Case Study
Patient Demographic: Name: Tony Clinical Issues: Feeling alone and disconnected from children Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 66 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client is well dressed and well-groomed. He appears healthy for his stated age. Speech flow is normal, and eye contact is appropriate. The client is cooperative with adequate rapport. His thought process is logical. He expresses feeling angry, "even though there is nothing to be angry about." You do not observe any physical evidence of anger. When asked to describe a time when he felt angry recently, he mentions a road rage incident. His affect is more sad than angry.
Presenting Problem: First session You are a licensed mental health professional working in a private practice setting. The client is a 66-year-old male who is returning to therapy with you. When he called to schedule the appointment, he asked if he could meet with you for dinner beforehand and offered to pay. He presents for his session today, reporting that he has been experiencing what he labels "anger," but he cannot figure out where these feelings are coming from. He says he often talks to himself and ruminates over problems to find solutions. He is seeking your help to improve his relationship with his children. He felt that working with you in the past was helpful, and now that his children are all adults and he is financially secure, he has the time and resources to spend with them.    The client has a history of difficulty in forming and maintaining meaningful relationships, particularly with his children. He has a history of conflict with them and has difficulty with communication and boundaries. He has had difficulty constructively expressing his feelings and has frequently resorted to outbursts of anger and aggression. He has had difficulty positively expressing his needs and has often felt overwhelmed and frustrated by his inability to be heard or understood.    The client also has difficulty with impulse control and self-regulation, contributing to his difficulty managing his anger. He has frequently engaged in self-destructive behaviors to manage these feelings and has had difficulty finding effective coping strategies to control his emotions. He has also reported a pattern of avoidance, in which he avoids or withdraws from difficult situations rather than confront them.    At the end of today's session, the client asks if he can go ahead and schedule therapy appointments with you every Tuesday for the next month so that he is "guaranteed" a spot. You can accommodate his request and plan to see him again in one week.

Question: Which of these issues would you address first?
(A): Impulse control and emotional self-regulation
(B): Difficulty with communication and boundaries
(C): Lack of interpersonal skills
(D): Unwillingness to deal with problematic behavior in the past

Correct Answer: Impulse control and emotional self-regulation
Explanation: This is the most critical issue, as the client's inability to manage his behavior and his emotions are affecting him in a negative way. His lack of impulse control and lack emotional self-regulation put him at risk for being in harmful and dangerous situations. Therefore, the correct answer is (B)
Competency: counseling skills and interventions