Case Study
Patient Demographic: Name: Jack and Diane Clinical Issues: Marital/partner communication problems Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 35 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Community-based mental health facility  
Mental Status Exam: The clients are a couple in their mid-30s. The husband is tall and healthy. The wife is petite and well-groomed. As they enter, you make note that though they came in the same vehicle, they enter with no contact between them. They sit far away from one another and do not look at each other but maintain excellent eye contact with you. The husband's movements seem to be more agitated; the wife appears subdued. He speaks quickly and loudly and often fidgets in his chair, rarely sitting still; in contrast, her speech is low and soft, and she remains still and moves very little. They both seem guarded. They both identify their son's diagnosis of Autism Spectrum as being a significant strssor.
Presenting Problem: First session Your clients are in their mid-30s and present to the community agency where you are employed as both a licensed mental health therapist and a marriage and family therapist. You begin by introducing yourself and telling the couple about your professional experience and explain the types of therapies that you provide for couples. When asked why the couple made an appointment to meet with you, the husband takes the lead and tells you that he and his wife have been "serious problems" with their relationship for a few years. The husband shares that his wife does not trust him since his alcohol use "got out of control." Although he has been able to maintain sobriety for two years, he says that his wife is "paranoid" that he is using again and insists on knowing where he is "every minute of the day." He further reports that his wife is "too dependent" on him, and he feels "suffocated." He says, "I just can't keep doing this" and puts his head in his hands. You thank him for sharing his perspective of the problem and encourage the wife to share her thoughts about what is going on with their relationship. She tells you, "Truthfully? I'm scared to death that he's going to start drinking again and leave me alone with our children. I don't know what I would do if I lost him." She wipes a tear away from her face. After taking a deep breath, she says that when she tries to approach him to talk about how she feels, "he just gets mad and leaves the room."    Using open-ended questions, you ask about each person's expectations for the counseling process and inquire about past experiences in therapy that may inform the current situation. Both partners look at each other, then back at you and share that they would like to re-establish trust and respect in their marriage. This is their first time seeking counseling. You also invite them to share the story of how they first met each other, memories of their relationship prior to getting married, and how they felt when they became parents. The husband shares that they first met when they were teenagers and have been together ever since. He talks about how their relationship was full of passion, respect, and trust. Even during the difficult times, they felt like nothing could tear them apart. He also shares that when their son was diagnosed with Autism Spectrum Disorder, they felt like the world had come to a standstill, but they were determined to get him the best care possible. He pauses. The husband and wife look at each other before the wife speaks. She explains that after their son's diagnosis, her husband began to drink more heavily as a way of dealing with his own stress and anxiety. He denied it for a long time, but eventually admitted he needed help and sought treatment. Although she was relieved that he got help, she is still struggling to trust him again.  Fourth session Today, the couple arrives for their afternoon appointment ten minutes late. The wife appears to have been crying. Her husband smells like mouthwash, and his movements are slightly slower than normal. You ask if he has been drinking today. He states that he has not had any alcohol today, but his wife says, "That's not true!" and proceeds to tell you that she "caught" him holding a bottle of liquor in their garage this morning. The husband replies, "I didn't do anything wrong. This is just another example of you looking for problems where there are none. Why can't you believe me when I tell you that I'm not drinking?" She replies, "I really want to believe you, but you make it really hard to do that." He shakes his head and throws his hands up in the air in frustration. You ask the husband to step out of the room for a few minutes. He agrees and says, "Fine. You know where to find me." The wife shares that she feels like her husband is not taking the process seriously, and she questions whether or not counseling will work for them. You thank her for expressing her thoughts and explain that it is very common for couples to have doubts about therapy, especially when there has been a history of substance abuse. You discuss the potential treatment barriers and emphasize that it is important to have insight into these problems in order to create positive outcomes. The wife appears to understand and is reassured by your words.    You invite the husband back into the room and ask him to share his thoughts about the counseling process. He takes a deep breath and says that he still wants to make their marriage work, but he is afraid of failing. He admits that he does not know how to "make things right" and this makes him feel helpless. You explain to him that counseling can help them gain insight into their communication patterns, learn new ways to interact with each other, and develop healthier coping strategies. You also discuss a plan for handling escalations in future sessions. You explain to the couple that it is important to have a plan in place whenever they are feeling overwhelmed or angry. Next, you discuss conflict resolution skills, emphasizing the importance of communicating their feelings and needs in an honest, respectful, and non-judgmental way. You also stress the importance of each partner taking responsibility for their own actions. You encourage them to practice these strategies outside of the session in order to improve their communication and relationship.    After the session, you discover that the community-based mental health facility where you work will be closing in six months due to a lack of funding. You view this as a potential barrier that will inhibit mental health treatment access for many clients as this is the only mental health treatment facility in the city.
Other Contexts:   The husband used to have severe issues with alcohol. He went to rehab three years ago and has maintained sobriety for two years. He continues to attend weekly meetings. As a result of his alcohol misuse, he has some medical issues with his liver, but they are not currently life-threatening as long as he continues to abstain from alcohol. The husband has worked hard to rebuild his relationships with his family and friends. He is actively trying to repair the damage that was done due to his alcohol misuse. He has been attending AA meetings and is focusing on rebuilding trust and communication. He has also been making an effort to be more present in his family life and to be a better husband and father.

Question: What would have been the most effective method for handling the emotional escalation that occurred during this session?
(A): Ask the husband to stay and explain why he was drinking in the morning.
(B): Ask the couple to take a break for a few minutes and then come back together to discuss the situation.
(C): Ask the husband to leave the session and to only attend therapy sober.
(D): Engage in a psychoeducational unit on metacommunicative techniques to give the couple the means to examine their communication style,

Correct Answer: Ask the couple to take a break for a few minutes and then come back together to discuss the situation.
Explanation: Taking a time out is a healthy way to de-escalate the situation. This allows the couple to take a break, cool down, and then come back together to discuss the situation and work on a solution. Therefore, the correct answer is (D)
Competency: counseling skills and interventions