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Mental Status Exam: Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects.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

Question: Which CBT technique did you use in the session summary when you responded to the husband’s statement about not feeling that his wife is attracted to him?
(A): Radical acceptance
(B): Guided discovery
(C): Cognitive challenging
(D): Downward arrow

Correct Answer: Downward arrow
Explanation: The downward arrow technique uses the client’s own statements to follow their thought process to its roots, which usually reveals the underlying cause of why the original thought is hurtful. The client’s original thought progressed from feeling that his wife is not attracted to him to fears that they will have a miserable marriage. Identifying this underlying fear can be helpful in targeting the deeper feelings that should be of focus during therapy. Radical acceptance is not a CBT technique and focuses on accepting the situation as it is. This may be helpful in accepting that the affair did indeed happen so that they can make a decision to either move forward together or separately. Guided discovery is a CBT technique that reflects on thoughts and feelings to discover the client’s thought process. Although this situation was about discovering the client’s thought process, the downward arrow technique is the specific method for how this discovery was completed. Cognitive challenging is a technique that focuses on challenging irrational or illogical beliefs or thoughts. Therefore, the correct answer is (A)
Competency: counseling skills and interventions