Wednesday, June 5, 2013

Counseling Plan: Addressing Attachment, Religion, and Sexual Orientation

**The below is the case study provided by my professor, which I was tasked with writing up a counseling plan (which is located after the case study). **

Case Study 1: Sara and Amy

Sara is White, middle-class and in her early thirties. She has been referred to you by her gynecologist because she is currently experiencing a lack of interest in a sexual relationship with her partner Amy. Sara has been living together with Amy for 1 year. Amy is Black and in her late thirties. The couple is very much in love and happy to have started a life together. Sara also reported that she is in good health overall. The only current medication that she takes is a daily multi-vitamin.

Having lost her job in corporate America, where she used to earn a good salary, Sara now maintains two jobs and works long hours. Amy works at a garden store. When Sara arrives at home, she is tired and sex is the last thing on her mind. At times, she feels like sex is just another chore on her “to do” list. Revealing feelings of rejection, Amy voiced frustration and sadness about being the initiator of all sexual activity in the couple’s relationship.

The couple explained that they have frequent arguments. They told you that all their arguments start because of Amy expressing how she wants sex more often. Sara gets very frustrated when arguing with Amy, because Amy is a yeller and loses her temper easily, and cannot let go of an issue. Sara says she would prefer to revisit a subject later than to go around in circles about it. The couple reported that after a couple of hours, Amy is able to calm down and they talk.

The couple is currently having sex once every two weeks. Sara does not have any experience with masturbation and prefers to just have partner sex instead.

Even though Amy was reluctant at first, she has accompanied Sara to the counseling appointment and they are open to your advice about whether they would come to therapy as a couple or Sara would attend the sessions individually. Amy’s initial reluctance was expressed in session when Sara explained that Amy said this is “her issue.”

The couple reports that sex is good, but that they are shy to talk about it. At this time, their love-making sessions last around 20 minutes. Sara reports that she has orgasms more than half of the times and that she enjoys being close to Amy when they are intimate. She reports that she likes affection, but she and Amy have not been affectionate outside the bedroom, because she is afraid a hug or kiss may lead to sex.

They also reported that they are good friends and rely on each other for life decisions. Sara tells you that she wants to enjoy sex and that her lack of sexual interest is putting a strain on her relationship.

The couple reported not much involvement in their local lesbian community. Both stated they rely mostly on each other for emotional, financial and other areas of support. The couple lives far away from both families. Only Amy’s family recognizes the couple’s lesbian relationship. Sara is an only child. She described growing up as difficult because her family was very conservative and deeply religious. They believe homosexuality is a sin. They do not believe in dating outside of one’s race either. Marriage and children are highly valued for a woman in the belief system of Sara’s family of origin.


Amy is the eldest of 3. Amy described her family as moderate and loosely religious. They do not have strong views either way on homosexuality. They value education for both women and men.

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Abstract
Sexual dysfunction affects the majority of couples at least once during their sexual lifetime, yet many seem too embarrassed to seek counseling for such issues. Individuals who are within the sexual minority population are less likely to seek mental health services, for a myriad of reasons. The following paper will address the case study of two lesbians, Sara and Amy, examining their chief complaint of Sara’s lack of sexual interest, as well as the possible contributing factors that may be present in their relationship. Finally, an application of a biopsychosocial counseling approach will be applied, with some suggested steps Sara and Amy can take to rekindle their sex life.
            Working with couples through relationship issues can often be an uncomfortable situation for the clients, as they are sharing their most intimate details with a relative stranger. Providing a welcoming atmosphere is essential to allow the clients to feel more at ease, which may bring about a relaxed communication style that can help clients and counselors work together in addressing the presenting issues.
            For the purpose of the current counseling plan, the relationship between Sara and Amy will be examined. The women, both in their 30s, are experiencing a variety of stressors in their relationship, some of which stem from their cultural backgrounds and also their current economic status. Additionally, the challenges faced by sexual minorities are accompanied by the fact that the two women are also from different racial backgrounds, which may contribute to their current relationship turmoil.
            The counseling plan and evaluation of the couple will include both individual assessments, as well as collective, since they are in a relationship which they desire to preserve. While Sara was the initial client suggesting the need for counseling in the relationship, and as such will be the primary client addressed in the counseling plan, Amy’s attitude towards obtaining counseling services is important to examine, as it may provide insight into the dynamics of the relationship.
Assessment of Sexual Issues
            Sexual issues in relationships happen for a myriad of reasons, and while usually portrayed as a heterosexual problem in the media, it also affects gay and lesbian relationships. While the issues may differ, as erectile dysfunction does not apply to Sara and Amy’s relationship, they do face some rather common sexual issues. Lack of sexual desire is one of the most common sexual dysfunctions reported in lesbian couples, which has spurred the development of the term “Lesbian Bed Death” to refer to the decrease in sexual activity (Hacioglu, Cosut, & Yildirim, 2011). While limited information is available regarding lesbian specific sexual disorders, a decrease in sexual desire, combined with external stressors and hormonal changes can contribute to a decrease in overall sexual activity (Hacioglu, Cosut, & Yildirim, 2011).
Female Sexual Disorders in Lesbian Relationships

