Case Study
Patient Demographic: Name: Jeff Clinical Issues: Referral following hospitalization for suicidal ideation Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F31.32 Bipolar I Disorder, Moderate, Most Recent Episode Depressed Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client's overall presentation during the examination is disheveled. He is thin, taller than average, and hunches over in his chair. He appears tired and exhibits low energy. Several times during the examination, he massages his neck and shoulders. He has inconsistent eye contact and often looks down at the floor. Speech is quiet and slow. You have to wait several seconds for him to answer questions. Thought content reveals negative themes. At various times he appears numb and indifferent but then shifts to tearfulness. Memory is slightly impaired, and he has difficulty staying focused. He denies homicidal ideations but states having past suicidal ideations.
Presenting Problem: First session You are a clinical mental health therapist working in a private practice setting. The client is a 33-year-old male referred to you by an ER physician as a follow-up after being hospitalized due to suicidal ideation. This is not the first time the client has been hospitalized. During the initial counseling session, the client discloses, "I don't know why I'm here. No one can help me. My sister made this appointment for me because I got this referral when I left the hospital. She drove me here and is sitting out in the waiting room." He continues with a tearful eye, "I'm a total failure. No one cares about. My sister looks after me, but I think it's because she feels sorry for me."    You continue with your assessment to gain a more thorough understanding of his current situation. He tells you that there are times when he feels "really low" and his mind tells him that he would be better off dead. Other times, he feels "pretty good" with a lot of energy, a positive self-image, and motivation to complete various projects. You ask about his relationships with friends and family, and the client reveals that he has lost contact with most of his close friends due to a "series of negative events" in his life. He further discloses that he has difficulty maintaining relationships. He expresses feelings of loneliness and disconnection from the world. He is worried that his sister will eventually "give up" on him. When asked about his parents, he softly laughs and says, "They took the easy way out and died. Mom in a car crash and Dad from cancer. They are the ones who deserve to suffer and instead, they've got it easy."    You discuss your role as a therapist and what the client can expect from the counseling process. You also review the parameters of confidentiality involved in therapy. He tells you that he would like to "give counseling a try" and see you for another session. You schedule an appointment to see him the following week.
Other Contexts: The client's parents divorced when he was ten years old. He has an older sister who he currently lives with. He recalls his childhood memories as traumatic and reports experiencing verbal and physical abuse by both parents. The client states that he lived with his dad after his mom died when he was 14 years old. He explains that living with his dad was difficult, saying, "Being around my dad was like being around a ticking time bomb. There were times when he was calm and seemed interested in what I was doing, but there were other times when he would become very angry and I was never sure what might set him off." The client works in a local pizza shop. He says he is written up weekly for being late to work. He reports verbal altercations with his coworkers because they will not listen to him. In his teen years, the client used alcohol to cope with his family situation. Since that time, he only drinks socially.

Question: What cognitive distortion is the client exhibiting during his initial session?
(A): Personalization
(B): Catastrophizing
(C): All-or-nothing thinking
(D): Overgeneralization

Correct Answer: All-or-nothing thinking
Explanation: All-or-nothing thinking is a cognitive distortion wherein a person views a situation in extremes, such as seeing themselves as an utter failure or believing that their thoughts are permanent. In this case, the client believes he is a "total failure", no one can help him, and no one cares about him. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis