Case Study
Patient Demographic: Initial Intake: Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “happy” and this is congruent with his affect. He demonstrates some social awkwardness in presentation and conversation both in missing social cues and oversharing. He demonstrates some motor hyperactivity, indicated by fidgeting, shifting in his seat, and upon entering the office, is invited to sit as he was touching items on the bookshelf. He presents as very talkative, distractible, and tangential in his conversation. It is necessary to redirect him often as his explanations and responses include excessive and irrelevant details, and provides responses before the question is completely stated. He demonstrates limited insight into his presentation or the concerns others have shared with him. He demonstrates appropriate judgment, memory, and orientation. He reports no substance use, no sleep or waking problems, and does not smoke. He is emphatic in his negative responses to questions related to suicidal or homicidal thoughts and intentions.
Presenting Problem: You are a counselor in a private practice setting.  Your client is a 45-year-old male who reports that his wife of two years suggested he seek help for what she says is “OCD.” The client says that several months after their marriage, his wife began complaining that the client had so many expectations for her and her children that they are overwhelmed and feel unable to please him. The client tells you that he has had friends tell him in the past that he is “OCD” and sometimes his employees make fun of him because he wants everything done a certain way. He says that they sometimes call him “the eye” because they say he is always watching to make sure they do things correctly.  Some of his closer friends will “test me” sometimes by moving something to see if the client notices it. He tells you they are doing it in fun, and he doesn’t really mind because he automatically notices things, whether they moved something or it has accidentally got put in the wrong place. He admits that he is concerned that things are done well because he owns his own business and needs it to be managed correctly, but he doesn’t really understand his wife and stepchildren’s concerns. He tells you that he would like to know if he “is the problem” and if so, how he can make changes to help his marriage. He tells you that he doesn’t see a problem with how he runs his business and thinks that his employees are just “complainers.”
Other Contexts: Family History:
The client reports being the youngest of two sons born to his parents. His parents have been married for 40-plus years. He tells you that his mother did complete high school with some difficulty and has never been employed. His father is now retired but was an accountant previously. He says his older brother had a difficult time several years ago with holding a job and going through a divorce, but is now doing much better. The client tells you that his family is still very close, his parents come over to visit often, and prior to buying his business, he often vacationed with family. He says that while growing up, their mother has always been overprotective of him and his brother and has always made sure that they did things the right way. The client states that until his marriage, he continued to live in his parent’s home in his childhood bedroom. He says that even though he took care of his own things, his mother still checked behind him every day to make sure the bed was made correctly and that nothing needed cleaning up. The client says that his parents were constantly frustrated with his brother because he didn’t take care of his room and things. The client reports that he completed a college degree in business and chose to open his own franchise business so that he could work for himself. He has owned his business for six years and enjoys it, although he rarely has time off. He tells you that his father and mother stop by the store frequently “just to help out.” He says his mother likes to help with cleaning and his father helps with the accounting.

Question: Which of the following would be most appropriate for helping the client navigate his dilemma?
(A): Why do you think you feel sad and angry at yourself?
(B): Your stepson didn't do it the way you wanted but you feel upset for getting angry
(C): The rules say your stepson was wrong, but a part of you seems to be questioning the rules
(D): Your rules created a barrier between you and your stepson's relationship

Correct Answer: The rules say your stepson was wrong, but a part of you seems to be questioning the rules
Explanation: Acknowledging the rules are present but that his emotions suggest a part of him is questioning them is a paraphrase of the client's dilemma without inferring judgement towards the client. Additionally, by using the term, "the rules," it allows the client to focus on the rules as separate from himself instead of viewing himself as bad. This statement also provides the client an opportunity to hear that his dilemma is happening inside himself and allows him to react to the statement using the insight he appears to be developing. Asking the client "why" may make the client feel attacked and that he needs to defend his rules and why they are important. This is not helpful for the therapeutic relationship. Response c and d are both paraphrases of the client's dilemma but in each, the focus of the paraphrases are on the client as the problem, rather than the rules. Therefore, the correct answer is (A)
Competency: counseling