            Much of the previous research that has sought to discover the unique aspects of the
female sexual disorders that may occur, have centered around primarily women in heterosexual relationships. The Masters and Johnson (1966) model of the sexual response cycle offered a good starting point and was effective in addressing the sexual disorders present in individuals, but the four stage model proposed by Masters and Johnson (1966) does not appear to be applicable in lesbian relationships. Research findings suggest that there is a larger difference between the techniques and disorders that occur in heterosexual women and lesbians, than between heterosexual and gay men (Tiefer, 1995).
            Instead of the four stage model proposed by Masters and Johnson (1966), which includes the excitement, plateau, orgasmic, and resolution phases (with the latter added by Helen Kaplan in 1979), a more applicable model to consult would be the nonlinear sexual response cycle developed by Joanne Loulan in the 1980s. Loulan suggested that the female sexual response cycle should start with “willingness,” instead of excitement, and end with “pleasure,” instead of orgasm (Loulan, 1984).         
            Considered to be feminist in approach, Loulan’s theory suggests that sexual desire can be influenced by “unexpressed feeling towards one’s partner” (Loulan, 1984). The desire that appears to be lacking between Sara and Amy could be contributed to the underlying issues present in their relationship. Additionally, a more recent theory posited by Rosemary Basson (2007) has expanded upon Loulan’s theory to address low sexual desire within lesbian couples.
The Basson model is more holistic in examining the possible causes of sexual dysfunction, which encompasses emotional intimacy, sexual stimuli, and relationship satisfaction (Basson, 2007). Within lesbian couples, the drive and motivation for sexual activities stem from a desire for intimacy (Basson, 2007), instead of lust as seen in the more traditional models of sexual response. If one of the women in a lesbian relationship loses sexual desire, in the present case that would be Sara, Basson suggests that the woman who still maintains a high sexual desire for their partner, which would be Amy, a feeling of rejection can be experienced (Bigner & Wetchler, 2012) , and is consistent with Sara’s presenting information provided. Additional research has supported the dysfunction finding regarding the inequality in sexual desire is a more common occurrence in lesbian relationships as compared to heterosexual women (Nichols, 2005).
Stress and Sexual Dysfunction
            Same-sex relationships often incur additional stress on top of the common daily events that may arise. While the economic downsizing may not discriminate depending on sexual orientation, the changes in employment experienced by Sara may have increased her current level of stress that was attributed to being part of a sexual minority relationship. Studies have suggested that one of the biggest differences between the experience of stress found within same-sex and heterosexual couples is that same-sex couples may find themselves in a community that may marginalize their relationship (Mohr & Daly, 2008).
Complicating matters is that stress can come from both internal and external factors, which have been linked to a diminished psychosocial functioning within same-sex couples (Mohr & Daly, 2008). External stressors can include discrimination, prejudice, violence, and hate crimes, while internal factors can stem from internalized homophobia, concealing of their sexual identity within their social circle, and fear of rejection from society (Derlega et al., 2011). Amy and Sara are may also be experiencing an additional stressor due to their interracial status, and are considered to be susceptible to experiencing multiple marginalized relational identities (Rostosky, Riggle, Savage, Roberts, & Singletary, 2008). The compounding stress may be a contributing factor to Sara’s report of “sex being one of the last things she wants to do when she comes home.” Conflict and difficulties communicating have also been cited as a significant cause of decreased sexual desire, which also leads back to the role stress plays in sexual dysfunction. Additional contributing factors associated with stress and its effect on a relationship includes fatigue, personal values, and even religious beliefs (Shifren, Monz, Russo, Segreti, & Johannes, 2008), which appear to be present in Sara’s life.
While the prevalence of sexual dysfunctions related to stress peak in middle-aged women (Shifren, Monz, Russo, Segreti, & Johannes, 2008), which neither Sara nor Amy have reached at the current point, the role of stress should not be ignored when examining the underlying causes for a decrease in sexual interest. When evaluating for the presence of stress in Sara’s life, it would be important to also screen for depression, as about 40% of individuals with a sexual disorder, such as loss of sexual desire, have concurrent depression (Rosen et al., 2009).
