Case Study
Patient Demographic: Initial Intake: Age: 54 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced, In a relationship Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: John presents as well-groomed with good hygiene and is dressed professionally. Motor movements are slightly fidgety, indicating nervousness or moderate anxiety. Eye contact is intermittent. Denies suicidal or homicidal ideation, no evidence of hallucinations or delusions. John tightens his fists when elaborating on situational issues between him and his ex-wife, with the same controlled expression and tense disposition when sharing about his girlfriend. John mentioned that his girlfriend is also unreasonable for complaining about how often John comes home smelling of alcohol, saying that meeting people for drinks is part of his job. He added the comment “I need to drink to deal with her attitude all the time.”
Presenting Problem: Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25), provisional
 

John calls your practice asking to speak to a counselor to help him with his relationship. John tells you he’s never been to a counselor before and does not want anyone to know that he is seeing one, mentioning he will pay for sessions privately using cash. John admits to struggling with anger, specifically with his ex-wife of 15 years whom he divorced three years ago. John asks for availability in the evening hours and demonstrates hesitancy and reluctance to commit to more than a handful of sessions. In the initial assessment session, you notice he has difficulty making eye contact and is uncomfortable talking about his situation. After some rapport building, he begins to share that he is only seeing you because his girlfriend Sherry told him she would break up with him if he did not get his “anger issues under control.” John denied physically hitting Sherry, but alluded to several interactions that he stated, “got so heated I lost it on her, and she wouldn’t stop crying.” John complained of women he gets involved with being overly controlling of him and that he doesn’t understand why they are so “needy.” John works a demanding job in the sports marketing industry where he takes frequent trips out of state and spends long nights out, entertaining clients. He wishes he had the freedom to “do what he has to do” without “being treated like a child” by his romantic partners.
Other Contexts: Family History:
John tells you he has two children, a 34-year-old son he had with a one-night stand in college and an 18-year-old daughter with his ex-wife the first year they were married. He has a decent relationship with his son and provides him and his family occasional financial support, visiting with his grandchild over social media video once a month. He reports once being close with his daughter but that their relationship became strained as she got older and that now they hardly speak, saying “she took her mother’s side during the divorce, so she doesn’t want anything to do with me right now.” While conducting further interviewing about John’s family health you learn that John’s father passed away at 56 after several heart attacks and his mother died of heart failure and diabetes complications at 49. John has no other living relatives besides an uncle in another state and his cousins who live near him. He tells you growing up he used to go to church with his mother every Sunday until she got sick and has not been to church since.
 
Work History:
John has a master’s degree in Business Marketing and made his connections with his current position through contacts he made while playing on collegiate basketball teams. John has always worked busy jobs with which he becomes heavily engaged in and puts in overtime hours. John prefers work that keeps him on the road and traveling often, as he does not like to engage in the same routine every day. He mentions when he was younger, he could not keep a 9-5 office job or at any place that did not encourage individuality, saying he “butted heads” with all his managers and bosses until he was older.
 
Legal History:
John has had two arrests made for domestic disturbances in his home that his wife called in after heated arguments that left his wife afraid for her life. He was always able to make bail and was never tried or sentenced as charges were usually dropped thereafter. John admits to one drinking and driving accident when he was 19 where he served community service and fines as punishment.

Question: John notes that he is having difficulty at work as well. He feels he can make more money as an executive for a construction company and is considering selling his shares in the marketing industry. You do not agree this is the right time for a major career change. The best approach is to?
(A): Cheer him on enthusiastically! He needs somebody on his side right now
(B): Open a spreadsheet and help him compare the pros and cons of his financial choices.
(C): Smile and nod, using motivational interviewing and Socratic questioning to learn more
(D): Explain the risks associated with changing career fields and urge him to reconsider

Correct Answer: Smile and nod, using motivational interviewing and Socratic questioning to learn more
Explanation: Your opinion is not helpful to John right now as he shares with you his career considerations from this vulnerable place in his life. The counselor's role is to support John's thinking process and provide clinical feedback and guidance to assist him in learning and practicing healthier, more adaptive strategies than what is being currently evidenced in his life. Learning more about his thoughts and feelings on the matter might steer the conversation in a therapeutic direction. Focusing on solely the content expressed in his concerns and not considering the whole picture dilutes the overall supportive counseling experience you are providing and takes away from what he could be learning for himself. Celebrating his every presented thought, especially thoughts you do not agree are in his best interest, is pandering to him as a friend and beyond the scope of your boundaries as his professional counselor. Helping him consider the pros and cons of his decision is not a bad option but getting involved in exploring the details of his financial situation is not the most appropriate use of this counseling moment. Therefore, the correct answer is (A)
Competency: counseling skills and interventions