I begin this study by assessment of the presenting problem and significant issues pertaining to his mental health state at this point in time. Mr G is at present suffering from depression. Due to the depression he will have a lack of motivation, self neglect, low self esteem, and at times hopelessness, and helplessness. He will possibly have anxiety, which, due to his fatigue with his illness, will be exacerbated because of the stress reaction and increase in adrenalin. This will cause him to be exhausted and possibly in need of sleep most of the time.
His self esteem issues will have an impact on his relationship with his wife due to the fact that he will become more reliant on her. This will make him feel disempowered. Mr G will have to get used to the idea that his wife has to care for him more, and this will have an impact on his own personal values and beliefs. Within their relationship there may be frustration from both parties, but there might not be opportunity to discuss such issues because of the embarrassment or depression that Mr G has at present, or it may be that doesn’t happen in their relationship whereby they discuss their feelings and emotions.
Due to the stress surrounding these issues, Mr G finds the impact of this affects the sexual part of their relationship and now has a dysfunction causing him more distress and making him feel a failure. He doesn’t feel he can become intimate with his wife because of this factor and feels there is a large part of their relationship missing at present. All these factors become heightened at times, making the depression more intense, leaving him feeling vulnerable and worthless. Before looking at a care plan for Mr G, I need to assess the importance of all these issues and how they impact on him as a person.
Then using my theoretical knowledge put those in order of preference to enable Mr G begin to take control of his life and increase his self worth. As a therapist I would begin to explore the relationship Mr G has with his wife and how he sees the relationship. Mr G will have his own thoughts and pre conceptions as to how she sees the relationship but he may not have explored that with his wife. The therapist at this point has to remain neutral as it would be easy to collude with the client with their presenting issues.
The therapist is there to support the client and help the client explore and evaluate the relationship for themselves. We may begin by looking at the balance of the relationship. I would use the `set of scales? theory to explore this. Mr G would have to identify where the relationship was on a set of scales. Would the balance be even or would one side be higher than the other? Who is putting most energy into the relationship? Was one person more committed than the other? Is there equity in the relationship?
By using this method I would gain insight as to the issues concerning Mr G and if they were negative statements because of his depression or self defeating in context, or if Mr G has communication problems with his wife or other issues. This would help with his explorations with his perceptions of the presenting issues or self awareness of how he alone sees the problem and the evidence he has to back up the thought s he is having. The therapist can also talk through with the client their perceptions of their own contributory factor to the present problem with the relationship which is very important to regain empowerment.
As a therapist working with only one person in the relationship may not bring about great change but explorations with the one party can make that person look at the relationship and challenge or discuss with their partner the changes that need to come into play to enable the couple to function together, making their relationship more whole, each being aware of how the other one thinks, behaves, and knows each other’s likes and dislikes, their needs and beliefs, and in harmony with each other.
My parents have this wholeness between them and are in a situation like that of Mr G. My father is disabled and relies on the use of a wheelchair and relies on mum to care for him. Their wholeness allows them to have a relationship which is special and one which most people comment on because the contentment and dedication to each other becomes very apparent when around them. In some relationships this wholeness can never be, due to the fact that trust is missing from the relationship, and trust is paramount to any relationship.
Statistics say that 80% of marriages suffer due to one party or the other having an affair. There is still widespread belief that monogamy is natural and expected in marriages and in committed relationships, however, that doesn’t stop some from engaging in affairs. But why do they? One of the main reasons is they are not getting their needs met in their relationship. People become bored within the relationship, they may have a need to feel attractive to others, or they may not feel attractive to their partner.
In some parts of society men feel they are not real men if they turn down the advances of a female. Some people find it hard, if not impossible committing to one person. Some people are thrill seekers and have affairs because they cannot pass up an opportunity for a thrill. A person may not be in love with their partner but fall in love with someone else. For some people with low self esteem when they meet someone who appears to care about them it’s a way of increasing their self esteem.
As well as these factors there may be other issues that drive people to having affairs. The affairs can cause scandal and excitement in the media, as we are all enthralled by the affairs of the famous and powerful. This could encourage people to enter into affairs of their own. As we grow and reach puberty we are often not in receipt of suitable education around sex and relationship issues which can lead to some people not being able to talk openly about sex with their partners.