The Influence of Attachment Styles in a Relationship
            When examining the behavior of both Sara and Amy, they each exhibit unique attitudes in how they relate to one another. One such explanation for the differences may lie in the different attachment styles each one possesses. While the majority of research into the different attachment styles have been based on heterosexual relationships, emerging studies have focused on the differences in attachment styles within lesbian, gay, and bisexual populations. Same-sex relationships that fall within the secure attachment realm, are characterized by an ability to effectively handle negative emotions and to seek help from outside sources when necessary (Wang, Schale, & Broz, 2010), which appear to be two attributes missing from Sara and Amy’s relationship.
Anxious Attachment Style
An anxious attachment style is usually hall-marked by a tendency to desire more intimacy than they receive, fear being abandoned by their partners, and not being loved in the manner that they desire (Horne & Biss, 2009). Such traits can be seen in the behaviors exhibited by Amy (feeling of rejection, frustration, wants more sex). Amy’s anger and feeling of rejection could also stem from another attribution associated with an anxious attachment style, namely being excessively reliant on the other individual to meet their needs, and when those needs are not met, a high level of emotional reactivity may be present (Derlega et al., 2011), which could explain Amy’s violent verbal escalations. A lower sense of self-worth and self-confidence may also be present in individuals with an anxious attachment style (Wang, Schale, & Broz, 2010), which may contribute to Amy’s report of sadness regarding being the one that usually has to initiate sex.
Avoidant Attachment Style
Contrasting the anxious attachment style is the avoidant attachment style, which is characterized by a feeling of being uncomfortable being close to others, find trust difficult to establish in others, and become nervous when others become too close (Simpson, 1990). Sara may fall within the avoidant attachment style, since she has stated that she refrains from displaying affection with Amy outside of the bedroom because she is scared of it leading to sex. Avoidant individuals also typically express extreme levels of emotional and behavioral withdrawal (Simpson, 1990), which could explain Sara’s role in the couple’s arguments, as she typically avoids confronting Amy, preferring to revisit the topic at a later time. Keeping physical and emotional distance when the couple experiences relationship turmoil is also indicative of an avoidant attachment (Derlega et al., 2011). Additionally, individuals with an avoidant attachment style are also more likely to engage in sexual behaviors to fulfill relationship obligations (Wang, Schale, & Broz, 2010), instead of pursuing sexual relations based on desire. However, Sara’s behavior could also be attributed to shyness, rather than an avoidant attachment style, which also includes social avoidance despite the desire for close relationships (Scholz, 2009). Further investigation would be necessary to discern which would be most applicable to Sara’s case.
Religion and Homosexuality
            The religious backgrounds of an individual have the capacity to influence one’s outlook on both how they view society’s norms, as well as how they view themselves. Religion often dictates what is acceptable, and if one’s behavior is to fall outside the boundaries of normal, there are often consequences associated with violating the rules set forth, including ostracization and even death, with the latter being associated with many Muslim nations (Adamczyk & Pitt, 2009). The role of religion in developing views regarding sexual orientation and gender roles is not to be dismissed, as previous studies have found that religion is one of the strongest influences in the United States as it pertains to attitudes towards homosexuality (Adamczyk & Pitt, 2009).
Effects of Religious Influences
            Sara’s childhood, which consisted of a very conservative and religious nature, has shaped who she is in the current day. The idea that her personal identification as a lesbian woman contradicts what she was raised to believe as the role adult women should play. Most religions categorize same-sex relationships as a sin, unnatural, and impure, with frequent exposure to religious material being associated with a higher level of homophobic attitudes (Adamczyk & Pitt, 2009). The inability of Sara’s parents to recognize her relationship with Amy could lead to further internal stress, primarily internalized homophobia.
