Case Study
Patient Demographic: Clients Age: Husband: 45 Wife: 43 Sex: Husband: Male Wife: Female Gender: Husband: Male Wife: Female Sexuality: Heterosexual Ethnicity: Both Individuals Are Caucasian Relationship Status: Married Counseling Setting: Private Practice Counseling Clinic Type of Counseling: Couples Counseling Presenting Problem: Marital Distress Diagnoses: Couple Diagnosis: Adjustment Disorder with Anxiety (F43.22) and Relationship Distress with Spouse or Intimate Partner (Z62.898) Individual Diagnosis (Wife): Generalized Anxiety Disorder (F41.1)
Mental Status Exam: Mental Status Exam: The husband and wife were both oriented to person, place, time, and situation. Both individuals were dressed appropriately for the season and appeared clean. The husband presented as angry, and the wife presented as remors
Presenting Problem: You are a licensed therapist working at a private practice. The couple comes to counseling in order to work on their relationship following an infidelity. The wife has difficulty expressing what happened, and the husband interrupts her and expresses that his wife had an affair with a coworker 3 weeks ago. The couple states that they are currently talking very little aside from conversations that involve their children. The wife states that she is regretful of what she did and that she does want her marriage “to be saved.” The husband explains that he is very hurt by her infidelity and that he is unsure if he can forgive her and continue being married to her. The couple has been married for 25 years and report that they both are in counseling to see if they can continue to be married following the affair. The husband expresses strong anxiety following the revelation of the affair and questions how he can be in a relationship with his wife following the infidelity. The wife is experiencing anxiety regarding her husband leaving her because she reports regretting the sexual interaction with her coworker and does not want to get divorced.
Other Contexts: The husband and wife come into the session and sit as far as they can from each other on the couch, and their individual body positions are oriented away from each other. You ask for any updates in the couple’s relationship, and the husband states that they have not been talking about the affair and continue to only communicate regarding the kids. You attempt to process with the couple what the affair means for their relationship and what events led up to the affair. During the session, the husband stops talking and looks away from his wife when she talks about how she became frustrated that her husband did not spend quality time with her prior to the affair. She thinks that this led to her seeking attention from a man outside of the couple’s relationship.  You want to explore the husband’s feelings regarding the affair using the downward/vertical arrow technique

Question: You want to explore the husband’s feelings regarding the affair using the downward/vertical arrow technique. Which of the following questions demonstrates the use of this intervention in response to the statement “She cannot even remain faithful, so she clearly does not love me”?
(A): “What would you need to see from your wife to be reassured that she loves you?”
(B): “If that is the case, what does it mean for your future in this marriage?”
(C): “How does that feeling affect your current relationship with your wife?”
(D): “How does this affect your hope for the marriage being successful?”

Correct Answer: “If that is the case, what does it mean for your future in this marriage?”
Explanation: The downward or vertical arrow technique is a CBT intervention that assists in identifying core beliefs regarding thoughts or a situation. The counselor accepts the premise of what the person says and asks a projective question such as what it means for the future of the marriage (if the wife does not love her husband) and then further questioning based on the husband’s response in order to narrow down what the husband’s core belief is. The other questions are all helpful to ask and to explore, but the downward/vertical arrow question technique can help identify what the husband’s deeper fear is regarding his wife’s infidelity. Therefore, the correct answer is (A)
Competency: counseling skills and interventions