Case Study
Patient Demographic: Name: Alex Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, Severe Age: 65 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Multiracial Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: Appearance: The client is dressed in a manner that can be described as casual, suggesting that they might not have made any special effort to dress up for the session. Additionally, he is unshaven, which you note might indicate either personal preference, a decline in grooming habits, or possibly, decreased motivation and energy.    Behavior: The client's overall behavior is withdrawn.    Mood and Affect: His stated mood is depressed, implying feelings of sadness, hopelessness, or desolation. His affect, the observable manifestation of his feelings, is flat.    Speech: His speech is both slowed and measured.    Thought Process and Content: The client's thought process is tangential. He tends to veer off-topic and does not consistently answer questions directly or stay on point. The content of his thoughts is notably negative and self-defeating.    Perceptual Disturbances: No delusions or hallucinations have been reported, indicating that the client has no gross misinterpretations of reality or perceptual disturbances.    Orientation: The client is oriented to person, place, and time.    Insight: It appears that the client has poor insight into his condition.    Attitude: His attitude towards the evaluator is compliant and cooperative.
Presenting Problem: First session You are a licensed mental health therapist. Today you are seeing a 65-year-old male via distance counseling. You introduce yourself and ask him what prompted him to schedule an appointment to see you. He reports that he has felt "down in the dumps" for several years, and as he gets older, he feels more depressed and is in constant pain. As he is talking, he shifts around in his seat, appearing to have difficulty staying in a comfortable position. He continues by saying he feels depressed most of the time, has lost interest in activities that he once found enjoyable, feels hopeless, and is fatigued all the time. He also says he has lost his appetite and has difficulty sleeping. He states that "no one wants me around." Then he looks down and says, "I don't really blame them. I wouldn't want to be around me either." At work, he has difficulty concentrating and making decisions and is distressed that his co-workers see him negatively. When you ask him about his relationship with his wife, he says that while they live together, they have "not been close for a long time now." They both sleep in separate bedrooms and they lead separate lives. He explains, "We just kind of grew apart. We still love each other and would never get divorced, but now we're more like roommates. She's very social and involved in the community. I'm more of a homebody."    After the client has shared why he is seeking counseling, you state, "I can hear that you are feeling very discouraged. It sounds like you have been going through a difficult time for quite some time now and it's taking a toll on your life. Let's explore what might be contributing to these feelings and how we can work together to help find solutions or ways to cope with the challenges you're facing." You use a solution-focused brief therapy technique and ask him visualize what successful treatment would look like. He contemplates it for some moments and says, "I'd feel better, I guess." You encourage the client to think more deeply about what successful treatment would look like and explain how this visualization process can help him gain clarity on his desired outcomes. He says, "Hmm, I'm not really sure. Can you give me some examples? This is my first time in therapy and I'm not really sure what to expect." You provide some examples of tangible goals that he might set for himself, such as improving sleep patterns, having better communication with family members and co-workers, and finding meaningful activities to engage in. The client is able to identify some areas that could be improved and formulates realistic, achievable goals. Together, you create an action plan for successful treatment, which includes specific steps he can take to reduce symptoms and increase positive outcomes. You schedule a follow-up appointment to meet with him next week.  Fourth session It has been three weeks since your initial session with the client, and he has been keeping his weekly appointments. Last week you suggested he see a psychiatrist, and you begin today's session by discussing the results of his psychiatric referral. The client reports that he was prescribed antidepressant medication. He is not feeling much relief from his depressive symptoms now, but his psychiatrist told him that it could take a few months for the medication to reach maximum efficacy. Next, you discuss treatment options and the use of cognitive-behavioral therapy combined with his medication regimen. He is willing to try the combined approach, and together you create a treatment plan with both short-term and long-term goals. He mentions his job being a source of frustration. You spend some time discussing the client's job and his feelings about it. He expresses his desire to retire, but he worries about the financial burden it may place on his wife. He says, "My retirement benefits are not that great, and I lost a lot of money in the stock market last year. I just don't know how I can make this work. I'm not sure if retiring now is the right decision." You discuss other possibilities for him to consider for retirement, such as part-time work or freelancing in a field he enjoys. You also brainstorm with him about ways for him to transition out of his current job in a way that reduces conflict with his co-workers, such as taking scheduled breaks and speaking with his supervisor about his workload. You provide support and suggest that he speak with his wife about their financial situation before making any decisions about his retirement. He agrees and states he will bring it up with her this upcoming week.    