In order to avoid affairs the couple need to be honest with each other, not slip into complacency in the relationship, and keep the relationship alive by communicating with each other about all aspects of the relationship in order to build a close emotional and sexual foundation within the relationship. In the case of Mr G, once we know how he sees the relationship with his wife, we would have a good understanding of how the equality is within the relationship from his perspective.
As I have said previously his awareness of the relationship and his contributions within it will be a place to begin work and exploration. If the relationship has equality and wholeness there will be no evidence for Mr G that he is not contributing in a good way to the relationship. His negative thoughts towards the relationship will be unfounded in this case. Mr G will have great self esteem issues due to his sexual dysfunction and his age will play a big part in that too.
As we get older we have to accept that some parts of our bodies begin to show signs of weakness and wear and tear, and in relationships, harmony, support, understanding, companionship and love of an unconditional nature all play a big part. If these are in place there may be very little need for sexual desires to take over and become as important as it may have done in teenage years. The sexual desires can be explored with the couple and referral to sex therapy may be the answer depending on the couple and their perspective on the problems.
It may e that just cuddling, heavy petting and general physical contact within the relationship is what may be lacking. Once a physical disability is diagnosed that person may begin to feel helpless and not worthy of anything. Their negativity may escalate to the point that they don’t see or feel that life is worth living, as what is described in the case of Mr. G. A therapist has to try and get the client focused on what they can do with slight changes within their lifestyle rather than what they can’t do. When looking at this the first hurdle is acceptance of their disability.
During this process the therapist will work on self esteem issues and acceptance of them as a person from within. The acceptance of the way their life may have changed since the disability plays a big part in their attitude and mental state towards their immediate future. A person who feels negative and unable to function may want to withdraw from society, will have low mood if not addressed, leading to clinical depression, will procrastinate and neglect themselves, all of which a therapist will address within the counselling sessions.
In addressing these issues the client will begin to see a future and look towards it with a more positive attitude. The relationship between Mr. G and his wife and her attitude towards him and his disability will have great impact during this process, and it may need to be suggested that she seeks counselling in her own right to address issues she may have, to enable the couple to eventually work together. It may be they need couple counselling but to enable this to work successfully addressing their own personal issues beforehand will be a way forward with this.
Looking at a ? time map` can help with both parties. The client can map out their emotional stressors and look into their partners stressors throughout life and it allows exploration of these stressors and the effects offlife events. When we look at sexual relationships and intimacy within the couple there are many factors to consider. The communication between each other about their individual sexual needs may be something they find difficult to discuss. It may be their upbringing is different causing problems later in life.
When I look at my relationship with my husband communication plays a big part in our marriage but something which causes most problems. My husband carries core beliefs that we keep things between ourselves and problems encountered are kept within close family not discussed with extended family. I hold core beliefs that families go through things together and support each other without being judgemental. My family have always been open about their problems and share them together. These discrepancies can cause problems.
Looking back at the case study Mr G may have core beliefs different to Mrs G causing problems and preventing them from discussing their sexual difficulties due to their upbringing and beliefs interjected by their parents and maybe similar problems, around not discussing certain issues including sexual relationships within a couple. Intimate problems should be discussed without prejudice or judgement and the couple should aim to discuss this in an adult manner without taking things out of context or as a personal criticism.
Mr G could be blaming himself for his body not reacting to stimuli when Mrs G is not doing anything to make the stimulus happen. One partner may not want sexual intimacy but more kissing and cuddles. All these things have to be discussed between the couple in order to make the relationship work. Factors and life changes like operations, changes in medication, mental health difficulties grief and loss, stress and general fatigue can all affect the sexual drive and if not discussed between the couple can cause misinterpretation with regards to how one person feels towards the other creating disharmony.
Couple therapy can help with these issues if the couple find it hard to converse with each other for whatever reason but the onus is on the counsellor to explore and make sure it’s what both parties want or else it may cause friction and the counselling becomes non productive. When couples go to a counsellor with sensitive or intimate problems the counsellor has to be both mindful and broadminded. As long as the couple both agree to the act and give each other consent to the specific behaviours then it will be part of their intimate and physical relationship.