            Internalized homophobia is described as a form of minority stress, which stems from a conflict between the attraction and desire for same-sex relationships, yet maintain a desire to also be heterosexual (Frost & Meyer, 2009). In Sara’s case, she identifies as a lesbian and is in a sexual relationship with Amy, yet may experience a deep desire to be a heterosexual, as she may be more readily accepted by her family. The idea that a large part of who Sara is as a person is not accepted by her family may lead her to experience depressive symptoms and a diminished relationship quality with her partner (Frost & Meyer, 2009).
            Religion also influences the act of masturbation, which Sara reports as something she does not engage in practicing, rather preferring sex with her partner Amy instead. While it is unclear exactly which denomination Sara’s family identifies as, according to the Catholic religion, masturbation is considered a sin, and that “the deliberate use of the sexual faculty, for whatever reason, outside of marriage is essentially contrary to its purpose,” which also applies to self-fulfillment via masturbatory action (Fisher, 2013).
            While Sara may not personally identify with being necessarily religious, her upbringing, in addition to the disapproval of her lifestyle by her family, may contribute greatly to her experience of personal distress. Sara’s low sexual desire, may also contribute to her sexually related personal distress, which is believed to be intensified when there is a mismatch in sexual drive with a partner (Rosen et al., 2009). The inner conflict could also potentially drive a wedge between Sara and Amy, as their backgrounds and experiences vary greatly. Due to the differences, Amy’s frustration, while a valid feeling, could stem from her inability to understand why Sara seems disinterested in sex.
Counseling Interventions
            While the disparities between Sara and Amy appear to be vast, with appropriate therapeutic intervention methods, their relationship can become stronger. However, it will take work and active participation by both partners. While Amy has stated that she believes the problem lies with Sara, working with the couple together would be beneficial. Additionally, both clients could potentially benefit from individual counseling sessions, as they each have their own personal challenges that, when addressed, can lead to their union growing stronger.
            Seeking counseling for individuals within the gay or lesbian community is often a challenge, as homophobia, both internal and external, can delay couples from seeking help. The obstacles same-sex couples encounter when seeking help also includes finding a counselor who is able to provide effective counseling, paying attention to the unique issues that may be present in lesbian and gay clients. In a heterocentric society, individuals within the lesbian and gay community may experience an increased rate of prejudice and oppression (Palma & Stanley, 2002). Finding a counselor who possesses both multicultural and sexuality competency would be essential for Sara and Amy, as being dismissed or judged disapprovingly by a mental health care worker could lead to further turmoil, both on the individual and relationship level.
            Three main therapeutic goals to address when working with clients from the lesbian or gay community includes an examination of intra- and interpersonal relationships, family and social supports, and societal support systems (Palma & Stanley, 2002). Establishing a comfortable rapport with clients is essential in allowing full disclosure of sensitive topics, such as sexual difficulties and honest discussion regarding the support systems (family, social, and societal) available for the clients. While the counselor may not have experience with the specific challenges faced by their clients, it is important to be self-aware of any personal biases that may be in place, which could prevent effective and ethical counseling. The American Psychological Association has addressed the ethical and educational requirements for counselors working with lesbian and gay clients. Practice guidelines established by the APA address attitudes toward homosexuality and bisexuality, relationships and families, issues of diversity, economic and workplace issues, and education and training suggestions (http://www.apa.org/pi/lgbt/resources/guidelines.aspx).
Some characteristics that counselors should keep in mind when working with same-sex couples include, “An accommodating posture, non-pressured speech, and a willingness to admit areas of knowledge or ignorance,” (Palma & Stanley, 2002). Keeping a neutral lobby, complete with brochures relevant to gay and lesbian needs can help to further establish a welcoming atmosphere, which may lead to a more effective therapeutic experience (Palma & Stanley, 2002).
