Case Study
Patient Demographic: Name: Ethan & Cindy Clinical Issues: Sexual functioning concerns Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 69 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Private Practice  
Mental Status Exam: The husband appears to be of average build. His dress is appropriate for the occasion, but his facial expression is blank and he keeps staring off into space. He has difficulty maintaining eye contact and speaks in an aimless monotone. His affect is blunted, and he appears to be emotionally detached from the situation. He reports feelings of worthlessness and emptiness that have been ongoing for many years. He has had recurrent suicidal ideations but is not currently making any plans to act on them. His thought process is disorganized, concrete and circumstantial in nature.    The wife is slightly overweight and dressed in loose clothing. She appears agitated and tense but is able to maintain good eye contact throughout the conversation. She speaks in a clear, consistent manner and expresses her thoughts in an organized fashion. Her thought content is focused on her current difficulties with her husband, and she expresses feelings of disappointment, rejection, and anger. She acknowledges feeling a sense of hopelessness in the situation and shares concerns about her future. Her mood reflects her thoughts and is generally pessimistic. Insight is intact as she is able to recognize the impact of her own actions on the current state of affairs. Her judgment is also intact as she recognizes that her current behavior and attitude are not helping the situation.
Presenting Problem: First session You are a mental health therapist in a private practice setting. A couple, a 69-year-old male and a 65-year-old female, enters your office together. The couple has been married for over 40 years and have two grown children. Their second child age 31 is currently living at home. When you ask what brings them to therapy, the wife immediately states that her husband is not attracted to her anymore. She tells you that he never wants to be in a situation where they are romantic together. She is feeling unwanted, unattractive, and as if they are "roommates" who just cohabitate together. When you ask the husband how feels, he says that he has a sense of disgust toward his wife when he thinks of having an intimate encounter with her. The wife believes that her husband is repulsed by her physical appearance as she is overweight. The husband confesses to feeling guilty for his lack of interest in his wife, but he is unable to pinpoint why he feels this way or understand why it has become an issue now after 40 years of marriage. Exploring further, you ask the couple about their family of origin. The wife states that her parents were highly critical and demanding, while the husband's parents were more passive and removed when it came to expressing affection or showing disapproval. She also expresses concern over possible sexual abuse in the husband's past, though he is not sure if anything happened or simply cannot remember due to its traumatic nature. With these additional pieces of information, you begin to develop a comprehensive picture of their situation and focus on working with the couple towards a positive outcome.  Fourth session You have seen the couple for three therapy sessions so far. Today is your fourth session with the couple. The wife tells you that she is "officially sleeping in the spare bedroom" and is considering a trial separation. Last week she bought lingerie to entice her husband, and he responded by ridiculing her, then turning away from her and going to sleep. The wife begins to cry as she says, "We don't talk anymore. He just berates me all the time, and that hurts a lot." As the wife tells you about the incident, the husband sighs audibly and shakes his head. He looks at you and states, "She's a mess. I don't know what to say."    You empathize with the couple's emotional struggles, and you acknowledge their pain. You explain to them that it can be helpful for couples to explore personal issues in an individual therapy setting before coming together as a couple to make progress on their relationship challenges. You let them know that they may find it easier to express themselves when one partner is not present, and that individual counseling can give them each the space to address their own personal issues in a safe environment. You encourage them to take some time to reflect further on whether they believe individual therapy would be useful for them at this time, and you offer to provide further information about the process if needed.    Finally, you let them know that you are here to support them as they make decisions about how best to move forward. You assure them that while their relationship may be in a difficult place right now, it is possible to heal and strengthen their connection with one another. You remind them that relationship issues are often complex and that it is important to be patient with each other as they work together to find solutions. You encourage them to stay committed to the process, even when things feel difficult, and you offer your ongoing support in helping them build a more fulfilling relationship.
Other Contexts: The wife states that she had an emotionally distant relationship with her parents growing up and never felt truly accepted by them. She also reveals that her father was often angry and verbally abusive, which left her feeling anxious and fearful in his presence. When asked about his family of origin, the husband speaks of his parents as being cold and unapproachable; they showed acceptance or rejection based on whether he met their expectations. He expresses difficulty in determining how he is supposed to act around them. Stressors & Trauma: When asked about how the family of origin showed acceptance or rejection, the husband states, “My parents ignored me when they were displeased. I got to sleep in their bed when they were pleased with the way I acted.” When asked about sexual abuse, the client states, “I'm not sure. It seems like something bad happened with my mother and uncle. There might be something more than that, too. I can't really remember.” Previous Counseling: The husband has been struggling with depression for the past few months after he lost his job in an economic downturn. He has been struggling with feelings of worthlessness and emptiness for many years, even when he was employed. He has had multiple periods of suicidal ideation, but never acted on them. The client also states that it is difficult for him to focus and stay motivated. He is currently taking Wellbutrin that was prescribed by his primary care physician and states that it helps "take the edge off." The client states he would rather deal with the pain than be emotionally blunted.  

Question: Which of the Four Horsemen of the Gottman Methods of Couples Therapy is the husband exhibiting in his interactions with his wife?
(A): Stonewalling
(B): Defensiveness
(C): Contempt
(D): Criticism

Correct Answer: Contempt
Explanation: The second horseman is Contempt. This horseman goes beyond criticism to being downright mean and disrespectful. According to Gottman, contempt was the greatest predictor of divorce. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis