The four counselling sessions documented within this case study originate from an in-house GP referral in January 1999, for a client with psychosexual difficulties. The client had identified her problem as a lifelong failure to achieve orgasm, but felt this physiological problem may have a cognitive aetiology. In the interests of receiving the client with an open mind, I did not read her medical history and, after consideration, chose not refer to specialist literature on psychosexual issues as I felt such knowledge would not be predictive of the client’s experience.
I was aware of my ‘trainee’ anxiety and was wary that if I encountered any confusion with the client’s behaviour, I may grasp onto an inaccurate interpretation from specialist literature. The sessions commenced in February and took place over four weeks at the counselling unit within the surgery. The client did not want to be audio-taped and I began by setting out the contract; an initial structure of six-eight sessions and then review. (Trust policy allows for flexibility on number of sessions.
) The confidentiality excluded only suicidal ideation or threatened harm to another individual. Introducing client-centred counselling, I explained the emphasis would be on a relationship of shared power and control, rather than my use of therapeutic techniques or interpretation. The client’s aim for therapy was to want and enjoy sexual intercourse with her husband, as throughout the marriage she had sporadically consented to have sex without expectation of enjoyment.
Her aim marked the beginning of a shift from an external to internal locus of evaluation, as since adolescence she had not trusted her organismic self. We agreed that we would initially focus on her beliefs and experiences of sex, moving onto recommended sex education literature when we agreed she had reached that point. Client A is 43 and has been married for 22 years with two children: a son (18) and daughter (14). Due to space restrictions, I have retained only material that I felt had been of particular significance.
KEY CONTENT ISSUES 1. The client received verbal anti-sex messages from her parents, (mostly her father), throughout her adolescence that left her fearful of boys and sexual relationships. She did not question these beliefs and remembered her childhood as warm, protected and affectionate. This was an overall memory of warmth rather than physical expressions of affection. She did not crave more independence than she was given, and never discussed her sexual difficulties with her family as she felt they were too personal. 2.
At the age of eighteen she had a consensual sexual experience (though not penetrative sex), with a slightly older boy. She recalled a feeling of panic and ‘wanting to get out of there’. She remembered the incident immediately felt ‘sickening and disgusting’, and described herself as ‘contaminated’ by the experience. This ‘contamination’ intensified when she discovered he carried a sexually transmitted disease. When dissected, the ‘contamination’ appeared to induce extreme anxiety and ‘edginess’. She felt hatred towards the boy and had consciously regretted the experience ‘every day since it happened’.
It was palpable how painful it was for her to recall the experience with such honesty, and I felt the client saw this incident as something that had been done to her, not as a consensual experience. The implied feeling was of being a ‘victim’ of the experience and she confirmed this. She hoped that talking might help her to think of things in a different way and, upon reflection, I related her phrase to the client-centred concept of feeling safe enough to allow experiencing into awareness without distortion or denial. I felt my part in this process, was to facilitate her feeling of being understood without threat or judgement.
3. The client had formed a very poor self-concept and the ‘contamination’ began to manifest behaviourally: The boy involved was employed by a company that advertised in the Yellow Pages directory, and this book became the trigger for her self-disgust and shame. Her daily routine centred on avoiding the directory, but on occasions when she inadvertently came into contact with the book or an advertisement, her feeling of contamination would be overwhelming. To reduce the feeling she would go home, put the clothes she had been wearing in the rubbish, remove her jewellery and then bathe.
Her avoidance behaviour increased, leading eventually to agoraphobia. 4. The client also spoke of the early death of her son, who lived only nine months following an illness that necessitated hospitalisation throughout his life. She felt anger towards her family who will not speak of him and continued to deny his existence. She was the only family member who bonded with the baby, and following depth reflections of her isolation and intense fear during the pregnancy and his short life, spoke of the blame and guilt she felt for his suffering.
She realised she had insisted on a sterilisation years later to ensure she could not bring another child into the world to endure such suffering. 5. Her degree of perceived ‘contamination’ increased following the sterilisation and despite being initially unable to understand why the operation had triggered such intense emotion, reflected on the ‘contamination’ and felt the intimate gynaecological examinations, may have brought back the ‘violation’ of her sexual experience.
After the sterilisation, her avoidance of the Yellow Pages intensified and she was sectioned under the Mental Health Act to receive one-to-one counselling in a mental health unit. She was not open with the counsellor and did not discuss her experiences with anyone until our counselling sessions began. THE THERAPEUTIC PROCESS During the opening session, the client assumed a minimal amount of eye contact. When relating the sexual encounter, she remained focused on the floor, giving factual details.
I reflected her shame and humiliation, voicing her self-rejection. I recall complete synchronicity between the content and her way of being. My focus was on understanding, accepting and communicating admiration for her courage in speaking with such honesty. She had developed a condition of worth in the face of her continuing need for parental approval. Her self-concept held the belief that sex was dirty, which would protect her from negative experiences, i. e. parental disapproval or rejection.
The conditioned self-concept was increasingly internalised and she became alienated from her organismic self, with the dichotomy between her self-concept and experiencing leading to an increasingly distorted perception. The client’s self-regard became vulnerable following the sexual incident, when she was aware that she would be judged by her parents as less worthy of positive regard. When the experiencing of the organismic self finds itself in confusion with the need for approval, the outcome must be confusion.
It is possible the experience was so incongruent with the self-concept that her defence system was unable to prevent it overwhelming the self-concept and the obsessive behaviour was the result. It is also possible that she has cognitively distorted her level of consent to the sexual experience; by remembering less control over her participation, she may preserve and consolidate her self-concept. The opening session involved a high level of client self-disclosure, which could have resulted in feelings of vulnerability and embarrassment some time after the session, so at the end of the session, we considered how she might feel.