Any dysfunction then may need exploration and possible referral to qualified sex therapist who is experienced in such matters. Psychotherapy may help initially. With the exploration during this process the therapist has to check with the client that they have discussed the problem with their G. P and that there is no medical problem preventing sexual function. Also the client needs to be aware that an expectant success rate for erectile dysfunction is generally around 85%.
During the counselling process the therapist will discuss what the client perceives as a fully functional sexual encounter. For some people they may need to adjust their perceptions on this. It is not essential for a women to have orgasm at each sexual encounter but their partner may well feel they have not concluded a satisfying encounter without an orgasm being present for a women. An important step in therapy is often to take the pressure away from the need for conclusive penetrative sex and concentrate on other forms of stimulation and pleasure with the consent of both parties.
Men may want to go down the medication route to address their erectile dysfunction but this doesn’t allow exploration of other psychological issues which may be preventing resolution of the problem. Research has indicated that the best quality sex is experienced in married couples even though it is considered by society to represent a routine and boring way to indulge in sexual gratification. Men are thought to be at their sexual peak between the ages of 16-22yrs. As men age this youthful sexual functioning begins to change into a mature way of being.
It becomes pleasure not performance orientated. Sex now comes with emotional intimacy, eroticism and spiritual union that were absent before. The sexual part of the relationship brings pleasure and there becomes a greater bond between couples as they become more committed to each other. When reading this I began to think of my parents and how committed they are to each other. They have such a strong bond and concrete relationship. They share everything, their thoughts and feelings, and are so open and honest in their relationship with each other.
They have no barriers with each other. They joke about their sexual incapability’s due to both of them having physical problems but the harmony between them is such that they have no embarrassments, and are free to discuss exactly what is on their mind with no one taking offence. They sort every problem they may have had in their relationship by talking and being open and honest with each other and resolving it before going to bed that evening. A core belief of my parents is they never ever go to sleep on an argument, and they never do.
Maybe if more couples spoke to each other about their problems in relationships and had this special bond with each other whereby they could trust and not be worried about offending their partner there wouldn’t be the need for so much couple counselling or people having affairs to give them what is missing from their current relationship. In the case of Mr G maybe the key to the way he may be feeling at present is communicate more with his wife.
He may need to look at his own negativity and how that manifests itself within the relationship and look at reframing his thoughts about his sexual unctioning. i. e. `I am afraid to have sexual contact with my wife in case I let her down by not having the ability to have an erection? to `I know my wife will understand if I don’t have the ability to gain an erection and we can use other methods to gain sexual fulfilment and be close to each other?. After work on his self esteem this will become easier. The client needs to decide whether to inform his partner of the changes they want to make in order to address their mental health at this present time or the things their partner can do to help.
Small achievable goals have to be put in place to enable the client to make changes at an appropriate level. Mr G would probably have a plan looking a little like this to work through. If I was the therapist working with Mr G I would present this to Mr G as a pie chart giving Mr G the chance to choose which he felt he needed to work through first giving him autonomy and empowerment to take charge of his life giving him self worth and a focus in his life. Identification of presenting problems,
Acceptance of lifestyle changes needed to accommodate recent physical health problems Being aware of contributing factors that can affect mood and cause depressive symptoms, and to explore these factors including suicidal ideation and risk factors. Understanding anxiety and how to be mindful of his anxiety levels Addressing procrastination and setting small goals Looking into relationship difficulties and sexual problems Looking towards future goals and support networks for both him and his wife.
Explore options for future aspirations as a couple including holidays and things they can do together given deterioration in Mr G, s physical wellbeing. This Plan would hopefully give Mr G insight into his presenting problem, and, depending on the work I would be completing, and which piece of pie I would be working through, would determine my approach in therapy. At the beginning of counselling a person centred approach is important, and allowing the client a safe space to discuss their problems is paramount. With the core conditions set down, the client has the safe space and this approach will develop naturally.
When looking at the history of a client, and how their past events may influence the present, working in a psychodynamic way would help the client explore their core beliefs and thinking patterns. A c. b. t. model may be helpful when challenging negative thoughts, reframing, and assessing anxiety levels. This model will also be very useful when looking and working with future goals. I feel there is a lot of support we can offer Mr G with his problems. What initially is presented as a big problem, can be explored and broken down into segments, each segment can then be used to work towards a more manageable and successful resolution.
Courtney from Study Moose
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