Case Study
Patient Demographic: Name: Alberto Clinical Issues: Sexual functioning concerns Diagnostic Category: Sexual Dysfunctions Provisional Diagnosis: F51.22 Erectile Disorder, Situational Age: 43 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client is dressed in casual clothing and appears to be clean and well-groomed. He is of average height and build, with short black hair. He is noticeably tense and avoids eye contact when describing his symptoms. His speech is audible and clear. He is able to express himself clearly and articulately. The client reports feeling frustrated, embarrassed, and confused concerning issues with his wife. He denies any suicidal or homicidal ideation. His mood is anxious and affect is flat. He is able to recall pertinent events and information. He has no difficulty understanding the session process or comprehending instructions. He appears to be alert and oriented to person, place, and time. The client displays average insight into his current situation and expresses willingness to explore relevant issues in more depth with the therapist. He displays average judgment when answering questions.
Presenting Problem: First session The client, a 43-year-old male, presents for his first Telehealth session through the agency where you are an intern, finishing your final hours for licensure under clinical supervision. You begin the session by striving to create a safe, comfortable, and non-judgmental environment. You provide the client with an introduction to yourself, your qualifications, and your approach to therapy. You also explain how Telehealth works and provide the client with an opportunity to ask questions about the process. Next, you review his informed consent and other paperwork that was filled out prior to the session. You explain the policies and procedures for confidentiality within your agency. He nods his head and verbally acknowledges understanding.    You then begin to explore the client's presenting issues and goals for therapy. You ask what prompted him to schedule an appointment for counseling, and he responds saying, "I don't know what is wrong with me, but lately, I've been having trouble with my wife....on an intimate level. It's been very frustrating and embarrassing, and it's causing a lot of tension between us. My wife is getting frustrated and accusing me of cheating on her. We have two children. I never thought this would happen to me." The client has seen a urologist and has no sign of prostate cancer but is in poor health. The client appears anxious when describing his symptoms. He is fidgeting and has trouble maintaining eye contact as you explore the issue more deeply.    This is your first client who presents with this particular issue, and you are not entirely sure of how to proceed. You take a few moments to pause and reflect on what he has said while also noting his body language. As you consider the best way forward, you remember the importance of validation in establishing rapport. You nod your head and say, "I can see how this has been difficult for you and your wife. It's understandable why it might be causing tension between the two of you."  Fourth session It has been a month since you began therapy with the client. You have been meeting with him weekly. Today, the client states he and his wife attempted to have sex last week, and he could not maintain an erection. He says she called him "a lousy cheat with a beer belly who can't satisfy her." He lets you know that this remark triggers him as it reminds him of his relationship with his mother. He reports that sex feels like a "chore," and it is not fun anymore. "Sometimes, I fantasize about being with an ex-girlfriend of mine just to get an erection." The client seems sad and looks down at his feet.    You and the client discuss his wife's comments, and he expresses feeling overwhelmed and helpless. You ask him to reflect on how he feels about his wife's reaction, and he reports feeling "hurt and rejected." You then discuss the possibility of exploring underlying issues that may be impacting his ability to find pleasure in sex. You then ask if he is able to recall any past experiences or traumas contributing to his difficulty with erectile dysfunction. He has never felt anxious about past experiences with erectile dysfunction, but now he sees to be struggling with feelings of guilt and shame. You then discuss strategies for improving communication with his wife and ways to build trust within their relationship. You encourage the client to explore his feelings and identify potential triggers impacting his ability to enjoy sex. Lastly, you role-play a scenario in which the client communicates his feelings to his wife in a non-confrontational manner. At the end of the session, he tells you that he is beginning to understand how he can relate better to his wife. He states, "I guess it's important to tell each other what we need and want."
Other Contexts: The client is an only child. As he grew up, he reports that his father was often vocal about his dissatisfaction with his sex life. The client also reports that his mother often expressed resentment toward him from the day he was born. This has left him with a deep-seated dislike of his mother, as well as resentment of women in general. Currently, his parents are facing health issues, with his father drinking heavily and his mother having lung cancer. The client feels overwhelmed and stressed due to his job and family responsibilities. He is worried about his parents' health and is not happy about the potential of having to take care of his mother if his father passes away. After a decade of working as an illustrator designing greeting cards, the client has recently been promoted to creative director of his department. Because of his introverted nature, he is now feeling overwhelmed with the new responsibilities and having to communicate with other departments within the company. The client drinks weekly and occasionally smokes marijuana. The client drinks at least one beer every other night after work with dinner. He will finish two six-packs on some weekends if they have company over to watch football. He says he rarely drinks hard liquor. The client has reported that his alcohol use or smoking marijuana is not causing any impairments in his ability to carry out his daily responsibilities, but he is overweight because of his inactivity and indicates he would like to return to his normal weight. He also says that he has never experienced any adverse physical or psychological effects due to his substance use.

Question: Based on the information you have gathered so far on the client, which issue is least significant to address?
(A): The client's potential triggers impacting his ability to enjoy sex
(B): The client's weight possibly impacting his erectile dysfunction
(C): The client's feelings regarding his wife's poor communication skills
(D): The client's fantasies about his ex-girlfriend

Correct Answer: The client's fantasies about his ex-girlfriend
Explanation: Although this issue might be emotionally significant for the client, it is not as important to address in therapy as his feelings of hurt and rejection from his wife's comments, exploring any underlying issues that may be impacting his ability to find pleasure in sex, and improving communication with his wife. These topics are more likely to lead to meaningful progress in the therapy sessions. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis