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: What is the most empathic approach for redirecting John back to addressing his treatment plan goals of anger management?
(A): "The best way for you to figure this out is to start implementing your anger management strategies before talking to your daughter."
(B): "Carpe Diem, John. Let's focus on practicing our deep breathing and then discuss them."
(C): "Why do you think Sherry left you? The same reasons your family won't speak to you?"
(D): "I'm sorry to hear things did not work out. Let's look at what problems we identified together in our last session and see if they apply to your most important relationships."

Correct Answer: "I'm sorry to hear things did not work out. Let's look at what problems we identified together in our last session and see if they apply to your most important relationships."
Explanation: John is visibly upset when he comes to you for support with how to win his family back. Using confrontational dialogue like in answer b) in the form of interviewing questions can be harmful, not only for your therapeutic alliance but for John's fragile state of mind and emotions especially if he has not come to those conclusions himself. Telling him what you think is best to do before he has come to terms with his anger on his own is not the most effective strategy for gaining his buy-in to the counseling process. Clients may often seem as though they want a clear answer for what to do, but counseling is intended to help a person find their own answers instead of handing answers to them. Clients may also push back defensively if they feel you are telling them what to do or might respond in opposition if they are in denial. Answer d) is not coming from a person-centered approach as the counselor is insisting on teaching new coping skill while putting off the subject of interest to the client until later. Answer a) is the most empathic approach and best way to help guide John to observe his condition and build insight on his own. Therefore, the correct answer is (A)
Competency: counseling skills and interventions