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Mental Status Exam: Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects.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: tion. Family History: The husband and wife have been married for 13 years. They report that they met when friends introduced them and that they dated for about 2 years before getting married. The couple have two children: two daughters (ages 7 and 10). The couple reports that they have been in “parent mode” for the past few years and have not been emotionally connected to each other because their attention has been predominantly focused on their children

Question: Which of the following is the most important area for you to focus on first when counseling this couple?
(A): Improving communication skills between the couple to facilitate conversations about how they got to this point in their marriage
(B): Stabilizing the couple’s relationship so that the goals of counseling can be identified
(C): Exploring thoughts and feelings about the affair so that counseling efforts can be targeted
(D): Processing how the couple got to this point to determine what the couple’s needs are

Correct Answer: Stabilizing the couple’s relationship so that the goals of counseling can be identified
Explanation: Stabilizing the relationship is the most important goal at this point in the therapeutic relationship. It is important to determine each individual’s commitment to therapy and their goals for the therapy process. This could also be an opportunity to set rules or guidelines so that certain topics are only discussed in counseling sessions, allowing the sessions to be guided and managed more effectively. Although improving communication is important, this goal will take some time because the couple has likely not been communicating wants and needs well, which may have led to the affair. It will also be helpful to focus on how the couple got to this point because this can open up conversations about deficits and needs that the couple has, but the relationship must be stabilized first. Exploring thoughts and feelings about the situation is very important and is likely a short-term goal, but making sure the couple is committed to the process and identifying their goals (to include whether the couple hopes to remain together or separate) is more pressing. Otherwise, therapy will not be productive. Therefore, the correct answer is (C)
Competency: counseling skills and interventions