Rosalyn is a 59-year-old woman who willingly schedules an appointment to see you but is a bit guarded during your initial phone conversation. Her responses to your questions were brief and direct, but lacked detail.

During the first session, you learn that Rosalyn is of African American descent, maintains a higher socioeconomic status (SES) as the result of educational attainment, financial security, and perceptions of social class. She struggled early in life to accomplish her and takes pride in the results of her efforts. She is quite reserved in the information she offers you.

After a rapport is established, Rosalyn begins to share her reasons for coming to see you. She and her husband were married for 31 years. They met in college, fell in love, and married after undergraduate school. Four years ago, her husband died of a heart attack at the age of 55.

Rosalyn has two adult children who live in different states but visit their mother regularly. Rosalyn has not dated since her husband's death, and has experienced no sexual urges or feelings, but in recent months, she realized the need to "learn to live again."

She met Matthew through a close friend. Matthew is six years younger than Rosalyn. He is a high school graduate who has never been married, and has one child as the result of a previous relationship. He lives modestly and can support himself, but has little need for extravagances. The two became close very quickly.

After only four dates, Rosalyn and Matthew engaged in intercourse. Rosalyn reports that she is glad to be sexually active again despite initial concerns and anxieties, but says that the interaction was not as enjoyable as anticipated. Matthew proceeded quickly without concern for Rosalyn's inhibitions, and during intercourse, she experienced pain due to vaginal dryness and did not achieve an orgasm. Matthew did not initiate oral stimulation and was not attuned to her sexual needs, only his. The sexual interaction did not last long and upon his climax, intercourse ended.

Afterward, Matthew was especially passionate as the two cuddled in bed for over an hour, during which time he spoke softly and reminded Rosalyn how much he enjoyed their sexual and emotional bonding experience.

Rosalyn explains that she is experiencing a combination of emotions that include excitement, fear, confusion, and even frustration. She enjoyed the experience, though it lacked the fulfillment she anticipated. She would have preferred the process to be slower, more sensual, and more meaningful.

She also notes that in their time together since, she has had trouble being aroused and has still not achieved an orgasm. She is not sure why this is happening, because she used to really enjoy sex with her husband. She wonders if it is her issue, or if it is because she is not with the right partner.

She also questions her ability to select a partner due to her life experiences; she has lived a good and prosperous life, believes that she deserves to be happy and satisfied in all aspects of a relationship, but wonders if Matthew can provide her with the lifestyle she desires. She does not want to negatively affect the relationship by making harsh demands or minimizing the positive aspects of the new relationship, but feels that a rational decision needs to be made about the couple's future before either of them gets hurt.

You avoid giving advice, and observe the proper counseling role, which includes being attentive, using active listening skills, exploring realistic options with the client, and becoming part of a support system that allows the client to make new choices that are safe, practical, and helpful. Rosalyn presents with many cultural factors that contribute to the unique woman she is; she is female, African American, of a higher socioeconomic status, is a mother, a widow, and is in a new relationship, among others.

How will you as her therapist honor Rosalyn's cultural background so that together, you can arrive at goals for her to be sexually and emotionally satisfied with life's new possibilities? What additional information do you need from either Rosalyn or Matthew so that sexual needs can be properly assessed?

In a subsequent appointment, Rosalyn demonstrates significantly more emotion. Some developments in the relationship have complicated matters.

Matthew has begun to demonstrate some concerning behaviors. When the couple disagree about something, he has begun to raise his voice and show anger that is way out of proportion to the disagreement. For example, not long ago, Matthew suggested a joint checking account and other moves to blend their finances. When Rosalyn showed insufficient enthusiasm for the idea, Matthew exploded, shouting that she clearly didn't trust him and insisting that only ceding control of finances to him would show that she really did love him.

Another incident developed when Rosalyn told Matthew she was planning to go visit her mother and sisters for a day. Matthew became irrationally angry that Rosalyn had "made plans without him," and kicked her dog. Rosalyn says that he was effusive in his apologies later, saying that it wouldn't happen again. Rosalyn is unsure whether to trust that it won't. She is also beginning to think ahead to prevent his bursts of anger, and doesn't like that.

Treatment plan on Rosalyn

Diagnosis

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Goals

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Treatment plan

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