Clinical Evaluation
Samantha (41) and David (43) arrive in their fourth session. They have been married 15 years with two children (11, 8). The presenting issue was their older son Jake's behavioral problems at school, but the therapist notices that Samantha and David have not touched each other in three consecutive sessions. When asked about this, Samantha says, 'We've been through this before in couples therapy, and David said he'd work on it and didn't.' David says, 'I don't know what she wants.' What is the FIRST clinical step?
Your answer: A•Correct: B
Rationale: Structural family therapy holds that child behavioral problems are frequently a manifestation of disruptions in the parental subsystem. The couple's physical and emotional distance — combined with David's withdrawal and Samantha's circular complaints — suggests a parental coalition that has collapsed or is near collapse. A structural map will identify whether the children have been drawn into the parental subsystem as pseudo-spouses or pseudo-parents, and whether Jake's symptoms are maintaining a fragile marital equilibrium.
Crisis Management
Amanda (28) tells her LMFT during a telehealth session that her estranged husband has been outside her apartment building twice in the past three days, despite a temporary restraining order she obtained the previous week. She says, 'He keeps driving by and I saw him parked across the street last night for an hour.' She appears anxious. She has no known history of violence. What is the MOST appropriate FIRST step?
Your answer: A•Correct: D
Rationale: The duty to protect requires the therapist to assess the level of danger in any situation where a client may be at risk. The estranged husband's violation of a restraining order and repeated surveillance constitutes possible stalking. The therapist must assess: does this behavior rise to the level of a serious threat of physical harm? If yes, Tarasoff duty applies. If no, the therapist should still help Amanda develop a safety plan and connect her with domestic violence resources.
Treatment Planning
The Nguyen family — mother Linh (36), father Thong (40), and their daughters Thuy (16) and Mai (11) — has been in therapy for three months. The presenting problem was Thuy's defiance and school avoidance. The therapist has been working with the parental subsystem and has noticed that Thuy's symptoms have partially improved but Mai, the younger sister, has begun refusing piano lessons and has become clingy. The therapist recognizes that the family system has shifted around Thuy's improvement. What is the MOST appropriate systemic response?
Your answer: A•Correct: B
Rationale: Structural family therapy predicts that when one identified patient's symptoms improve, another family member may be recruited to maintain the family homeostasis — a process called 'symptom shift.' Mai's new clinginess and piano refusal may be serving the same systemic function that Thuy's defiance served. A structural assessment of the sibling subsystem — who is aligned with whom, who is the more symptomatic sibling, and what would happen if both sisters were healthy — is the essential first step before treating Mai individually.
Treatment Planning
Marco (42) and Luca (38) are estranged adult brothers who have not spoken in 10 years following a dispute over their father's estate. Their mother Maria (70) has been diagnosed with a terminal illness and has asked the therapist to see both brothers together for 'one last chance to fix this.' Both brothers agree to come to a single session under the condition that the other attends. Neither brother acknowledges any responsibility for the estrangement. Marco begins the session by saying, 'I'm only here for Mom. I don't need Luca, and he doesn't need me.' Which intervention represents the MOST systemic Bowenian approach?
Your answer: A•Correct: B
Rationale: Bowenian family therapy uses the 'family diagram' — a structured genogram-based conversation — to track siblings' emotional process over time, particularly in estrangement. Asking each brother to describe the other from childhood through the estrangement reveals the multigenerational emotional triangles, sibling position dynamics, and differentiation levels that underlie the current cutoff. This is more systemic than addressing content, confronting resistance, or using a surrogate messenger.