Case Study
Patient Demographic: Name: Ruth and Dale Clinical Issues: Parenting/co-parenting conflicts Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse or Intimate Partner Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Agency  
Mental Status Exam: Appearance: The client is casually dressed and adequately groomed. She appears healthy, and her age is consistent with her stated age.  Behavior: The client's behavior is tense and purposeful. She is cooperative with adequate rapport.  Speech: Speech volume is normal, and speech flow is normal and spontaneous.  Mood: The client's mood is dysphoric and anxious.  Thought Process: Thought process is logical. Thoughts are negative.  Affect: The client's affect is broad and appropriate to the discussion.  Cognition: The estimated level of intelligence is within average range with abstract thinking. Concentration is intact. The client shows no problems with memory impairment.  Insight and Judgment: Insight is fair. Impulse control and judgment appear to be below average.
Presenting Problem: First session You are a therapist working at a marriage counseling agency. Ruth is a 41-year-old female who comes to your office with her husband. The couple has been married for seven years and have two children, ages five and one. The husband also has a 16-year-old daughter from a previous marriage who lives in the home. The client is a stay-at-home mom, and her husband works at a correctional institution. Their five-year-old has been removed from three separate daycare facilities because of her defiant behavior. In addition, the 16-year-old was recently arrested for shoplifting.    At the end of the session, the client turns to her husband and says, "I'm the one who has to stay home with the kids all day. You just don't get it. You don't know what it's like having no time for yourself and no quiet place to relax. You think all this stuff with the kids is a normal phase and everyone will grow out of it. Well, I don't think it's normal, and I'm tired of it! I've been talking to my ex-husband lately because he listens to me, and I feel better after I talk to him."    Ruth demonstrates elevated stress and anxiety levels, as evidenced by her verbalization of feeling overwhelmed by the demands of caring for their children and lack of personal time. She also expresses feelings of frustration with her husband, who she perceives as not understanding her struggles. Her husband's absence during the day and the children's challenging behaviors have likely contributed to the client's feelings of isolation and burnout. Ruth's decision to reach out to her ex-husband for emotional support may indicate that she is not receiving adequate support from her current partner.  Third session In accordance with Ruth's decision at the last session, she ceased communication with her ex-husband. After affirming this, she turns to her husband and says, "He called twice last week, but I didn't answer. At least someone wants to talk with me!" Dale gives her an exasperated look, folds his arms over his chest, and shakes his head in disgust, at which Ruth says, "See? That's all I ever get! Nothing!" and begins to cry. Dale seems angry but remains quiet.    Dale sighs and rubs his temples. "This is why I don't talk about it," he says. "You always make it about you. Do you think I don't want to talk to you? Do you think I don't care?" Ruth sniffs and wipes her eyes. "Of course not, but it feels like you don't want to talk to me. Like you don't care. You never talk to me, and then you get quiet when I try to talk to you."    Dale rolls his eyes. "That's because you don't listen when I try to talk to you. You just jump to your own conclusions and then get mad at me when I don't do what you think I should do. I'm tired of it. I'm tired of trying to talk to you, but you never listen." Ruth bristles, tears streaming down her face. "Well, what am I supposed to do? You never tell me what you want me to do, so how am I supposed to know?" Dale throws his hands and walks away in frustration. "I don't know, Ruth. I really don't know."  Tenth session The couple enters in better spirits than previously. They have been speaking with each other in the lobby while waiting. They enter laughing. Ruth reports that the communication techniques you shared seem to have helped. She no longer feels the need to leave her husband. They report that the 16-year-old daughter arrived home from her time at the crisis center somewhat subdued by the experience, although still showing challenging behaviors. They also say that the five-year-old still exhibits defiant behaviors at home and school.    The couple had worked hard to repair their communication and marriage, which is paying off. The husband and wife have found a new understanding and mutual respect. They have developed newfound patience and empathy for one another, helping to create a more harmonious environment at home. The couple had also applied the communication techniques they had learned to their interactions with their children. As a result, Ruth and her husband are now workings together to find a way to better understand and respond to their children's needs. They have set up a school conference to determine how to handle their children's behavior.
Other Contexts: Ruth's parents died in a boating accident while she was in college. She has two brothers and one sister, but they are not close, partially due to the strain of losing their parents. Her husband's first wife left him soon after their daughter was born. She does not discuss her place in the family's dysfunction but talks about other family members who need help. Ruth has been unable to heal her relationship with her sister and feels guilty about it. She also expresses concern for her husband's well-being after his first wife's divorce, which she was partly responsible for. Additionally, Ruth struggles with depression and anxiety due to trauma related to the death of her parents. Personal/Social Relationships: Ruth feels that her husband minimizes their children's problems and is to blame for their lack of improvement. Ruth feels her marriage is "on the rocks.'" Her husband knows his wife is unhappy but does not know what to do. Finally, you learn that Ruth recently reconnected with her ex-husband and is seriously considering having an affair. Previous Counseling: The client has been working on her low self-esteem through therapy but says she is not getting any better. Her husband says, "I know Ruth is unhappy. That much is obvious. She's stressed out all the time, and she's stopped talking to me. She gets in the car, is gone for hours, and isn't home when I arrive after work. I'm worried I will lose her, but I don't know what to do."  

Question: What would be the best additional service given the disclosures during this session?
(A): Play therapy for their five year old
(B): Family Therapy
(C): Parent support group
(D): Individual therapy for the daughter

Correct Answer: Family Therapy
Explanation: In this case, there are several issues at hand. You have helped the couple improve communication and trust up to this point. This entire family, however, appears to be struggling to manage their feelings toward each other and mesh as a whole. Family therapy would be the next logical step for your client to improve communication and identify areas of need and structure for the children to focus on their goals. Therefore, the correct answer is (D)
Competency: treatment planning