Just as the communication and disclosure between the client and counselor are essential, the communication between the two individuals within the relationship is imperative in making progress in counseling sessions. The communication between Sara and Amy appears to be a challenge. While Amy’s primary complaint consists of her being angry and feeling rejected because Sara doesn’t appear to have the sexual interest she had in the beginning of the relationship, the communication breakdown may be contributing to Sara’s diminished interest in engaging in sexual relationships with Amy.
While couples therapy would be included when working with Sara and Amy, individual sessions are also recommended. During individual sessions, counselors can gain an insight into each woman as an individual, rather than her role in the relationship. Additionally, counselors can crosscheck information gathered from the other partner and also allow the client to say something to the counselor that she wouldn’t feel comfortable saying in front of her partner. And finally, individual sessions can allow for a full disclosure of a detailed sexual history, including experience with heterosexual partners and possible past sexual, physical, or emotional abuse (Nichols, 2005).
Biopsychosocial Approach
            Using the biopsychosocial approach when working with Sara and Amy may be quite beneficial. Such an approach views disorders through a blended lens, including the influence of psychology, medicine, and sociology on the individual (Sarafino & Smith, 2012). The stress Sara is experiencing, both internal and external, can greatly affect her relationship with Amy. While both Sara and Amy state that they rely on one another for emotional support, the pressure Amy is placing on Sara regarding sexual desire can negatively influence Sara’s health. A lack of emotional support can be associated with several stress-related illnesses, including heart disease, gastrointestinal issues, and even a weakened immune system (Sarafino & Smith, 2012).
            Individual health and emotional wellbeing of an individual is influenced by a variety of factors, including resources (skill, experience, and genetic factors), social support, and environmental demands. When the demands are evened out by the resources available, emotional health is easier to obtain (Frankenhaeuser, 1994). Working with Sara and Amy to examine their relationship, their resources available, and how more effectively communicate their needs to one another would be useful in moving forwards in their relationship.
Physical Intimacy Suggestions
            While the underlying concerns in Sara and Amy’s relationship may stem from other factors (stress, religion, attachment style), providing guidance on how they can increase their physical intimacy may be useful. Some tips include (Parks, 2008):
·       Schedule sex
·       Commit to five minutes of foreplay
o   Enter into foreplay with no expectations
·       Treat your partner special
o   Do the dishes, rub her feet, compliment her
·       Read erotical aloud to each other
o   May allow Sara to explore her fantasies and/or desires
·       Court your partner
o   Often relationships become stale because of stagnation
·       Try something new
o   Sex toys, fantasies, location in the house
Conclusion
            Sexual dysfunction often has underlying causes, aside from medical issues. Often individuals are too embarrassed to approach counselors to address sensitive topics, but with continuing education and self-reflection, counselors can effectively assess and support clients in need. Working with clients who identify as gay or lesbian may pose additional challenges for counselors, especially if they are unaware of the additional stresses that are experienced by sexual minorities. It would be unethical to treat a lesbian couple the same way one would treat a heterosexual couple, as sexual minorities often face obstacles which do not apply to heterosexual couples.
            Working with couples to understand that often sexual dysfunctions occur not because their partner is no longer attracted to them, but because of a myriad of reasons, is essential to improving the strength of the relationship. Empathy, not only on the part of the counselor, but in the couple for one another, is also key in addressing the lack of sexual interest experienced by Sara. Both individual and couples counseling would be one of the most effective approaches, as it would offer the ability for a counselor to evaluate both Sara and Amy as a couple, and individually.
            Due to the limited availability of studies addressing gay and lesbian sexual dysfunction, further research would benefit not only individuals seeking counseling, but also the sexual minority population and society as a whole.
**References Available Upon Request** 

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