Case Study
Patient Demographic: Name: Jack and Diane Clinical Issues: Marital/partner communication problems Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 35 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Community-based mental health facility  
Mental Status Exam: The clients are a couple in their mid-30s. The husband is tall and healthy. The wife is petite and well-groomed. As they enter, you make note that though they came in the same vehicle, they enter with no contact between them. They sit far away from one another and do not look at each other but maintain excellent eye contact with you. The husband's movements seem to be more agitated; the wife appears subdued. He speaks quickly and loudly and often fidgets in his chair, rarely sitting still; in contrast, her speech is low and soft, and she remains still and moves very little. They both seem guarded. They both identify their son's diagnosis of Autism Spectrum as being a significant strssor.
Presenting Problem: First session Your clients are in their mid-30s and present to the community agency where you are employed as both a licensed mental health therapist and a marriage and family therapist. You begin by introducing yourself and telling the couple about your professional experience and explain the types of therapies that you provide for couples. When asked why the couple made an appointment to meet with you, the husband takes the lead and tells you that he and his wife have been "serious problems" with their relationship for a few years. The husband shares that his wife does not trust him since his alcohol use "got out of control." Although he has been able to maintain sobriety for two years, he says that his wife is "paranoid" that he is using again and insists on knowing where he is "every minute of the day." He further reports that his wife is "too dependent" on him, and he feels "suffocated." He says, "I just can't keep doing this" and puts his head in his hands. You thank him for sharing his perspective of the problem and encourage the wife to share her thoughts about what is going on with their relationship. She tells you, "Truthfully? I'm scared to death that he's going to start drinking again and leave me alone with our children. I don't know what I would do if I lost him." She wipes a tear away from her face. After taking a deep breath, she says that when she tries to approach him to talk about how she feels, "he just gets mad and leaves the room."    Using open-ended questions, you ask about each person's expectations for the counseling process and inquire about past experiences in therapy that may inform the current situation. Both partners look at each other, then back at you and share that they would like to re-establish trust and respect in their marriage. This is their first time seeking counseling. You also invite them to share the story of how they first met each other, memories of their relationship prior to getting married, and how they felt when they became parents. The husband shares that they first met when they were teenagers and have been together ever since. He talks about how their relationship was full of passion, respect, and trust. Even during the difficult times, they felt like nothing could tear them apart. He also shares that when their son was diagnosed with Autism Spectrum Disorder, they felt like the world had come to a standstill, but they were determined to get him the best care possible. He pauses. The husband and wife look at each other before the wife speaks. She explains that after their son's diagnosis, her husband began to drink more heavily as a way of dealing with his own stress and anxiety. He denied it for a long time, but eventually admitted he needed help and sought treatment. Although she was relieved that he got help, she is still struggling to trust him again.
Other Contexts:   The husband used to have severe issues with alcohol. He went to rehab three years ago and has maintained sobriety for two years. He continues to attend weekly meetings. As a result of his alcohol misuse, he has some medical issues with his liver, but they are not currently life-threatening as long as he continues to abstain from alcohol. The husband has worked hard to rebuild his relationships with his family and friends. He is actively trying to repair the damage that was done due to his alcohol misuse. He has been attending AA meetings and is focusing on rebuilding trust and communication. He has also been making an effort to be more present in his family life and to be a better husband and father.

Question: When forming your treatment plan for the couple, how do your observations from the mental status exam inform your approach?
(A): Focus on improving the couple's emotional connection and trust
(B): Focus on the wife's lack of assertiveness skills and explore ways for her to gain more independence
(C): Focus on the son's treatment for Autism.
(D): Focus on their communication issues, and incorporate cognitive-behavioral techniques to address them.

Correct Answer: Focus on improving the couple's emotional connection and trust
Explanation: During the MSE, your observations indicate that the couple is experiencing a lack of trust between them - they are sitting far apart from each other and refusing to look at each other. Exploring the trust issues between the husband and wife would be the most effective approach when creating a treatment plan for this couple. Therefore, the correct answer is (A)
Competency: treatment planning