Toward the end of the session, the client reveals that he has been contemplating cutting back on his drinking, but he is worried that he will not have any friends if he stops drinking. He says, "I already feel like a failure at work and as a husband. If I lose the few friends that I still have, I'll be alone and will never be happy again." You utilize motivational interviewing strategies and suggest that if he stops drinking, it will not mean that he has to give up all of his friends, but rather that he may need to find new friends who do not drink alcohol or who can meet with him in an alcohol-free context. He nods his head and says, ""I hear what you're saying, but who is the world would want to be friends with someone like me? The only reason I've got any friends left is because I like to drink with them." You empathize with his feelings of self-doubt, but remind him that it is possible to find meaningful friendships without drinking. You give him a homework assignment to find at least one activity or group that seems interesting to him and create a plan to start building positive relationships with others. You reassure him that you will be there to support him through this process and set a date for his next appointment.  15th session You have been seeing the client regularly for the past four months. He states that he is feeling "better" these days, and he is doing better at work. He has been taking his antidepressant medication as prescribed and feels therapy has been helpful. You review the treatment plan and discuss the progress he has made and the termination process.    Near the end of the session, he tells you, "Well, there is one more thing. I'm worried that my wife might be having an affair. I know it's probably crazy, but I can't help but think that she's seeing someone else. And you know what, I wouldn't blame her. I haven't been the best husband with my constant depression. I just think about her leaving me, and it makes me feel afraid." You express understanding and validate his feelings, noting that it's not uncommon for people to have affair-related thoughts when feeling insecure in their relationship. You inquire whether he has been spending time with his wife and how he and his wife have been communicating. He reports that they have been talking more and that he has been trying to be more present when he is with her. You remind him of his progress in therapy and how much better he has been feeling overall, which has likely contributed to him being able to engage more in his marriage. You suggest that as he continues to work on himself and generally feels better, his worries about his wife cheating on him will likely lessen. In the meantime, you caution against drinking to cope with his anxiety, as it can lead to further problems down the road.
Other Contexts: The client reports that his relationships with family members were strained growing up, with his father often away for work and his mother struggling with her own mental health. He reports that his mother drank a lot, which the client defends saying, "I guess I'd drink a lot if I had 5 kids by the time I was 22 years old. The client grew up feeling unsupported and unimportant, which led to a disconnect from the rest of his family. Of his four siblings, the client keeps in touch with one brother, but "my other two brothers and sister live in different states and have different lives. I think they've struggled with depression, too. We don't talk much." Despite this difficulty in connecting, the client has an adult daughter whom he "loves very much and tries to stay in contact with. He wishes he could have done better for her during his parenting years, and despite their rocky past, has a deep desire to maintain a healthy relationship. He says, "I don't want her to think the same way I do about family and relationships. I want her to have good ones." The client is currently employed as a corrections officer and feels his job has no potential for advancement. He has been working there for 20 years and is ready to retire in less than a year. He expresses that it has been challenging and physically and mentally exhausting. In addition, he is tired of "dealing with both the inmates and the administration." He tells you his co-workers consider him a "slacker" because he is always tired and takes as many breaks as he can get away with. He is also worried about "word getting back to his co-workers" that he is in therapy. The client expresses that he has some drinks, especially after work, to calm down. He reports that he will drink in social settings as well. He states that his preferred drink of choice is whiskey.

Question: Given the revelations within this session and considering your observations of the client during the subsequent sessions, which statement is most accurate to document in the client's therapy record?
(A): The client and his wife are experiencing Folie à Deux, sharing jealous delusions.
(B): The client's work conditions negatively affect his mental health, and he needs to retire earlier than planned.
(C): Suicide risk factors have decreased, and he does not need to be screened for suicidal ideations, intent, and plan.
(D): Suicide factors have increased, and he needs to be screened for suicidal ideations, intent, and plan.

Correct Answer: Suicide risk factors have decreased, and he does not need to be screened for suicidal ideations, intent, and plan.
Explanation: The client has a history of substance use and disclosed a new major life stressor with his wife, but he has learned coping mechanisms to deal with this new fear. Screening for suicidal ideations, intent, and plan is not necessary. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis