Case Study
Patient Demographic: Name: Alexei Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.99 Unspecified Alcohol-Related Disorder Age: 32 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: German American Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: A 32-year-old German American man confidently enters your office. He is tall and slender and appears older than his stated age. His physical appearance is unkempt. The client's voice quality is strong and loud, and his command of English is minimal. His posture and gait are limp and unsteady at times. He is slurring his words and appears to be actively intoxicated. He portrays no accountability or responsibility for his actions with substance use. He denies any current thoughts of homicidal ideations. The client lacks insight, and his thought processes are not logical or appropriate.
Presenting Problem: First session You are a psychoanalytic therapist in private practice and often work with clients who struggle with substance use issues. You believe these issues often arise from unresolved conflicts and the inability to manage emotions. Today, you are seeing a 32-year-old German American male named Alexei, who was referred to you due to occupational disciplinary issues related to alcohol use. Alexei was referred to you by his employer, where he works in a manufacturing plant in the Midwest. His supervisor noticed marked changes in his behavior and productivity over the last few months and was concerned that Alexei might be dealing with a drinking problem. The supervisor initially suggested an employee assistance program, but Alexei was adamantly opposed to talking to anyone involved in his workplace.    You introduce yourself and explain to Alexei that this is a safe and confidential space where he can discuss whatever is troubling him. You reassure him that the only people who will know about the details of this session are himself and yourself. Then, you begin to ask open-ended questions to assess Alexei's current state of mind and identify his current challenges. You are particularly interested in understanding his thoughts and feelings about his substance use and the occupational problems it has created. You notice that Alexei seems excessively relaxed as you establish the confidentiality of the session. As you delve deeper into his thoughts and feelings, you ask him to describe his relationship with substances, particularly how they have affected his daily life and work performance. Alexei hesitantly opens up, admitting that his substance use has become a coping mechanism to deal with mounting stress and anxiety. You listen empathetically and validate his emotions while gently probing into the factors that have contributed to this pattern of behavior.    Alexei tells you that his boss has never liked him and is trying to get him fired. He reports that he sees nothing wrong with having a few drinks in the morning and after lunch. He has been late to work "only a few times" because of a hangover. Alexei states that he needs help finding a new job. You ask Alexei if he can tell you more about his drinking habits. He says he usually starts drinking around 9 am and has been drinking more in the past few weeks. He also admits to drinking at work a couple of times. He looks at you suspiciously, wondering why you need to know this. You explain that it is important to understand his drinking habits and the context of his behavior to provide the best care.    As the session continues, you observe that Alexei's cognitive functioning appears impaired, as he struggles to maintain focus and has difficulty recalling important details. He expresses frustration and anger when discussing his work situation but minimizes the impact of his alcohol consumption on his professional life. Alexei's denial of his alcohol-related problems and the escalating pattern of his drinking behavior indicate a potential substance use disorder. Furthermore, his physical symptoms, such as sweating and slurred speech, suggest that he may be experiencing acute effects of alcohol during the session. It becomes evident that addressing Alexei's alcohol use and its consequences is crucial to provide appropriate care and support for him in his current situation.  Fourth session You completed a risk assessment in the last session and worked on safety planning with Alexei. He arrives 15 minutes late to today's session. When you mention his tardiness, he begins yelling in German. When you appear confused, he switches over to English, saying you are harassing him just like his wife. You respond by acknowledging his feelings and gently reminding him that you are there to help him process his emotions in a safe and productive way. Once he is calm, you explore what it is about your presence that he may be perceiving as hostile or threatening. He takes a breath, apologizes to you for his outburst, and begins to talk about his wife and her disparaging comments. He explains that, when you asked why he was late, it felt like a reminder of how his wife often disregards his needs and makes him feel worthless. "She makes some negative comment like 'you're late' or 'you never do this right'. It make me just want to give up!" He begins talking about wanting to take a break from home and go back to Germany where he can "start fresh". He says that his wife's constant harassment is unbearable. Lately, he has been hoping that she will leave him. You spend the rest of the session planning with Alexei ways he can express his feelings of frustration in productive ways.
Other Contexts: The client grew up in Germany and recently immigrated to America with his wife and mother. Both parents have a history of alcohol abuse and divorced when he was five. After his father left, his mother's enmeshment with her son intensified. She made him spend time with her rather than his school friends and used the threat of leaving him in an orphanage to control his behavior. Whenever he became upset or anxious, she would cuddle him and give him sips of whatever alcohol she consumed.  The client was recently arrested for driving under the influence. The client's wife is contemplating separating because of her husband's continued drinking. He identifies a couple of bartenders as "friends" but cannot recall anyone he knows in an alcohol-free context. He has also been late or missed work due to hangovers and will likely lose his job. His co-workers have often complained that he smells of alcohol. Previous Counseling: The client has had suicidal thoughts thrice, all of which were recent. The initial occurrence was after a DUI incident, followed by a write-up at work, and the third after his wife proposed a separation. The client has shared that he has a specific plan in mind for ending his life, which involves either ingesting pills or cutting his wrists.

Question: Taking into account the session's content, what should be your primary focus initially?
(A): Process his feelings and thoughts regarding his wife and their relationship.
(B): Continue to evaluate his level of lethality and update his safety plan.
(C): Begin the psychoanalytic process of dealing with his past traumas
(D): Encourage the client to explore productive ways he can express his frustrations.

Correct Answer: Continue to evaluate his level of lethality and update his safety plan.
Explanation: The statement of feeling like giving up is ambiguous and needs to be explored and acted on. It is critical to know precisely to what extent this client will or will not act on these thoughts and to mutually agree in writing to not act on those feelings or thoughts. Determining his level of lethality provides a baseline determination of his current suicidal status. It simultaneously gives you a standard to compare when there is progress in the future. This also provides you with documentation of his verbal commitment to avoid self-harm as legal confirmation that you have addressed this concern professionally. Therefore, the correct answer is (A)
Competency: intake, assessment, and diagnosis