to privacy, confidentiality, and self-determination, Counselors must protect the rights and welfare of people communicating in decision-making. Counselors must be aware and respect cultural, individual, and role differences, including those based age, gender, identity, race, ethnicity, national origin, religion, sexual orientation, disability, language, and socioeconomic status when working with this group. Counselors must avoid placing their biases on these factors and those of prejudices (APA, 2007). Michelle could not be denied therapy because she was 42 years of old, female, feminine, woman, South American, Latina, Submissive, Catholic, heterosexual, handicapped, Spanish, or poor. In the like manner, Tom could not be discriminated against because he was a male, masculine, Arabic, distant, Islamic, Baptist, homosexual, disabled, or blue collar.
Conclusion
The case study focused on the mental and sexual health of a woman diagnosed with female orgasmic disorder. The goal of the interdisciplinary team in care is to provide contextual, gender-specific, culturally-sensitive assessment and treatment options. By giving women evidence based information, the team can assist them in forming a well-thought out decision about their mental health issues. Through collaborative care, primary care clinicians can offer therapy interventions that improve the well-being of diverse women within their relational and cultural contexts. The approach promotes good care, and the team anticipates that it is relevant to all persons, regardless of race, gender, class, age, or ableness according to the ethical guidelines.
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