Case Study
Patient Demographic: Name: Dave Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders;Substance Use Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder; F10.99 Unspecified Alcohol-Related Disorder Age: 42 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 presents at the intake session biting his nails and cannot keep his legs from shaking. He feels anxious about his wife and work. He continually places his hands on his head and complains of headaches and nausea. He admits to drinking a bit more than he should. He denies thoughts of self-harm but sometimes wishes that he could "disappear."
Presenting Problem: First session You are a counseling intern at an agency that works with clients from various socioeconomic backgrounds. Your client is a 42-year-old married male massage therapist who owns two therapeutic massage practices. Over the past nine months, his business has been reduced by fifty percent. He is having great difficulty paying the bills for the business, and he has exhausted his personal savings. His wife is currently not working due to a back injury. He has difficulty concentrating during the day and is irritable around his employees, friends, and family. He states that he drinks "too much" in order to relax at night and admits that his hangover adds to his anxiety the next day. His wife has begun to complain, and their relationship has been strained over the past three months. The client is concerned about paying for the sessions due to financial issues. He offers to exchange massage sessions for therapy.    The client is aware that anxiety and alcohol use are impacting his work and family life negatively, but he does not know how to get a handle on them. He reports feeling overwhelmed with worry about the future of his business and whether he will be able to continue providing for his family. The client has been avoiding people lately, including old friends, and only sees his mother occasionally due to her health problems. In terms of self-care, the client acknowledges that he tends to put everyone else's needs before his own, which leads to feelings of exhaustion and anxiety. Additionally, he finds it difficult to recognize or accept compliments from others and has difficulty expressing gratitude for their help. During the intake session, you identify anxiety as one of the primary issues the client is seeking help with. You also discuss the role that alcohol is playing in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to developing a plan with the client for addressing these issues, such as scheduling regular self-care activities, limiting or eliminating alcohol use, and exploring cognitive behavioral therapy techniques for managing anxiety levels.  Fourth session The client presents for his fourth session. You were able to work out a payment plan with him which has relieved his immediate concerns about paying for therapy sessions. However, he reports ongoing tension about finances and says that his his wife packed a bag to leave after a "big fight" about money. She told him she needs some space to see if she wants a divorce. The client breaks down and begins to cry and shaking uncontrollably. While looking at the ground he laments, "I don't know what to do. It wasn't always like this. We used to be happy, but now I'm just stressed and worried about everything. I'm never going to be able to make enough money to support my family." He tells you that he works hard to provide for his family, but his wife does not appreciate or support him. He has been drinking more but knows that it is not helping. He has decided he needs to make some lifestyle adjustments; he is ready to make changes and work on his issues.    In the session, you provide a supportive environment, helping your client to see his anxiety from a place of self-awareness and empowerment. You offer him concrete strategies for managing anxiety including relaxation techniques, cognitive restructuring, and grounding exercises. You also explore how he can work towards building better communication with his wife by expressing himself in an assertive yet respectful way. You both discuss how alcohol serves as a distraction but ultimately leads to additional anxiety. Together you come up with a plan that includes reducing the amount of alcohol he consumes, engaging in positive self-talk, and scheduling weekly activities such as going on walks to help him reduce stress levels. At the end of this session, you encourage your client to continue making strides towards his goals and remind him of the progress he has already made. You assure him that anxiety is something that can be managed with regular practice and together you will continue to work towards positive change.  Eighth session The client has been seeing you once a week for the last two months. Today, he appears calm, and his thoughts are coherent. The client tells you that he has not completely abstained from alcohol, but his use has significantly decreased. He reports that he went to a virtual AA meeting but did not find it helpful, so he signed off. The client opens up and states, "I think one of the reasons I am anxious is because I am having an affair. Ever since my wife hurt her back, we have not been intimate." The client's speech becomes more rapid, and he begins to lose eye contact as he discloses the details of his affair to you. Your client tells you, "I'm not happy with my wife, either sexually or emotionally. The new woman I'm seeing understands me, and I don't want to drink when I'm around her. She helps me forget everything that causes me stress." In response to your client focusing on the positives of his affair, you engage the client in a discussion to explore the issue from other perspectives. You ask questions like, "What do you think would happen if your wife found out about your affair?" Your client pauses for a moment and looks down, and then says, "I'm not sure. I care about my wife, but I don't know if she will ever be able to understand me in the way that this other woman does. I feel like I'm trapped." You listen empathically as your client expresses his feelings of anxiety, despair and confusion. You provide clarification when necessary and strive to help your client gain insight into his thoughts and behaviors.    In the session, you explore the client's anxiety and how it has been related to his affair. You address underlying issues that may be contributing to the anxiety such as unresolved feelings of guilt or fear of being discovered. You emphasize that anxiety is often a sign of trying to avoid uncomfortable emotions and situations, but acknowledging them can help him understand anxiety in a different way. You also talk about the role alcohol has played in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to incorporating strategies to address these issues in his treatment plan, such as scheduling regular self-care activities and exploring the relationship between his thoughts and behaviors. Toward the end of this session, the client appears calmer and confident in his ability to make positive changes. As you are wrapping up the session, the client confides to you that ever since he started having an affair, he has found himself sexually attracted to his daughter. He says, "It's just kind of exciting to peek in the bathroom and watch her in the bathtub. But I would never touch her! It's just a passing thought. I know that I need to stop. The thrill of my affair is satisfying enough."
Other Contexts: The client has been married for ten years. He and his wife have two children together, a son, age 10, and a daughter, age 12. The client does not speak to his father, who divorced his mother when he was four years old. The client and his mother have a good relationship. The mother lives 15 minutes away from the client and helps his wife with the children. During the past nine months, his massage therapy practice revenue has decreased by fifty percent, and it has been difficult to pay the bills. The client has exhausted all personal savings. The client is the sole income provider for his family, as his wife is not working while recovering from a back injury. 

Question: How do you proceed when the client confides in you at the end of the session about his recent thoughts and behavior toward his daughter?
(A): Suggest a joint session with him and his wife in order to further assess the situation
(B): Document his disclosure in his therapy record as a topic to discuss during the next session
(C): Explore his sexual tension as an expression of anxiety resulting from having an affair
(D): Notify the appropriate legal authorities about the client's behavior

Correct Answer: Notify the appropriate legal authorities about the client's behavior
Explanation: The client has disclosed that he is sexually attracted to his daughter (who is a minor) and has been watching her in the bathroom without her knowledge or consent. In the event that a client reports inappropriate behavior with a child, therapists must immediately notify the appropriate legal authorities to ensure safety of the minor. Therefore, the correct answer is (D)
Competency: professional practice and ethics