Case Study
Patient Demographic: Client Age: Husband, 38; wife, 37 Sex: Husband,male; wife, female Gender: Husband,male; wife, female Sexuality: Husband,heterosexual; wife, bisexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Couples counseling Presenting Problem: The couple is experiencing distress because the wife has had a sexual affair with a woman. Diagnosis: Adjustment disorder, unspecified (F43.20) and relationship distress with spouse or intimate partner (Z63.0)
Mental Status Exam: Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects. Both individuals are oriented to person, place, time, and situa
Presenting Problem: You are a licensed counselor meeting with a couple in your private practice clinic. The couple comes in, and they both sit down at far ends of the couch and do not look at each other. After explaining informed consent and other intake policies, you begin to ask the couple what brought them to counseling, and they both sit silently. You ask the couple if it is hard to start this conversation because of why they came, and they both nod. You ask the couple if it might be easier to start with how they met and why they fell in love with each other, and they both nod in agreement that they can talk about that. The couple appears more comfortable after this and even say a few statements to each other about shared experiences during the conversation. You circle back to the reason why they came to therapy, and the wife says that she assumes that she should talk first. She states that about a week prior she told her husband that she had an affair with a woman a few months before. She continues that, at the time, she was curious and it occurred while she was drunk and insists that it meant nothing. The husband states that he still loves her, but he is not sure how he is going to move past this. He emphasizes that not only did she have an affair, but her action exposed an aspect of her that he did not know about, making him question whether she even finds him attractive.
Other Contexts: The couple comes into the session and sits down. Their body language does not appear as uncomfortable as it has in previous sessions because they are sitting a little closer together. You ask both individuals what they need to work on. The wife says that she knows that she needs to rebuild trust, and the husband says that he wants to know more about what happened in the affair before they move forward. The couple report that they tried to engage in sex, but that the husband stopped during intercourse. The husband states that he could not get the idea out of his mind that his wife does not find him attractive because she was with a woman. You ask the husband what it means for their marriage if his wife does not find him attractive, and he states that it means he will not be able to please her. You then ask him what it means for the relationship if he cannot please her, and he responds that it means he cannot be a good husband. You follow up asking what it means if he cannot be a good husband, and he says that they will have a miserable marriage. You support effective communication strategies and empathize with the couple. After the session, the wife comes back to get her coffee that she left and says that she knows that she hurt her husband and is in the wrong, so she will do whatever her husband needs to rebuild trust.  At one point during the session, the husband stops talking completely

Question: At one point during the session, the husband stops talking completely. Which one of the following actions is the most effective way to deal with this example of stonewalling?
(A): Encourage the couple to support each other in coping with strong emotions and then help them process how they are feeling.
(B): Instruct the client to walk away without saying something that would escalate the situation.
(C): Instruct the client to express that he is overwhelmed and to request a break.
(D): Encourage the couple to discuss how they are feeling and address their presenting emotions and thoughts.

Correct Answer: Instruct the client to express that he is overwhelmed and to request a break.
Explanation: According to Dr John Gottman’s four negative behaviors, or the “Four Horsemen of the Apocalypse,” there are four characteristics of communication within a couple that increase the risk for divorce: stonewalling, contempt, criticism, and defensiveness. The most effective way to manage stonewalling, according to Gottman, is for the client to express that he is overwhelmed and to request a break. Walking away without saying anything would reinforce the stonewalling and would likely escalate the situation. A discussion with the couple or encouragement in coping with strong emotions together may lead to further escalation due to the gravity and rawness of the husband’s emotions and would not support him in managing these strong emotions. Therefore, the correct answer is (A)
Competency: counseling skills and interventions